HOUSEHOLD QUESTIONNAIRE 1997
PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION (FARITANY) _____
RURAL 2
CITY/ADMINISTRATIVE CENTER ____
FARITANY AND ANTSIRABE ADMINISTRATIVE CENTER 2
FIVONDRONAMPOKONTANY ADMINISTRATIVE CENTER 3
FIRAISAMPOKONTANY ADMINISTRATIVE CENTER 4
RURAL 5
DATE ___
INTERVIEWER'S NAME ____
RESULT____
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) ____________________
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR 1997
NAME _____
RESULT _____
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____
SUPERVISOR
NAME ________
DATE _______
FIELD EDITOR
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.
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?
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 NIECE/NEPHEW BY BLOOD
10 NIECE/NEPHEW BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NOT RELATED
14 DOESN'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
EDUCATION. IF AGE 6 YEARS OR OLDER:
8. Has (NAME) ever attended 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 2
POST-SECONDARY 3
DOESN'T KNOW 8
98 DOESN'T KNOW
EDUCATION. IF LESS THAN 25 YEARS:
10. IF ATTENDED SCHOOL: Is (NAME) still attending school?
NO 2
SURVIVORSHIP AND RESIDENCE OF PARENTS FOR PEOPLE UNDER 15 YEARS:
11. Is (NAME)'s natural mother alive?
NO 2
DOESN'T KNOW 8
12. Does (NAME)'s natural mother live in this household? IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
RECORD '00' IF THE MOTHER IS NOT A MEMBER OF THE HOUSEHOLD.
13. Is (NAME)'s natural father alive?
NO 2
DOESN'T KNOW 8
14. Does (NAME)'s natural father live in this household? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
RECORD '00' IF THE MOTHER IS NOT A MEMBER OF THE HOUSEHOLD.
ELIGIBILITY:
15. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
CHECK HERE IF ANOTHER SHEET IS 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) 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. What is the main source of drinking water for members of your household?
PIPED TO EXTERIOR 12
PUBLIC TAP/STANDPIPE 13
NOT EQUIPPED WITH PUMP 22 (GO TO 18)
DRAIN WELL 23 (GO TO 18)
NOT EQUIPPED WITH PUMP 25
DRAIN WELL 26
RIVER 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18)
OTHER (SPECIFY) _____________ 96
17. How long does it take to go there, get water, and come back?
ON SITE 996
18. What kind of toilet facility is in your household?
VENTILATED PIT LATRINE 22
RUDIMENTARY PIT LATRINE 23
NO TOILET/OUTSIDE 31 (GO TO 19)
OTHER (SPECIFY) ________ 96 (GO TO 19)
18A. Is the toilet facility only used by your household or do you share it with other households?
SHARED USE 2
NO 2
NO 2
NO 2
NO 2
NO 2
20. In your household, how many rooms do you use for sleeping?
21. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
22. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
23. How many people in this household smoke?
NONE 00
24. Can you show me the salt that you used to cook the main meal yesterday or last night?
FINE SALT IN PACKET 01
LOOSE FINE SALT 02
COARSE SALT IN PACKET 03
LOOSE COARSE SALT 04
OTHER (SPECIFY) _____ 96
REFUSES TO SHOW 05
NON-IODIZED SALT (WHITE) 2
SALT NOT TESTED 3