IDENTIFICATION

PROVINCE __________
DISTRICT __________
LOCATION/TOWN __________
SUBLOCATION/WARD __________
NASSEP CLUSTER NUMBER
KDHS CLUSTER NUMBER
HOUSEHOLD NUMBER

NAIROBI/MOMBASA 1, SMALL CITY 2, TOWN 3, RURAL 4

NAME OF HOUSEHOLD HEAD _______________

HOUSEHOLD SELECTED FOR MALE SURVEY?

INTERVIEWER VISIT 1
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________

INTERVIEWER VISIT 2
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________

INTERVIEWER VISIT 3
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________

FINAL VISIT
DAY __
MONTH __
YEAR __
NAME ___
RESULT __

TOTAL NUMBER OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL WOMEN 15-49 __

MEN 15-54 __

LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE __

*RESULT__

LANGUAGE OF QUESTIONNAIRE: ENGLISH 10

FIELD EDITED BY
NAME __________
DATE __________

OFFICE EDITED BY
NAME ____________
DATE ____________

KEYED BY
NAME _____________
DATE _____________

HOUSEHOLD SCHEDULE

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 and guests of the household who stayed here last night, starting with the head of the household. (2)

3. RELATIONSHIP TO HEAD OF HOUSEHOLD*
What is the relationship of (NAME) to the head of the household? (3)

* CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEP CHILD 11
NOT RELATED 12
DON'T KNOW 98

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

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

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

7. AGE: How old is (NAME)?

EDUCATION

IF AGE 6 YEARS OR OLDER

8. Has (NAME) ever been to school?

IF ATTENDED SCHOOL

9.What is the highest level of school (NAME) attended?

What is the highest grade (NAME) completed at that level?***

** CODES FOR Q.9
EDUCATION LEVEL:
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8

EDUCATION GRADE:
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

IF AGE LESS THAN 25 YEARS

10. Is (NAME) STILL IN SCHOOL?

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD***

*** Q.11 THROUGH Q.14
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
RECORD '00' IF PARENT NOT MEMBER OF HOUSEHOLD.

11. Is (NAME)'s natural mother alive?

(IF ALIVE)
12. Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.

13. Is (NAME)'s natural father alive?

(IF ALIVE)
14. Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

ELIGIBILITY WOMEN
15. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

ELIGIBILITY MEN
16. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

TICK HERE IF CONTINUATION SHEET USED __

NO. OF ELIGIBLE WOMEN __

NO. OF ELIGIBLE MEN__

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) Are there any guests or temporary visitors staying here, or anyone else who slept here last night that have not been listed?

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

17. How long does it take to go there, get water, and come back?

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

19. Does your household have:

20. How many rooms in your household are used for sleeping?

21. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

22. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

23. Does any member of your household own: