PLACE NAME __________
NAME OF HOUSEHOLD HEAD ____________
EA NUMBER _____________
STRUCTURE NUMBER ___________
HOUSEHOLD NUMBER ___________
REGION ____________________
RURAL 2
LARGE CITY/MEDIUM CITY/SMALL CITY/TOWN/VILLAGE ____________
MEDIUM CITY 2
SMALL CITY 3
TOWN 4
VILLAGE 5
FOR OFFICE USE
Large city 1,000,000 and over
Medium city 500,000 - 999,999
Small city 50,000 - 499,999
Town 5,000 - 49,999
Village under 5,000
INTERVIEW 1
DATE ____
INTERVIEWER'S NAME _____
RESULT ______
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 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:
DATE ____
TIME ____
INTERVIEW 2
DATE____
INTERVIEWER'S NAME _____
RESULT ______
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 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:
DATE ____
TIME ____
INTERVIEW 3
DATE ____
INTERVIEWER'S NAME _____
RESULT ______
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ______ 9
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ______ 9
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ____
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. (1)
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?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED 10
NOT RELATED 11
DON'T KNOW 98
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. RESIDENCE: Did (NAME) sleep here last night?
NO 2
6. SEX: Is (NAME) male or female?
FEMALE 2
8. What is (NAME)'S current marital status?
CONSENSUAL 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
NEVER MARRIED 6
9. Has (NAME) ever been to school?
NO 2 (GO TO 11b)
10. What is the highest level of school (NAME) attended?
What is the highest grade (NAME) completed at that level?
GRADE ____
LEVEL OF EDUCATION:
MIDDLE/JSS 2
SSS/COMMERCIAL/TECHNICAL/4 YEAR IRG. COLLL. 3
POST SEC./NURSING TRG/POLYTECHNIC 4
HIGHER 5
DK 8
GRADE:
DK 98
11a. Is (NAME) still in school?
NO 2
SCHOOL TOO FAR 2
LACK OF INTEREST 3
DISABILITY 4
NEEDED TO HELP IN FAMILY 5
GRADUATED 6
OTHER 7
FOR THOSE AGED 7 YEARS AND ABOVE
12. What work did (NAME) do during the past 7 days, even if (NAME) was not paid for it?
Describe what (NAME) did in this work?
IF ONLY STUDENT/HOMEMAKER/UNEMPLOYED (SKIP TO Q17)
13. What kind of industry is it connected with?
14. In this work did (NAME) work on own account, as an employer, as unpaid family worker or for wages/salary?
EMPLOYER 2
UNPAID FAMILY WORKER 2
FOR WAGES/SALARY 4
15. For how many days during the past 7 days did (NAME) do this work?
16. During these days how many hours per day did (NAME) do this work? (16)
RECORD HOURS WORKED AND SKIP TO Q18.
17. Did (NAME) look for work during the past 7 days?
NO 2
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 may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO
18. During the past 2 weeks has (NAME) suffered from either an illness or an injusry?
NO 2
19. Has (NAME) had a health consultation in the past 2 weeks?
NO 2 (GO TO 21)
20. In the past 2 weeks whom did (NAME) consult?
DENTIST 02
MEDICAL ASSISTANT 03
NURSE 04
MIDWIFE 05
PHARMACIST 06
DRUGGIST 07
TRADITIONAL HEALER 08
TB 09
SPIRITUALIST 10
OTHER (SPECIFY) ___ 96
21. Did (NAME) pay anything for medical supplies or consultation in the past 2 weeks? (21)
IF YES: How much?
IF NO: ENTER "0"
ALL USUAL RESIDENTS AGED 15 OR OLDER
22. Was (NAME) born in this locality?
NO 2 (GO TO 24)
23. Has (NAME) lived anywhere else for at least 6 months?
NO 2
24. At the time of (NAME'S) birth, was his/her birthplace a:
Town 2
Village 3
***(Q24) CHECK IF YES IN Q22 AND NO IN Q23 THEN SKIP TO Q31.
25. How old was (NAME) when he/she left his/her place of birth for the first time to live somewhere else?
26. What was the main reason (NAME) moved the first time?
WORK RELATED 2
MARRIAGE 3
SCHOOL 4
ADVENTURE/BRIGHTLIGHTS 5
ESCAPE FAMILY PROBLEMS 6
OTHER (SPECIFY) _____ 7
ALL USUAL RESIDENTS AGED 15 OR OLDER
27. How long has (NAME) lived in (PRESENT PLACE OF RESIDENCE) since his/her last move?
TIME IN YEARS
IN MONTHS IF LESS THAN 1 YEAR.
