NAME OF HOUSEHOLD HEAD_____
PLACE NAME_____
PROVINCE_____
URBAN/RURAL:
RURAL 2
CLUSTER NUMBER _____
HOUSEHOLD NUMBER______
SELECTED HOUSEHOLD FOR MEN'S QUESTIONNAIRE?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_______
INTERVIEWER'S NAME______
ENTIRE HOUSEHOLD ABSENT 2
REFUSED 3
DWELLING VACANT 4
DWELLING DESTROYED 5
DWELLING NOT FOUND 6
OTHER (SPECIFY) _____ 7
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR 2003
CODE _____
RESULT_____
TOTAL IN HOUSEHOLD_____
TOTAL NUMBER OF WOMEN 15-49_____
TOTAL NUMBER OF MEN 15-64_____
LINE NUMBER OF RESPONDENT______
SUPERVISOR
NAME_____
DATE_____
FIELD EDITOR
NAME_____
DATE_____
OFFICE EDITOR_____
KEYED BY_____
RE-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 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
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER CHILD
12 NOT RELATED
98 DOESN'T KNOW
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
ELIGIBILITY:
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
ELIGIBILITY:
8A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-64
ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
9A. BIRTH PLACE: Where was (NAME) born?
02 CABO DELGADO
03 NAMPULA
04 ZAMBÉZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW
PLACE OF PREVIOUS RESIDENCE. ONLY FOR PEOPLE AGE 1 OR MORE:
9B. Where did (NAME) reside during (DATE OF THE INTERVIEW MONTH____ YEAR 2002)?
02 CABO DELGADO
03 NAMPULA
04 ZAMBÉZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW
PLACE OF PREVIOUS RESIDENCE. ONLY FOR PEOPLE AGE 5 OR OLDER:
9C. Where did (NAME) reside 5 years ago?
02 CABO DELGADO
03 NAMPULA
04 ZAMBÉZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS:
10. Is (NAME)'s natural mother alive?
NO 2
DOESN'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
RECORD '00' IF NATURAL MOTHER IS NOT PART OF THE LIST OF THE HOUSEHOLD MEMBERS.
12. Is (NAME)'s natural father alive?
NO 2
DOESN'T KNOW 8
12A. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name? RECORD FATHER'S LINE NUMBER
RECORD '00' IF NATURAL FATHER IS NOT PART OF THE LIST OF THE HOUSEHOLD MEMBERS.
EDUCATION. IF AGE 5 YEARS OR OLDER:
13. Does (NAME) know how to read and write?
NO 2
DOESN'T KNOW 8
14. 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 grade (NAME) completed at that level?
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
98 DOESN'T KNOW
16. Is (NAME) still 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 grade [is/was] (NAME) attending?
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
19. During the previous school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT LINE)
20. During the previous school year, what level and grade did (NAME) attend?
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
CHECK 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 were 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
MODULE OF CARDIOVASCULAR ASPECTS
20A. LINE NUMBER:
20C. Have you ever smoked or consumed any type of tobacco?
NO 2 (GO TO 20H)
DOESN'T KNOW 8 (GO TO 20H)
20D. Do you currently smoke or consume any type of tobacco?
NO 2 (GO TO 20H)
DOESN'T KNOW 8 (GO TO 20H)
20E. What type of tobacco do you usually consume?
PIPE 2 (GO TO 20G)
HAND-ROLLED CIGARETTES 3 (GO TO 20G)
CIGARS 4 (GO TO 20G)
SNUFF 5 (GO TO 20G)
OTHER (SPECIFY) ___ 6 (GO TO 20G)
20F. During the last 24 hours, how many cigarettes have you smoked?
NONE 00
DOESN'T KNOW 98
20G. Approximately, how old were you when you started to smoke/consume tobacco regularly?
DOESN'T KNOW 98
20H. Have you ever consumed an alcoholic beverage?
NO 2 (GO TO 20L)
DOESN'T KNOW 8 (GO TO 20L)
20I. Currently, are you consuming alcohol?
NO 2 (GO TO 20L)
DOESN'T KNOW 8 (GO TO 20L)
20J. What type of alcoholic beverages do you usually consume?
WINE 2
DISTILLED LIQUOR (GIN, WHISKY, VODKA, ETC.) 3
TRADITIONAL ALCOHOLIC BEVERAGES 4
OTHER (SPECIFY) _____ 6
20K. How many days a week do you consume alcohol?
