HOUSEHOLD SCHEDULE
PLACE NAME ______
REGION ______
EA NUMBER _____
STRUCTURE NUMBER _____
HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD _____
HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE
NO 2
MEDIUM CITY 2
SMALL CITY 3
TOWN 4
VILLAGE 5
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 ___
RESULT* ___
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)______
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ___
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) Please give me the names of the persons who usually live in your household who stayed here last night, starting with the head of the household.
RELATIONSHIP TO HEAD OF HOUSEHOLD*
(3) What is the relationship of (NAME) to the head of the household?
*CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON/DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEP CHILD
12 NOT RELATED
98 DON'T KNOW
(4) RESIDENCE: Does (NAME) usually live here?
NO 2
(5) RESIDENCE: Did (NAME) stay here last night?
NO 2
(6) SEX: Is (NAME) male or female?
FEMALE 2
AGE AS REPORTED 0 to 96
AGE 97 OR ABOVE 97
DON'T KNOW 98
(8) Does (NAME) suffer from partial/total loss of limbs OR is paralysed?
NO 2
(9) Is (NAME) partially/totally blind?
NO 2
(10) Is (NAME) partially/totally deaf?
NO 2
(11) Is (NAME) mentally retarded?
NO 2
(12) Does (NAME) have leprosy?
NO 2
(13) Does (NAME) have fits/epilepsy?
NO 2
(14) Does (NAME) have mental problems?
NO 2
(IF AGE 12 YEARS OR OLDER)
(15) What is (NAME'S) current marital status?
*CODES FOR Q.15
CURRENTLY MARRIED 1
LIVING WITH A MAN/WOMAN 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
NEVER MARRIED 6
(16) Has (NAME) ever been to school?
NO 2
(IF AGE 6 YEARS OR OLDER)
(IF ATTENDED SCHOOL)
(17) What is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at that level?**
**CODES FOR Q. 17
EDUCATIONAL LEVEL:
MIDDLE/JSS 2
SECONDARY/SSS 3
HIGHER 4
DON'T KNOW 8
EDUCATION GRADE
DON'T KNOW 98
(IF AGE 6 YEARS OR OLDER)
(IF ATTENDED SCHOOL)
(IF AGE LESS THAN 25 YEARS)
(18) Is (NAME) still in school?
NO 2
(IF AGE 6 YEARS OR OLDER)
(IF ATTENDED SCHOOL)
(IF AGE LESS THAN 25 YEARS )
(IF NOT STILL IN SCHOOL)
(19) Why is (NAME) not in school?***
***CODES FOR Q. 19
REASONS FOR NOT ATTENDING SCHOOL:
SCHOOL TOO FAR 2
LACK OF INTEREST 3
DISABILITY 4
NEEDED TO HELP IN FAMILY BUSINESS 5
GRADUATED 6
OTHER 7
PARENTAL SURVIVORSHIP AND RESIDENCE OF PERSONS LESS THAN 15 YEARS OLD
(20) Is (NAME)'s biological mother alive?
NO 2
DK 8
(21) IF MOTHER ALIVE: Does (NAME)'s biological mother live in this household? IF YES:
What is her name?
RECORD MOTHER'S LINE NUMBER. IF NOT LIVING IN HOUSEHOLD WRITE '00'.
(22) Is (NAME)'s biological father alive?
NO 2
DK 8
(23) IF FATHER ALIVE: Does (NAME)'s biological father live in this household? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NOT LIVING IN HOUSEHOLD WRITE '00'.
(24) ELIGIBILITY WOMAN: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR WOMEN'S QUESTIONNAIRE (Women age 15-49).
(25) ELIGIBILITY MAN: CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR MEN'S QUESTIONNAIRE (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 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 ___
26. What is the main 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 28)
OTHER (SPECIFY) ____ 96
27. How long does it take you to go there, get water, and come back?
ON PREMISES 996
28. Does your household get drinking water from this same source?
NO 2
29. What is the main source of drinking water for members of your household?
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 31)
OTHER (SPECIFY) ____ 96
30. How long does it take you to go there, get water, and come back?
ON PREMISES 996
31. Who usually fetches water (for both laundry/dishwashing and drinking) for the household?
SPOUSE/PARTNER 2
SON 3
DAUGHTER 4
BOTH SON AND DAUGHTER 5
OTHER MALE MEMBER 6
OTHER FEMALE MEMBER 7
OTHER (SPECIFY) _____ 8
32. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
BUCKET/PAN 23
OTHER (SPECIFY) _____ 96
Electricity?
A radio?
A television?
A video deck?
A telephone?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
34. How many rooms in your household are used for sleeping?
35. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
MUD MIXED WITH DUNG 12
PALM/BAMBOO 22
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
TERRAZZO 36
36. Does any member of your household own:
A bicycle?
A motorcycle?
A car?
A tractor?
A horse/cart?
NO 2
NO 2
NO 2
NO 2
NO 2
37. What type of salt is usually used for cooking in your household?
MARKET PACKAGED NON-IODATED SALT 02
FACTORY PACKAGED IODATED SALT 03
FACTORY PACKAGED NON-IODATED SALT 04
OTHER (SPECIFY) ____ 96
38. TEST THE SALT AND WRITE THE RESULT.