DEPARTMENT OF CENSUS AND STATISTICS OF SRI LANKA
DEMOGRAPHIC AND HEALTH SURVEY
ZONE____
DISTRICT____
SECTOR:
RURAL
ESTATE
WARD/GS DIV/ESTATE____
SURVEY BLOCK NUMBER____
HOUSING UNIT NUMBER____
HOUSEHOLD NUMBER____
FIRST VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9
NEXT VISIT
DATE____
TIME____
SECOND VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9
NEXT VISIT
DATE____
TIME____
FINAL VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9
FIELD EDITED BY
NAME____
DATE____
OFFICE EDITED BY
NAME____
DATE____
KEYED BY
NAME____
DATE____
Now we would like some information about the people who usually live in your household, or who are staying with you now.
1) NAMES: Please give me the names of the persons who usually live in your household or who are staying with you now. (RECORD NAME OF HEAD OF HOUSEHOLD FIRST)
2) Does (NAME) usually live here?
NO 2
3) Did (NAME) usually sleep here last night?
NO 2
4) SEX: Is (NAME) male or female?
FEMALE 2
CURRENTLY 2
NEVER MARRIED 3
7) ELIGIBILITY: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
TICK HERE IF CONTINUATION SHEET USED____
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET____
Just to make sure that I have this right:
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 usually live here but are not members of your family, such as domestic servants, lodgers or friends whom we have not listed?
NO
3) Are there any guests or visitors who are temporarily staying with the family and who spent last night here that are not listed?
NO