PLACE NAME ______
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD________
INTERVIEW 1
DATE ____
INTERVIEWER'S NAME _____
RESULT** ______
NEXT VISIT:
DATE ____
TIME ____
INTERVIEW 2
DATE ____
INTERVIEWER'S NAME _____
RESULT** ______
NEXT VISIT:
DATE ____
TIME ____
INTERVIEW 3
DATE ____
INTERVIEWER'S NAME _____
RESULT** _______
FINAL VISIT
MONTH ____
YEAR ____
INTERVIEWER'S NAME ____
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
TOTAL IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
FIELD EDITED BY
NAME _____
DATE _____
OFFICE EDITED BY
NAME _____
DATE _____
KEYED BY
NAME _____
DATE _____
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 NO.
2. USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household or are staying with you now, starting with you now, starting with the head of the household.
3. Does (NAME) usually live here?
NO 2
4. Did (NAME) sleep here last night?
NO 2
5. SEX
Is (NAME) male or female?
NO 2
FOSTERING
ONLY FOR CHILDREN UNDER 15 YEARS OLD:
7. Do any of his/her parents usually live in this household?
NO 2
8. ELIGIBILITY
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
9. WOMAN SUCCESSFULLY INTERVIEWED?
TICK IF YES
NO 2
10. HUSBAND'S ELIGIBILITY
CIRCLE LINE NUMBER OF HUSBAND'S ELIGIBLE FOR INTERVIEW
TICK HERE IF CONTINUATION SHEET USED ____
TOTAL NUMBER OF ELIGIBLE WOMEN ____
TOTAL NUMBER OF ELIGIBLE HUSBANDS ____
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
2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO 2
3) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO 2