MONTHS ___
28. What was the main reason (NAME) came to (PRESENT PLACE OF RESIDENCE)?
WORK RELATED 2
MARRIAGE 3
SCHOOLS 4
BRIGHTLIGHT 5
ESCAPE FAMILY PROBLEMS 6
OTHER (SPECIFY) ____ 7
29. Which region or country did (NAME) move from?
CENTRAL 02
G/ACCRA 03
VOLTA 04
EASTERN 05
ASHANTI 06
B. AHAFO 07
NORTHERN 08
U. WEST 09
U. EAST 10
NIGERIA 11
C. D'IVORE 12
B. FASO 14
OTHER AFRICA 15
OUTSIDE AFRICA 16
30. Was the place where (NAME) was living before coming here a city, town or village?
TOWN 2
VILLAGE 3
31. Does (NAME) have difficulty moving?
NO 2
32. Does (NAME) have difficulty seeing?
NO 2
33. Does (NAME) have difficulty hearing/speaking?
NO 2
34. Does (NAME) have difficulty learning?
NO 2
35. Has (NAME) loss of feeling in the hand/foot?
NO 2
NO 2
37. Does (NAME) behave strangely?
NO 2
38. Does (NAME) have any other difficulty?
NO 2
39. IF MORE THAN ONE "YES": Which is the main difficulty (NAME) has?
SEEING 2
HEARING/SPEAKING 3
LEARNING 4
LOSS OF FEELING IN THE HAND/FOOT 5
FITS 6
BEHAVE STRANGELY 7
OTHER 8
PARENTAL SURVIVORSHIP AND RESIDENCE
FOR PERSONS LESS THAN 15 YEARS OLD***
40. Is (NAME)'s natural mother alive?
.
NO 2 (GO TO 42)
DK 8 (GO TO 42)
41. IF MOTHER ALIVE: Does (NAME)'S natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
42. Is (NAME)'S natural father alive?
NO 2 (GO TO 44)
DK 8 (GO TO 44)
43. IF FATHER ALIVE: Does (NAME)'S natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
44. ELIGIBILITY (WOMAN)
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.
(15-49 YEARS)
45. ELIGIBILITY (MAN)
CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INTERVIEW.
(15-49 YEARS)
46. What is the source of water your household uses for laundry and dishwashing?
PUBLIC TAP/NEIGHBOUR'S HSE 12
PUBLIC WELL 22
BOREHOLE 23
RIVER/STREAM 32
POND/DAM 33
DAM 34
DUGOUT 35
TANKER TRUCK 51
BOTTLED WATER 61 (SKIP TO 48)
OTHER (SPECIFY) ____ 96
47. How long does it take to go there, get water, and come back?
RECORD RESPONSE
HOURS ___
ON PREMISES 996
48. Does your household get drinking water from this same source?
NO 2
49. What is the source of drinking water for members of your household?
PUBLIC TAP/NEIGHBOUR'S HSE 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/DAM 33
DAM 34
DUGOUT 35
TANKER TRUCK 51
BOTTLED WATER 61 (SKIP TO 51)
OTHER (SPECIFY) ____ 96
50. How long does it take to go there, get water, and come back?
RECORD RESPONSE
MINUTES ____
ON PREMISES 996
51. What kind of toilet facility does your household use?
SHARED WC 12
VENTILATED IMPROVED PIT (VIP LATRINE) 22
OTHER (SPECIFY) ____ 96
52. Does your household have:
Electricity?
A functioning radio?
A functioning television?
A functioning refrigerator?
A functioning video?
NO 2
NO 2
NO 2
NO 2
NO 2
53. How many rooms in your household are used for sleeping?
54. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
MUD MIXED WITH DUNG 12
PALM/BAMBOO 22
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
TERRAZO 36
55. Does any member of your household own:
A bicycle?
A motorcycle?
A motor vehicle?
A tractor?
A horse/cart?
NO 2
NO 2
NO 2
NO 2
NO 2