NONE 0
DOESN'T KNOW 8
20L. How many days a week do you consume fruit?
NONE 0
20M. How many days a week do you consume vegetables?
NONE 0
TRAUMATISM CAN BE CAUSED BY: A TRANSIT/CAR ACCIDENT, A FALL, BURN INJURY, PHYSICAL AGGRESSION, SEXUAL ABUSE, POISONING, CUT OR STAB, INTOXICATION, GUN INJURY, HANGING/STRANGLING.
29. During the last 30 days, has any member of the household suffered from traumatism?
NO 2 (GO TO 41)
DOESN'T KNOW 8 (GO TO 41)
30. RECORD THE NAME AND LINE NUMBER OF HOUSEHOLD MEMBER:
31. During the last 30 days, how many times has (NAME) experienced traumatism?
TWO TIMES 2
THREE OR MORE TIMES 3
DOESN'T KNOW 8
32. During the last 30 days, when was the last time (NAME) suffered a traumatic event?
HOW LONG AGO DID (NAME) SUFFER A TRAUMATIC EVENT?
ONE TO TWO WEEKS 2
THREE WEEKS OR MORE 3
33. What was the cause of (NAME)'s traumatism? Is there another cause?
RECORD ALL ANSWERS.
FALL B
STRIKE/PHYSICAL AGGRESSION/ATTACK C
CUT/STAB D
HANGING/STRANGLING E
GUNSHOT INJURY F
POISONING/INTOXICATION G
SEXUAL ABUSE H
BITE I
BURN J
LAND MINE K
OTHER (SPECIFY) ____X
34. Was (NAME)'s traumatism accidental or intentional?
IF INTENTIONAL, ASK: Suicide or homicide?
INTENTIONAL (SUICIDE) 2
INTENTIONAL (HOMICIDE) 3
LEGAL INTERVENTION 4
OTHER (SPECIFY) ___ 6
DOESN'T KNOW 8
35. What is the relationship between (NAME) and the person who caused the traumatic experience?
PARENTS (STEP-FATHER OR STEP-MOTHER) 02
OTHER RELATIVE 03
KNOWN PERSON 04
STRANGER 05
LEGAL AUTHORITY 06
HIM/HERSELF 07
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98
36. Where did (NAME)'s traumatic experience occur?
SCHOOL/DAYCARE/EDUCATIONAL INSTITUTION 02
WORK 03
PUBLIC STREET 04
PUBLIC SPACE (CHURCH, MARKET, ETC.) 05
BAR/STAND/RESTAURANT 06
SEA/RIVER/POND 07
PLANTATION 08
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98
37. What was (NAME) doing, when the traumatic experience happened?
TRAVELING 02
PLAYING SPORTS 03
DURING LEISURE TIME 04
WHILE STUDYING 05
SLEEPING/EATING/RESTING 06
WHILE DOING NOTHING IN PARTICULAR 07
OTHER (SPECIFY) ____ 96
DOESN'T KNOW 98
38. Has (NAME) been treated at a health facility for trauma?
NO 2
DOESN'T KNOW 8
39. Is (NAME) handicapped/disabled because of his/her trauma?
NO 2 (GO TO NEXT PERSON OR QUESTION 41)
DOESN'T KNOW 8 (GO TO NEXT PERSON OR QUESTION 41)
39A. RECORD THE NAME AND LINE NUMBER OF HOUSEHOLD MEMBER
40. What type of disability does (NAME) have?
LIMPS 02
LOSS OF HEARING 03
LOSS OF SIGHT 04
INCAPACITY TO REMEMBER 05
INCAPACITY TO CHEW 06
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98
41. During the last 12 months, have any of the household members died due to traumatism?
NO 2 (GO TO 48)
42. How many members of the household have died due to traumatism?
SEX AND AGE OF DEAD PERSONS DUE TO TRAUMATISM:
42A. SEX:
FEMALE 2
42B. AGE:
43. What was (NAME)'s death cause?
Any other accident?
RECORD ALL ANSWERS.
FALL B
STROKE/PHYSICAL AGGRESSION/ATTACK C
CUT/STAB D
HANGING/STRANGLING E
GUN INJURY F
POISONING/INTOXICATION G
SEXUAL ABUSE H
BITE I
BURN J
LAND MINE K
OTHER (SPECIFY) _____ X
44. Was (NAME)'s traumatism accidental or intentional?
IF INTENTIONAL, ASK: Suicide or homicide?
