INDIA 1992-1993
NAME OF STATE ______
PSU NUMBER ______
NAME OF DISTRICT ______
NAME OF TEHSIL/TALUK ______
RURAL 2
NAME OF TOWN AND TOWN BLOCK OR VILLAGE ______
LARGE CITY/SMALL CITY/TOWN/RURAL AREA ______
SMALL CITY 2
TOWN 3
RURAL AREA 4
NAME OF HOUSEHOLD HEAD ______
ADDRESS OF HOUSEHOLD ______
INTERVIEWER VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT______
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY ________
MONTH ________
YEAR _____
NAME ______
RESULT CODE ______
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 ______
1. RECORD THE TIME.
MINUTES _____
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?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 BORTHER OR SISTER-IN-LAW
10 OTHER RELATIVE
11 ADOPTED/FOSTER CHILD
12 NOT RELATED
98 DOESN'T KNOW
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
7. SEX: Is (NAME) male or female?
FEMALE 2
9. MARITAL STATUS: What is the current marital status of (NAME)?
2 SEPARATED
3 WIDOWED
4 DIVORCED
5 NEVER MARRIED
10. EDUCATION: Can (NAME) read and write?
NO 2
11. EDUCATION: Has (NAME) ever attend school?
NO 2
12. EDUCATION. IF ATTENDED: What is the highest standard (NAME) has completed?
98 DOESN'T KNOW
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?
NO 2
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?
YES, COMPLETE 2
NO 3
16. DOES ANYONE SUFFER FROM: Tuberculosis?
NO 2
17. DOES ANYONE SUFFER FROM: Leprosy?
NO 2
18. DOES ANYONE SUFFER FROM: Any physical impairment of limbs?
YES, LEGS 2
YES, BOTH 3
NO 4
19. Did anyone listed suffer from malaria any time during the last THREE months?
NO 2
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?
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 stayed here last night?
NO
22. What is the main source of water your household uses for bathing and washing?
PUBLIC TAP 12
PUBLIC HANDPUMP 22
PUBLIC WELL 24
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
OTHER (SPECIFY) _____ 81
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?
NO 2
25. What is the main source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC HANDPUMP 22
PUBLIC WELL 24
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 81
26. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
PUBLIC FLUSH TOILET 13
SHARED PIT TOILET/LATRINE 22
PUBLIC PIT TOILET/LATRINE 23
OTHER (SPECIFY) _____ 41
27. What is the main source of lighting for your household?
KEROSENE 2
GAS 3
OIL 4
OTHER (SPECIFY) _____ 5
28. How many rooms are there in your household?
29. Do you have a separate room which is used as a kitchen?
NO 2
30. What type of fuel does your household mainly use for cooking?
COW DUNG CAKES 02
COAL/COKE/LIGNITE 03
CHARCOAL 04
KEROSENE 05
ELECTRICITY 06
LIQUID PETROLEUM GAS 07
BIO-GAS 08
OTHER (SPECIFY) _____ 09
31. TYPE OF HOUSE.
RECORD OBSERVATION.
WALLS______
FLOOR______
KACHHA 2
SEMI-PUCCA 3
32. What is the religion of the head of the household?
SIKH 02
BUDDHIST/NEO BUDDHIST 03
CHRISTIAN 04
JAIN 05
JEWISH 06
MUSLIM 07
ZOROASTRIAN 08
NO RELIGION 09
OTHER (SPECIFY) _____ 10
33. Does the head of the household belong to a scheduled tribe?
NO 2 (GO TO 35)
34. What is the name of the tribe?
35. To which caste does the head of the household belong?
NO CAST 996
36. Does this household own any agricultural land?
NO 2 (GO TO 39)
37. What is the size of non-irrigated land under cultivation, in acres?
NONE 000
LESS THAN ONE 996
38. What is the size of irrigated land under cultivation, in acres?
NONE 000
LESS THAN ONE 996
39. Does this household own any livestock?
NO 2 (GO TO 42)
40. What type of livestock do you own?
RECORD ALL MENTIONED.
COW B
BUFFALO C
GOAT D
SHEEP E
CAMEL F
OTHER (SPECIFY) ______ G
41. Where do you usually keep the animals at night?
OUTSIDE THE HOUSE 2
42. Does the household own any of the following?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
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?
NO 2 (GO TO 45)
44. How many births took place?
45. Did any visitor to this household give birth to a child since (Pongal/Makar Sankranti/January) 1990?
NO 2 (GO TO 47)
46. How many births took place?
NO (GO TO 58)
48. What name was given to the baby born (first/next)?
49. Was the mother a usual resident of the household or a visitor?
VISITOR 2
50. RECORD LINE NUMBER OF MOTHER IN THE HOUSEHOLD SCHEDULE.
MOTHER DIED 95
LEFT HOUSEHOLD 96
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.
MULT 2
53. Is (NAME) a boy or a girl?
GIRL 2
54. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In what season was he/she born?
YEAR______
NO 2
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.
MONTHS 2 _____
57. COMPARE SUM OF 44 AND 46 WITH NUMBER OF BIRTHS IN 48 AND MARK:
NUMBERS ARE DIFFERENT, PROBE AND RECONCILE
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?
NO 2 (GO TO 60)
60. Did any visitor to this household die since (Pongal/Makar Sankranti/January) 1990?
NO 2 (GO TO 62)
61. How many deaths took place?
NO DEATHS (GO TO 75)
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?
VISITOR 2
65. Was (NAME) a male or a female?
FEMALE 2
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.
MONTHS 2______
YEARS 3______
67. In what month and year did (NAME) die?
YEAR_____
68. CHECK 65 AND 66:
DECEASED WAS FEMALE AGED 13-49 AT THE TIME OF DEATH?
NO 2 (GO TO 73)
69. Was (Name) pregnant when she died?
NO 2
70. Did (NAME) die during childbirth?
NO 2
71. Did (NAME) die within two months after the end of a pregnancy or childbirth?
NO 2 (GO TO 73)
72. Was the death of (NAME) due to a complication of the pregnancy or childbirth?
NO 2
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:
NUMBERS ARE DIFFERENT, PROBE AND RECONCILE
MINUTES _____