GENERAL MANAGEMENT OF STATISTICS AND ECONOMIC STUDY
IDENTIFICATION
NAME OF LOCATION______
NAME OF HEAD OF HOUSEHOLD_____
EDSG CODE____
STRUCTURE NUMBER________
NUMBER OF HEAD OF HOUSEHOLD__________
EDSG REGION________
PROVINCE__________
DEPARTMENT_________
RURAL 2
OTHER CITIES 2
RURAL 3
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY_____
MONTH_____
YEAR_____
NAME_____
RESULT
RESULT CODES:
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____
TOTAL PERSONS IN HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_____
SUPERVISOR
NAME_____
DATE_____
FIELD EDITOR
NAME_____
DATE____
OFFICE EDITOR_____
KEYED BY_____
Now we would like some information about the people who usually live in your household or who are staying with you now.
1) LINE NUMBER
2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
3) Relationship to head of household: What is the relationship of (name) to the head of the household?
02= WIFE OR HUSBAND
03= SON OR DAUGHTER
04= SON-IN-LAW OR DAUGHTER-IN-LAW
05= GRANDCHILD
06= PARENT
07= PARENT-IN-LAW
08= BROTHER OR SISTER
09=NIECE/NEPHEW
10=UNCLE/AUNT
11=OTHER RELATIVE
12= ADOPTED/FOSTER CHILD
13=NO RELATION
98=DON'T KNOW
4) SEX: Is (name) male or female?
FEMALE 2
5) RESIDENCE: Does (name) usually live here?
NO 2
6) RESIDENCE: Did (name) stay here last night?
NO 2
7) AGE: How old is (NAME)?
IF 95 OR MORE, RECORD 95
EDUCATION IF AGE 6 YEARS OR OLDER
8) Has (name) ever attended school?
NO 2
9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?
SECONDARY 1ST CYCLE/SECONDARY TECHNICAL 2
SECONDARY 2ND CYCLE/SECONDARY TECHNICAL 3
HIGHER 4
DON'T KNOW 8
0=LESS THAN ONE YEAR COMPLETED
1=CP1
2=CP2
3=CE1
4=CE2
5=CM1
6=CM2
2=SECONDARY 1ST CYCLE/SECONDARY TECHNICAL
0=LESS THAN ONE YEAR COMPLETED
1=6TH/1ST YEAR
2=5TH/2ND YEAR
3=4TH/3RD YEAR
4=3RD /4TH YEAR
3=SECONDARY 2ND CYCLE/TECHNICAL HIGH SCHOOL
0=LESS THAN ONE YEAR COMPLETED
1=2ND/1ST YEAR
2=1ST/2ND YEAR
3=FINAL/3RD YEAR
4=HIGHER
0=LESS THAN ONE YEAR COMPLETED
1=1ST YEAR
2=2ND YEAR
3=3RD YEAR
4=4TH YEAR +
8=DON'T KNOW
10) IF AGE 25 OR LESS: Is (name) currently attending school?
NO 2
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS FOR PERSONS AGE 15 OR LESS
Q. 11 TO 14: THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. IN Q. 12 AND Q. 14, RECORD 00 IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE
11) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
12) IF ALIVE: Does (NAMES)'s natural mother usually live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
13) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
14) IF ALIVE: Does (NAME)'s natural father usually live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
15) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
15A) CHECK COVER: IF MEN'S SURVEY=YES, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.
TICK HERE IF CONTINUATION SHEET USED_____
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO
2) In addition, are there any other people who many not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
NO
3) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
16) What is the main source of drinking water for members of your household?
PUBLIC PUMP/PUBLIC TAP/NEIGHBOR'S TAP/PURCHASED FAUCET 12
VILLAGE HYDRAULIC/OTHER PROTECTED WELL 22
PUBLIC WELL OR OTHER OPEN WELL 32
STREAM/RIVER/CANAL 42
RAINWATER 51 (GO TO 18)
TANKER TRUCK 61 (GO TO 18)
BOTTLED WATER 71 (GO TO 18)
OTHER (SPECIFY) 96 (GO TO 18)
17) How long does it take you to go there, get water, and come back?
ON PREMISES 996
18) What kind of toilet facility do members of your household usually use?
IMPROVED LATRINE 21
RUDIMENTARY PIT 22
NO FACILITY/BUSH/FIELD 31 (GO TO 22)
OTHER 96 (GO TO 22)
19) What is the distance between the latrines/pits and the house?
IF DON'T KNOW, ESTIMATE DISTANCE
6 METERS OR MORE 2
20) How deep are the latrines?
IF DON'T KNOW, TRY TO GET AN ESTIMATE.
3 METERS OR MORE 2
DON'T KNOW 8
21) Do you share this toilet facility with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
23) What type of fuel does your household mainly use for cooking?
BOTTLED GAS 02
PETROLEUM 03
WOOD COAL 04
WOOD FOR BURNING, STRAW 05
OTHER 96
24) Does anyone in your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
25) How many rooms in this household are used for sleeping?
26) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
TILE 32
LINOLEUM/GERFLEX 33
CEMENT 34
27) MAIN MATERIAL OF WALLS
RECORD OBSERVATION
DIRT 32
BOARDS 33
SEMI-HARD (HARD AND OTHER) 34
CINDER BLOCK/CEMENT 41
OTHER 96
28) MAIN MATERIAL OF ROOF
RECORD OBSERVATION
SHEET METAL AND CEILING 32
TILE/SLATE 33
DUNG 34
OTHER 96
29) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.
RECORD RESULTS OF TEST.
TEST NEGATIVE/NON-IODINE SALT 2
TEST INDETERMINATE 3
NO SALT AVAILABLE 4