INTENTIONAL (SUICIDE) 2
INTENTIONAL (HOMICIDE) 3
LEGAL INTERVENTION 4
OTHER (SPECIFY) _____ 6
DOESN'T KNOW 8
45. Where did (NAME)'s traumatic experience occur?
SCHOOL/DAYCARE/EDUCATIONAL INSTITUTION 02
WORK 03
PUBLIC STREET 04
PUBLIC SPACE (CHURCH, MARKET, ETC.) 05
BAR/STAND/RESTAURANT 06
SEA/RIVER/POND 07
PLANTATION 08
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98
46. How long after the traumatic experience did the person die?
BETWEEN 1 AND 24 HOURS 2
DURING THE FIRST WEEK OF THE TRAUMATIC EXPERIENCE 3
MORE THAN 1 WEEK AFTER THE TRAUMATIC EXPERIENCE 4
DOESN'T KNOW 8
47. Was (NAME) treated at a health facility before dying?
NO 2
DOESN'T KNOW 8
48. During the last 12 months, has anyone else died in this household besides those that were declared dead due to a traumatic experience?
NO 2 (GO TO 51)
49. Specify sex, age and cause of death:
FEMALE 2
51. What is the principle source of drinking water for members of your household?
IN NEIGHBOR'S RESIDENCE/YARD 12
PUBLIC TAP 13
WELL IN NEIGHBOR'S YARD/PLOT 22
PROTECTED PUBLIC WELL 23
OPEN PUBLIC WELL 24
OTHER (SPECIFY) _____ 96
52. How long does it take to get there, get water, and come back?
ON PREMISES 996
53. What kind of toilet facility does your household have?
TOILET WITHOUT FLUSHING SYSTEM 02
LATRINE 03
NO FACILITY/BUSH 04 (GO TO 54)
OTHER (SPECIFY) ____ 96
53A. Is the bathroom used by only the members of your household or other people?
OTHER FAMILIES 2
A. Electricity?
B. A radio?
C. A television?
D. A telephone (land line)?
E. A refrigerator/freezer?
NO 2
NO 2
NO 2
NO 2
NO 2
55. How many rooms in your household are used for sleeping?
56. Does your house have windows?
NO 2
56A. What type of fuel does your household mainly use for cooking?
NATURAL GAS 02
PETROLEUM/PARAFFIN/KEROSENE 03
COAL 04
CHARCOAL 05
FIREWOOD 06
ANIMAL DUNG 07
OTHER (SPECIFY) _____96
57. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.
ADOBE 22
CERAMIC TILES 32
CEMENT 33
58. Does any member of your household own:
A. A bicycle?
B. A motorcycle?
C. A car?
NO 2
NO 2
NO 2
58A. What type of salt do you use to cook with?
(ASK TO SEE SALT TO TEST)
SALT (IODIZED) 2
SALT (NON IODIZED) 3
OTHER (SPECIFY) _____ 6
WEIGHT AND HEIGHT OF CHILDREN AND WOMEN
RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
60. WOMEN AGE 15-49: LINE NUMBER FROM COLUMN 8:
61. WOMEN AGE 15-49: NAME FROM COLUMN 2:
62. WOMEN AGE 15-49: AGE FROM COLUMN 7:
63. WOMEN AGE 15-49: What is (NAME)'s date of birth?
WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49:
64. WEIGHT (KILOGRAMS):
NOT PRESENT 2
REFUSED 3
OTHER 6
60. LINE NUMBER FROM COLUMN 8:
63. What is (NAME)'s date of birth? ______
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER:
64. WEIGHT (KILOGRAMS):
66. MEASURED LYING DOWN OR STANDING UP:
STANDING UP 2
NOT PRESENT 2
REFUSED 3
OTHER 6
68. Did (NAME) sleep under a hammock/bed-net last night?
NO 2
TICK HERE IF CONTINUATION SHEET USED ______
TO BE FILLED OUT AFTER COMPLETING INTERVIEW.
COMMENTS ABOUT RESPONDENT _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS _____
SUPERVISOR'S OBSERVATIONS_____
NAME _____
DATE _____
EDITOR'S OBSERVATIONS_____
NAME _____
DATE _____