9 September 2000
IDENTIFICATION
NAME AND CODE OF REGION _________
NAME OF VILLAGE/TOWN/CITY __________
DHS CLUSTER NUMBER________
HOUSEHOLD NUMBER __________
NAME OF HOUSEHOLD HEAD _________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY
NO 2
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
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
NEXT VISIT:
DATE ____
TIME ____
FINAL VISIT:
DAY __
MONTH __
YEAR 20__
INT. CODE ___
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
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
TOTAL PERSONS IN HOUSEHOLD ____
LINE NO. OF RESP. TO HOUSEHOLD QUEST. ____
FIELD EDITOR
NAME ____
DATE ____
OFFICE EDITOR ____
KEYED BY ____
ERONGO 02
HARDAP 03
KARAS 04
KHOMAS 05
KUNENE 06
OHANGWENA 07
KAVANGO 08
OMAHEKE 09
OMUSATI 10
OSHANA 11
OSHIKOTO 12
OTJOZONDJUPA 13
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?
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?
F 2
5) RESIDENCE: Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.
9A) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
10) Is (NAME)'s natural mother alive?
NO 2
DK 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
DK 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 3 YEARS OR OLDER : Has (NAME) ever attended school or pre-school?
NO 2 (GO TO NEXT LINE)
15) IF AGE 3 YEARS OR OLDER: What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
GRADE___
16) IF AGE 3-24 YEARS : Is (NAME) currently attending school (or pre-school)?
NO 2
17) IF AGE 3-24 YEARS: During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 19)
18) IF AGE 3-24 YEARS: During the current school year, what level and grade [is/was] (NAME) attending?
GRADE___
19) IF AGE 3-24 YEARS: During the previous school year, did (NAME) attend school at any time?
NO 2 (NEXT LINE)
20) IF AGE 3-24 YEARS: During that school year, what level and grade did (NAME) attend?
GRADE____
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.
CODES FOR Qs. 15, 18 AND 20
EDUCATION LEVEL:
PRIMARY 1
SECONDARY 2
HIGHER/UNIV. 3
DON'T KNOW 8
EDUCATION GRADE:
DON'T KNOW 98
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) During the rainy season, what is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
UNPROTECTED SPRING 22
PROTECTED DUG WELL 32
RIVER/STREAM/POND/LAKE 42
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) ____ 96
22) How long does it take you to go there, get water, and come back (during the rainy season)?
ON PREMISES 996
23) During the dry season, what is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 25)
PUBLIC TAP 13
UNPROTECTED SPRING 22
PROTECTED DUG WELL 32
RIVER/STREAM/POND/LAKE 42
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 25)
24) How long does it take you to go there, get water, and come back?
ON PREMISES 996
25) What kind of toilet facility do most members of your household use?
POUR FLUSH LATRINE (WATER SEAL) 12
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
BUCKET 23
NO FACILITY/BUSH/FIELD 31 (GO TO 27)
OTHER (SPECIFY) _____ 96
26) Do you share this toilet with other households?
NO 2
Electricity?
A radio?
A television?
A telephone?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
28) What type of fuel does your household mainly use for cooking?
GAS 2
PARAFFIN/KEROSENE 3
CHARCOAL FROM WOOD 4
FIREWOOD 5
OTHER (SPECIFY) ____ 6
29) What type of energy does your household mainly use for lighting?
GAS 2
PARAFFIN/KEROSENE 3
CANDLE 4
OTHER (SPECIFY) ____ 6
30) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
WOOD PLANKS/PALM/BAMBOO 21
VINYL/LINOLEUM/CERAMIC TILES 31
CEMENT/CONCRETE 32
CARPET 33
OTHER (SPECIFY)____ 96
31) Does any member of your household own:
A donkey cart or a horse?
A bicycle?
A motorcycle or motor scooter?
A car or bakkie or other motor vehicle?
NO 2
NO 2
NO 2
NO 2
32) How many rooms does this household have for sleeping?
