IDENTIFICATION

STATE NAME ___________________ ___
LOCAL GOVT. AREA ________________ ___
LOCALITY NAME ___________________ ___
ENUMERATION AREA _______________ ___

URBAN/RURAL ___

CLUSTER NUMBER __

BUILDING NAME/NUMBER __

HOUSEHOLD NUMBER __

MEN'S INTERVIEW__

LARGE TOWN/MEDIUM TOWN/SMALL TOWN/VILLAGE __

INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ____
RESULT _____

TOTAL NO. OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN__

TOTAL ELIGIBLE MEN __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED?

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY___

HOUSEHOLD SCHEDULE

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. (1) (01-23)

(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?*
SEE CODES BELOW.

(4) SEX: Is (NAME) male or female?

(5) RESIDENCE: Does (NAME) usually live here? (5)

(6) RESIDENCE: Did (NAME) stay here last night?

(7) AGE: How old is (NAME) as of last birthday?

(8) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

(8A) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

(9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.

(10) Is (NAME)'s natural mother alive?

(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 PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

(12) Is (NAME)'s natural father alive?

(13) (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 PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

EDUCATION IF AGE 5 YEARS OR OLDER

(13A) (IF AGE 5 YEARS OR OLDER) Can (NAME) read and write in any language with understanding?

(14) Has (NAME) ever attended school?

(15) What is the highest level of school (NAME) has attended?***
What is the highest class/year (NAME) completed at that level?***
FOR 'HIGHER', TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL.

IF AGE 5-24 YEARS:

(16) Is (NAME) currently attending school?

(17) During the current school year, did (NAME) attend school at any time?

(18) During the current school year, what level and class/year [is/was] (NAME) attending? ***
FOR 'HIGHER', TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL.

(19) During the previous school year, did (NAME) attend school at any time?

(20) During that school year, what level and class/year did (NAME) attend? ***
FOR 'HIGHER', TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL.

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?

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?

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

21. What is the main source of drinking water for members of your household?

22. How long does it take you to go there, get water, and come back?

23. What kind of toilet facilities does your household have?

24. Do you share these facilities with other households?

25. Does your household have:

Electricity?
A radio?
A television?
A telephone/Cellular phone?
A refrigerator?
A gas cooker?
An electric iron?
An electric fan?

26. What does your household mainly use for cooking?
PROBE TO DETERMINE EXACT TYPE.

26A. How many rooms in total are in your household, including rooms for sleeping and all other rooms?

26B. How many rooms are used for sleeping in your household?

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

28. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?
A donkey or horse or camel?
A canoe or boat or ship?

29A. Does your household own any mosquito nets that can be used to protect against mosquitoes while sleeping? I am talking about nets people sleep under.

29B. How many mosquito nets does your household own?

30A. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. ASK OR RECORD APPROPRIATE ANSWER FOR THE FOLLOWING QUESTIONS. IF UNABLE TO OBSERVE THE NETS, CIRCLE APPROPRIATE CODE AND ASK QUESTIONS.

30B. How long ago did your household obtain the mosquito net?

30C. OBSERVE OR ASK THE BRAND OF MOSQUITO NET(S) IN THE HOUSEHOLD.

30D. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?

30E. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

30F. Who slept under this mosquito net last night?
RECORD RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

30G. Does your household do anything else to protect themselves against mosquito?

30H. What does your household do?

33. Where do you usually wash your hands?

34. Where you wash your hands, do you have the following:

Water/tap?
Soap, ash or other cleansing agent?
Basin?

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).

There will be an education survey done at a later point in time. Your household may or may not be asked to participate in the survey. If your household is included in the survey someone will return to your house and ask additional questions about education.

HEIGHT AND WEIGHT

CHECK COLUMNS (8) AND (9): RECORD LINE NUMBER, NAME AND AGE OF WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

WOMEN 15-49/CHILDREN UNDER AGE 6

(36) LINE NO. FROM COL.(8)

(37) NAME FROM COL.(2)

(38) AGE FROM COL.(7)

(39) What is (NAME)'s date of birth?*
*FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49/ CHILDREN BORN IN 1998 OR LATER

(40) WEIGHT (KILOGRAMS)

(41) HEIGHT (CENTIMETRES)

(42) MEASURED LYING DOWN OR STANDING UP

(43) RESULT

TICK HERE IF CONTINUATION SHEET USED __