VILLAGE/PLACE NAME__________
NAME OF HOUSEHOLD HEAD _________
MDHS CLUSTER NUMBER __________
HOUSEHOLD NUMBER ___________
RURAL 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME _____
RESULT* ______
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME 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
FINAL VISIT
DAY ___
MONTH____
YEAR ____
NAME ___
RESULT___
TOTAL NUMBER OF VISITS ____
TOTAL PERSONS IN HOUSEHOLD____
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE____
TUMBUKA 2
OTHER (SPECIFY) ____ 3
SUPERVISOR
NAME _____
DATE _____
FIELD EDITOR
NAME _____
DATE _____
OFFICE EDITOR_______
KEYED BY_______
Now we would like some information about the people who usually live in your household or who are staying with you now.
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?*
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98
4) SEX: Is (NAME) male or female?
FEMALE 2
5) RESIDENCE: Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
8) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
8a) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.
9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**:
10) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
12) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
14) IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
15) What is the highest level of school (NAME) has attended?***
What is the highest year (NAME) completed at that level? ***
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
16) IF AGE 5-24 YEARS: Is (NAME) currently attending school?
NO 2
17) During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 19)
18) During the current school year, what level and class [is/was] (NAME) attending? ***
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
19) During the previous school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT LINE)
20) During that school year, what level and year did (NAME) attend? ***
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
**Q. 10 THROUGH Q. 13
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q. 11 AND Q. 13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.
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 may 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 slept here last night, who have not been listed?
NO
21. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 23)
COMMUNITY STAND PIPE 13
PROTECTED WELL 31
BOREHOLE 41
RIVER/STREAM 52
POND/LAKE 53
DAM 54
TANKER TRUCK/BOWSER 71
BOTTLED WATER 81 (GO TO 23)
OTHER (SPECIFY) ____ 96
22. How long does it take you to go there, get water, and come back?
ON PREMISES 996
23. What kind of toilet facility does your household use?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) ____ 96
24. Do you share this facility with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
PARAFFIN 02
CHARCOAL 03
FIREWOOD 04
STRAW 05
OTHER (SPECIFY) ____ 96
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
BROKEN BRICKS 23
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
BRICK 35
28. Does any member of your household own:
NO 2
NO 2
NO 2
29. Does your household have any mosquito nets that can be used while sleeping?
IF YES ASK: How many?
NO 2 (GO TO 33)
30. How many mosquito nets are white in color?
NONE 0
33. Where do you usually wash your hands?
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)
34. ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.
NO 2
NO 2
NO 2
35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).
15-20 PPM 2
20-74 PPM 3
75 + PPM 4
Now I would like to ask you about any work children in this household may do.
36. LINE NO.
COPY LINE NUMBER OF CHILDREN AGES 5 - 14 YEARS FROM THE HOUSEHOLD LISTING
37. CHILD'S NAME
COPY THE NAMES OF CHILDREN AGES 5 - 14 YEARS FROM THE HOUSEHOLD LISTING
38. During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?
UNPAID 2
NO 3 (GO TO 40)
39. Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of the household?*
*IF MORE THAN ONE JOB, INCLUDE ALL HOURS AT ALL JOBS
40. During the past week, did (NAME) help with housekeeping chores such as cooking, shopping, cleaning, washing clothes, fetching water, or caring for children?
NO 2 (GO TO 42)
41. Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?
42. During the past week, did (NAME) do any other family work on the farm or in a business?
NO 2 (GO TO NEXT LINE)
43. Since last (DAY OF THE WEEK), about how many hours did he/she do this work?
CHECK COLUMNS (8) AND (9):
RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WOMEN 15-49/ CHILDREN UNDER AGE 6:
47) What is (NAME)'s date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]
MONTH ___
YEAR ___
WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49/CHILDREN BORN IN 1995 OR LATER:
50) MEASURED LYING DOWN OR STANDING UP
[FOR CHILDREN BORN IN 1995 OR LATER ONLY]
STANDING 2
NOT PRESENT 2
REFUSED 3
OTHER 6