DO NOT INCLUDE BATHROOMS OR CLOSETS.
33) Does your household have any bednets that can be used while sleeping?
NO 2
34) May I see a sample of the salt used for cooking last time?
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).
BELOW 15 PPM 2
ABOVE 15 PPM (STRONG COLOR) 3
NO SALT AT HOME/NOT TESTED 4 (GO TO 37)
UNCOVERED GRANULAR SALT 2
BLOCK SALT 3
OTHER 6
36) What is the source of this salt: was it bought in a shop or from an open market or does it come from a salt pan?
OPEN MARKET 2
SALT PAN 3
OTHER 6
DOES NOT KNOW 8
37) What is the name of the nearest government health facility that provides health services to this community?
FOR OFFICE USE _____
GPS ______
DOES NOT KNOW 998 (GO TO 41)
38) How do you get from here to (HEALTH FACILITY NAME)?
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
OTHER (SPECIFY) ____ 6
NO.
QUESTIONS AND FILTERS
CODING CATEGORIES
GO
39) How long does it take you to get from here to (HEALTH FACILITY NAME)?
(RECORD IN MINUTES IF LESS THAN 2 HOURS AND IN HOURS IF 2 HOURS OR MORE)
HOURS ____ 2
40) CHECK 37: IS THE NEAREST FACILITY A HOSPITAL?
YES, A HOSPITAL (GO TO 44)
41) What is the name of the nearest government hospital that provides health services to this community?
FOR OFFICE USE ____
GPS ____
DOES NOT KNOW 998 (GO TO 44)
42) How do you get from here to (NAME OF HOSPITAL)?
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
OTHER (SPECIFY) ____ 6
43) How long does it take you to get from here to (NAME OF HOSPITAL)?
(RECORD IN MINUTES IF LESS THAN 2 HOURS AND IN HOURS IF 2 HOURS OR MORE)
HOURS ____ 2
44) In the last 12 months, has anyone in this household stayed overnight in a hospital or other health facility other than to deliver a baby?
NO 2 (GO TO 49)
DOES NOT KNOW 8 (GO TO 49)
45) How many days did that person stay in hospital?
IF MORE THAN ONE PERSON, ASK ABOUT THE MOST RECENT.
46) What type of health facility did he or she stay in?
GOVERNMENT HEALTH CENTRE 12
GOVERNMENT CLINC 13
PRIVATE HOSPITAL 21
TRADITIONAL HEALING CENTRE 35
OTHER (SPECIFY) ____ 96
47) Did you or a family member pay for this stay in the hospital, either in cash or in goods or gifts?
GOODS/SERVICES 2 (GO TO 49)
PAID NOTHING/FREE 3 (GO TO 49)
DOES NOT KNOW 8 (GO TO 49)
48) Altogether how much was paid for the hospital care: including examinations, laboratory tests, medicines, meals, and staff fees?
49) In the last 2 weeks, has anyone in this household visited a health facility or consulted a doctor or nurse or traditional healer for any reason?
INCLUDE VISITS FOR CHILDREN.
NO 2 (GO TO 52)
DOES NOT KNOW 8 (GO TO 52)
50) Did you or another family member pay for this visit or consultation, either in cash or in goods or gifts?
GOODS/SERVICES 2 (GO TO 52)
PAID NOTHING/FREE 3 (GO TO 52)
DOES NOT KNOW 8 (GO TO 52)
51) Altogether how much was paid for this health care: including examinations, laboratory tests, medicines, and staff fees?
CHECK COLUMN (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN UNDER AGE 6.
CHILDREN UNDER AGE 6:
52) LINE NO. FROM COL. (9)
55) What is (NAME)'s date of birth?
MON. ____
YEAR ____
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1995 OR LATER:
56) WEIGHT (KILOGRAMS)
58) MEASURED LYING DOWN OR STANDING UP
STANDING 2
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY)______ 6
TICK HERE IF CONTINUATION SHEET USED __