HOUSEHOLD SCHEDULE
PROVINCE OR PREFECTURE
CIRCLE
MUNICIPALITY:
RURAL COMMUNE
CENTER
PRIMARY UNIT NUMBER
SECONDARY UNIT NUMBER
LEVEL
LARGE CITY 2
CITY 3
COUNTRYSIDE 4
HOUSEHOLD NUMBER ____
HOUSEHOLD ADDRESS _____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME _____
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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: (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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
TOTAL NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
SUPERVISOR
NAME
FIELD EDITOR
NAME
OFFICE EDITOR
KEYED BY
Now we would like information about the people who usually live in your household or who are staying with you now.
1) LINE NUMBER _____
2) FIRST AND LAST NAME ____
Please give me the name of the people 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 THE HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of household?
WIFE OR HUSBAND 2
SON OR DAUGHTER 3
SON-IN-LAW OR DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
BROTHER OR SISTER 8
OTHER RELATIVE 9
ADOPTED CHILD/FOSTER CHILD 10
NOT RELATED 11
DON'T KNOW 98
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGE 7 YEARS OR OLDER
8) Has (NAME) ever been to school?
NO 2
9) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?**
EDUCATION LEVEL
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE
DON'T KNOW 98
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 WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
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
16) 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
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18
17) How long does it take to go there, get water, and come back?
ON PREMISES 996
18) Does your household get drinking water from this same source?
NO 2
19) What is the main source of drinking water for your household?
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
20) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31
OTHER (SPECIFY) 41
NO 2
NO 2
NO 2
NO 2
NO 2
22) How many rooms in your household are used for sleeping?
23) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION
DUNG 12
PALMS/BAMBOO 22
VINYL OR ASPHALT 32
TILES 33
CEMENT 34
CARPET 35
24) Does any member of your household own:
NO 2
NO 2
NO 2
25) What is the roof of your dwelling made of?
PLANKS/REEDS/BRANCHES WITH EARTH 02
PLANKS/REEDS/BRANCHES WITH NO EARTH 03
SHEET METAL/TIN 04
PLANKS/TILES 05
OTHER (SPECIFY) 06
26) What is the occupation status of the dwelling?
RENTER 2
FREE USAGE 3
OTHER (SPECIFY) 4