Household Questionnaire
FEDERAL ISLAMIC REPUBLIC OF COMOROS
NATIONAL CENTER OF DOCUMENTATION AND SCIENTIFIC RESEARCH
ISLAND NAME AND CODE
MOHELI 2
ANJOUAN 3
PREFECTURE NAME AND CODE
LOCALITY NAME AND CODE
COUNTING ZONE CODE
NAME OF HEAD OF HOUSEHOLD
CLUSTER NUMBER
HOUSEHOLD NUMBER
RURAL 2
THIS HOUSEHOLD WAS SELECTED FOR MEN'S SURVEY_____
MORONI 1
OTHER CITY 2
COUNTRYSIDE 3
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
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 OF TIME 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____
FINAL VISIT
DAY___
MONTH___
YEAR____
NAME____
RESULT___
TOTAL PERSONS IN HOUSEHOLD____
ELIGIBLE MEN_____
LINE NUMBER OF PERSON SURVEYED______
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) 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 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
ADOPTED CHILD/FOSTER CHILD/STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98
4) RESIDENCE: Does (NAME) usually live here?
NO 2
5) Did (NAME) stay here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
7) AGE: How old is (NAME)? (In years)
EDUCATION IF AGE 6 YEARS OR OLDER:
8) Has (NAME) ever been to school?
NO 2
9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?**
SECONDARY 1ST CYCLE 2
SECONDARY 2ND CYCLE 3
HIGHER 4
DON'T KNOW 8
CP2 02
CE1 03
CE2 04
CM1 05
CM2 06
6TH 01
5TH 02
4TH 03
3RD 04
2ND 01
1ST 02
FINALE 03
10) Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD **
11) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
12) IF ALIVE: Does (NAME)'s natural mother usually live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
13) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
14) IF ALIVE: Does (NAME)'s natural father live in this household?
If yes, what is his name?
RECORD FATHER'S LINE NUMBER.
ELIGIBILITY:
15) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
16) CIRCLE LINE NUMBER OF ALL MEN AGE 15-64
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 many not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
>Q. 11 TO Q. 14
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
RECORD 00 IF PARENT NOT MEMBER OF HOUSEHOLD
1 extra year=01;
2 extra years=02
3 extra years=03
4 years and more=04
17) What is the main source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
TANKER ELSEWHERE 42
BOTTLED WATER 61 (GO TO 19)
OTHER (SPECIFY) 96
>18) How long does it take to go there, get water, and come back?
ON PREMISES 996
>19) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) 96
>20) Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
>21) How many rooms in your household are used for sleeping?
>22) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION.
VINYL OR ASPHALT 32
TILES/CEMENT 33
>23) Does any member of your household own:
NO 2
NO 2
NO 2