IDENTIFICATION

NAME OF STATE ______
PSU NUMBER ______
NAME OF DISTRICT ______
NAME OF TEHSIL/TALUK ______

URBAN/RURAL ______

NAME OF TOWN AND TOWN BLOCK OR VILLAGE ______

LARGE CITY/SMALL CITY/TOWN/RURAL AREA ______

NAME OF HOUSEHOLD HEAD ______
ADDRESS OF HOUSEHOLD ______

INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT______

NEXT VISIT
DATE ______
TIME ______

FINAL VISIT
DAY ________
MONTH ________
YEAR _____
NAME ______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

TOTAL IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
LINE NO. OF RESPONDENT TO HOUSEHOLD SCHEDULE _____

SPOT-CHECKED BY
NAME ______
DATE ______

FIELD EDITED BY
NAME ______
DATE ______

OFFICE EDITED BY
NAME ______
DATE ______

KEYED BY
NAME ______
DATE ______

KEY BY ______

HOUSEHOLD SCHEDULE

1. RECORD THE TIME.

2. LINE NUMBER

3. 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.

4. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

5. RESIDENCE: Does (NAME) usually live here?

6. RESIDENCE: Did (NAME) stay here last night?

7. SEX: Is (NAME) male or female?

8. AGE: How old is (NAME)?

IF AGED 6 YEARS OR OLDER:

9. MARITAL STATUS: What is the current marital status of (NAME)?

10. EDUCATION: Can (NAME) read and write?

11. EDUCATION: Has (NAME) ever attend school?

12. EDUCATION. IF ATTENDED: What is the highest standard (NAME) has completed?

Now I would like some information about the people who usually live in your household or who are staying with you now.

EDUCATION. IF ATTENDED AND IF LESS THAN 15 YEARS:

13. Is (NAME) still in school?

14. OCCUPATION: What kind of work does (NAME) do most of the time?

AFTER COMLETING QUESTIONS 1-14 FOR ALL LISTED PERSONS, ASK:

15. DOES ANYONE SUFFER FROM: Blindness?

16. DOES ANYONE SUFFER FROM: Tuberculosis?

17. DOES ANYONE SUFFER FROM: Leprosy?

18. DOES ANYONE SUFFER FROM: Any physical impairment of limbs?

19. Did anyone listed suffer from malaria any time during the last THREE months?

ELIGIBILITY:
20. CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
(EVER MARRIED FEMALES AGED 13-49)

TICK HERE IF CONTINUATION SHEET USED _____

21. 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?

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?

3) Do you have any guests or temporary visitors staying here, or anyone else who stayed here last night?

22. What is the main source of water your household uses for bathing and washing?

23. How long does it take to go there, get water, and come back in one trip?

24. Does your household get drinking water from this same source?

25. What is the main source of drinking water for members of your household?

26. What kind of toilet facility does your household have?

27. What is the main source of lighting for your household?

28. How many rooms are there in your household?

29. Do you have a separate room which is used as a kitchen?

30. What type of fuel does your household mainly use for cooking?

31. TYPE OF HOUSE.
RECORD OBSERVATION.

32. What is the religion of the head of the household?

33. Does the head of the household belong to a scheduled tribe?

34. What is the name of the tribe?

35. To which caste does the head of the household belong?

36. Does this household own any agricultural land?

37. What is the size of non-irrigated land under cultivation, in acres?

38. What is the size of irrigated land under cultivation, in acres?

39. Does this household own any livestock?

40. What type of livestock do you own?
RECORD ALL MENTIONED.

41. Where do you usually keep the animals at night?

42. Does the household own any of the following?

Now I would like to ask you about the births that have taken place to any member of your household or visitor during the last two years.

43. Did any usual resident of this household give birth to a child since (Pongal/Makar Sankranti/January) 1990 in this (city/town/village) or outside?

44. How many births took place?

45. Did any visitor to this household give birth to a child since (Pongal/Makar Sankranti/January) 1990?

46. How many births took place?

47. CHECK 44 AND 46:

48. What name was given to the baby born (first/next)?

49. Was the mother a usual resident of the household or a visitor?

50. RECORD LINE NUMBER OF MOTHER IN THE HOUSEHOLD SCHEDULE.

51. How old was the mother at the time of birth of (NAME)?
RECORD AGE IN COMPLETE YEARS.

52. RECORD SINGLE OR MULTIPLE BIRTH STATUS.

53. Is (NAME) a boy or a girl?

54. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In what season was he/she born?

55. Is (NAME) still alive?

56. IF DEAD: How old was he/she when he/she died?
IF "1 YEAR", PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN ONE MONTH.

57. COMPARE SUM OF 44 AND 46 WITH NUMBER OF BIRTHS IN 48 AND MARK:

Now I would like to ask you about the deaths of any member of your household or visitor during the last two years.

58. Did any usual resident of this household die since (Pongal/Makar Sankranti/January) 1990 in this (city/town/village) or outside?

59. How many persons died?

60. Did any visitor to this household die since (Pongal/Makar Sankranti/January) 1990?

61. How many deaths took place?

62. CHECK 59 AND 61:

63. What (was/were) the name(s) of the person(s) who died?

64. Was (Name) a usual resident of the household or a visitor?

65. Was (NAME) a male or a female?

66. How old was he/she when he/she died?
RECORD DAYS IF LESS THAN ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR YEARS.

67. In what month and year did (NAME) die?

68. CHECK 65 AND 66:
DECEASED WAS FEMALE AGED 13-49 AT THE TIME OF DEATH?

69. Was (Name) pregnant when she died?

70. Did (NAME) die during childbirth?

71. Did (NAME) die within two months after the end of a pregnancy or childbirth?

72. Was the death of (NAME) due to a complication of the pregnancy or childbirth?

73. What were the major symptoms observed before the death of (NAME)?

74. COMPARE SUM OF 59 AND 61 WITH NUMBER OF DEATHS IN 63 AND MARK:

75. RECORD THE TIME.