REPUBLIC OF LIBERIA
MINISTRY OF PLANNING AND ECONOMIC AFFAIRS
COUNTY_____
DISTRICT____
TOWN/VILLAGE_____
EA NUMBER____
CLUSTER NUMBER_____
STRUCTURE NUMBER____
HOUSEHOLD NUMBER____
NAME OF HOUSEHOLD HEAD_____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
NO COMPETENT RESPONDENT AT HOME 2
DEFERRED 3
REFUSED 4
DWELLING VACANT 5
ADDRESS NOT A DWELLING 6
HOUSEHOLD NOT FOUND OR NONEXISTENT 7
OTHER (SPECIFY) 8
FIELD EDITED BY:
NAME____
DATE_____
OFFICE EDITED BY:
NAME_____
DATE_____
KEYED BY:
NAME____
DATE_____
I would like some information about the people who usually live in your household or are staying with you now.
1) LINE NUMBER
2) NAMES OF USUAL RESIDENTS AND VISITORS: Please give me the names of all the people who usually live in your household and any visitors.
3) RESIDENCE: Does (NAME) usually live here?
NO 2
4) RESIDENCE: Did (NAME) sleep here last night?
NO 2
FEMALE 2
7) Does this child's mother usually live in this household?
NO 2
8) What kind of work does this person do?
EMPLOYEE 2
SELF-EMPLOYED 3
UNEMPLOYED 4
HOUSEWIFE 5
STUDENT 6
10) PUT A CHECK FOR ALL WOMEN 15-49 WHO SLEPT HERE LAST NIGHT
IF CONTINUATION SHEET USED, CHECK HERE:_____
1. Is there anybody else, such as babies or servants or lodgers, that I have not listed?
NO 2
2. Do you have any visitors staying with you that I did not list?
NO 2