FARITANY (REGION) NAME ___________________
FIVONDRONAMPOKOTANY (DISTRICT) NAME _______________
NAME OF HOUSEHOLD HEAD ____________________
CLUSTER NUMBER __________
HOUSEHOLD UNIT NUMBER __________
RURAL 2
FARITANY AND ANTSIRABE ADMINISTRATIVE CENTER 2
FIVONDRONAMPOKONTANY ADMINISTRATIVE CENTER 3
FIRAISAMPOKONTANY ADMINISTRATIVE CENTER 4
RURAL 5
DATE ____
INTERVIEWER'S NAME ____
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______
FINAL VISIT
DAY _____
MONTH _____
YEAR ____
NAME __________
RESULT __________
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
FIELD EDITOR
NAME _______
DATE _______
SUPERVISOR
NAME _______
DATE _______
OFFICE EDITOR ____
KEYED BY ____
We would like some information about people who usually live in your household or are staying with you now.
WRITE THE NAME OF THE RESPONDENT HERE _________.
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.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 HUSBAND OR WIFE
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 NOT RELATED
98 DON'T KNOW
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. RESIDENCE: Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
FEMALE 2
8. Has (NAME) ever attended school?
NO 2
9. What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
MIDDLE SCHOOL 06, 07, 08, 09
HIGH SCHOOL 10, 11, 12
POST-SECONDARY 13, 14, 15, 16, 17, 18, 19, 20
EDUCATION IF LESS THAN 25 YEARS:
10. Is (NAME) still attending school?
NO 2
SURVIVORSHIP AND RESIDENCE OF PARENTS IF AGE UNDER 15 YEARS:
11. Is (NAME)'s natural mother alive?
NO 2
DK 8
12. Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
13. Is (NAME)'s natural father alive?
NO 2
DK 8
14. Does (NAME)'s natural father live in this household?
IF YES: What is his name?
ELIGIBILITY:
15. CIRCLE LINE NUMBER OF ALL WOMEN ELIGIBLE FOR THE INDIVIDUAL INTERVIEW.
CHECK HERE IF ANOTHER SHEET IS USED. _____
TOTAL NUMBER OF ELIGIBLE WOMEN: _____
Just to make sure that I have a complete list:
1) Are there any other persons such as small children or infants that we have not listed?
NO
2) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends, who usually live here?
NO
3) Are there any other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
16. Where does the water come from that your household uses to wash hands and dishes?
PUBLIC TAP/STANDPIPE 12
WELL OUTSIDE THE DWELLING/YARD/PLOT 22
RIVER 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18)
OTHER (SPECIFY) _____ 71
17. How long does it take to go there, get water, and come back?
ON SITE 996
18. For drinking water, does your household use water from the same source?
NO 2
19. Where does your household's drinking water come from?
PUBLIC TAP/STANDPIPE 12
WELL OUTSIDE THE DWELLING/YARD/PLOT 22
RIVER 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 71
20. What kind of toilet facility is in your household?
SHARED FLUSH TOILET 12
RUDIMENTARY PIT LATRINE 22
VENTILATED PIT LATRINE 23
OTHER (SPECIFY) ____ 41
NO 2
NO 2
NO 2
NO 2
NO 2
22. In your household, how many rooms do you use for sleeping?
23. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
24. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2