IDENTIFICATION
DISTRICT NAME AND NUMBER
VILLAGE/MUNICIPALITY NAME AND NUMBER
WARD NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
CITY/TOWN/COUNTRYSIDE
TOWN 2
COUNTRYSIDE 3
NAME OF HOUSEHOLD
NAME OF RESPONDENT
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
TOTAL NUMBER OF VISITS _________________
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 IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NUMBER OF RESPONDENT IN HOUSEHOLD SCHEDULE
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 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?
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
F 2
EDUCATION IF AGED 6 YEARS OR OLDER:
8. Has (NAME) ever been to school?
NO 2
9. IF ATTENDED SCHOOL: What is the highest grade** completed by (NAME)?
IF AGE LESS THAN 25 YEARS:
10. Is (NAME) still in school?
NO 2
MARITAL STATUS IF AGE 10 YEARS OR OLDER:
11. Has (NAME) ever been married?
NO 2
IF EVER-MARRIED AND AGE LESS THAN 20:
12. Has (NAME) started living with his/her spouse?
NO 2
ELIGIBILITY:
13. CIRCLE LINE NUMBER OF ALL ELIGIBLE WOMEN: IF FEMALE AGE 15-49 AND YES TO COL (11) AND COL (12) IS YES OR NOT ASKED.
14. What is the main source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC WELL 22
PUBLIC 32
RIVER/STREAM 42
POND/LAKE 43
STONE TAP (DHARA) 44
15. How long does it take to get there, get water, and come back?
ON PREMISES 996
16. What kind of toilet facility does your household have?
VENILATED IMPROVED PIT 22
NO FACILITY/BUSH/FIELD 41
OTHER (SPECIFY) 96 ___
NO 2
NO 2
NO 2
NO 2
NO 2
18. How many rooms in your household are used for sleeping?
19. What is the religion of the head of the household?
BUDDHIST 02
MUSLIM 03
CHRISTIAN 04
OTHER (SPECIFY) ___ 96
20. What is the caste of the head of the household?
WRITE CASTE IN SPACE PROVIDED. CODE WILL BE ENTERED BY FIELD EDITOR
21. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION
CEMENT 32
LINOLEUM 33
MARBLE CHIPS 34
CARPET 35
22. What type of salt is usually used for cooking in your household?
ASK TO SEE SALT PACKAGE.
NOT IODIZED 12
LOOSE SALT 22
23. TEST THE SALT AND WRITE THE RESULT.