PLACE NAME____
NAME OF HOUSEHOLD HEAD____
PREFECTURE (ADMINISTRATIVE CENTER)____
TOWN OR MUNICIPALITY____
SECTOR____
SUB-SECTOR___
HOUSEHOLD NUMBER
RURAL 2
LARGE CITY, OTHER CITY, RURAL?
OTHER CITY 2
RURAL 3
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME____
RESULT____
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)_____
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME____
FINAL VISIT
DAY___
MONTH____
YEAR: 2000
NAME____
RESULT____
TOTAL NUMBER OF PEOPLE IN HOUSEHOLD____
TOTAL NUMBER OF ELIGIBLE WOMEN____
TOTAL NUMBER OF ELIGIBLE MEN____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___
OTHER LANGUAGE (SPECIFY)_____ 2
NO 2
SUPERVISOR
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 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
COUSIN, NEPHEW, OR NIECE 09
OTHER RELATIVE 10
ADOPTED/FOSTER CHILD 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) RESIDENCE: Did (NAME) stay here last night?
NO 2
ELIGIBILITY:
8) CIRCLE THE LINE NUMBER OF ALL WOMEN 15-49
ELIGIBILITY:
8A) CIRCLE THE LINE NUMBER OF ALL MEN 15-59 IF MEN'S SURVEY IS PLANNED
ELIGIBILITY:
9) CIRCLE THE LINE NUMBER OF ALL CHILDREN UNDER 6 YEARS OLD
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS UNDER 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. RECORD '00' IF MOTHER IS NOT A MEMBER OF THE HOUSEHOLD.
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. RECORD '00' IF FATHER IS NOT A MEMBER OF THE HOUSEHOLD.
EDUCATION IF 5 YEARS OR OLDER:
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 last class that (NAME) successfully completed at that level?
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98
16) Is (NAME) currently attending school?
NO 2
17) Has (NAME) attended school at any time during the current school year?
NO 2 (GO TO 19)
18) During this current school year, what level and class was (NAME) attending?
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98
19) During the last school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT LINE)
20) During the last school year, what level and class was (NAME) attending?
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98
CHECK HERE IF A CONTINUATION SHEET IS USED__
Just to make sure that I have a complete listing:
1) Are there any other people such as small children or infants who have not been 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 COURTYARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
UNCOVERED WELL IN COURTYARD/PLOT 22 (GO TO 23)
UNCOVERED PUBLIC WELL 23
COVERED WELL IN COURTYARD/PLOT 32 (GO TO 23)
COVERED PUBLIC WELL 33
RIVER/STREAM 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY)_____ 96
22) How long does it take to go there, get water, and come back?
ON PREMISES 996
23) What kind of toilet do members of your household use?
VIP IMPROVED PIT LATRINE 22
OTHER (SPECIFY)____ 96
24) Do you share this installation with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26) In your household, what kind of fuel do you mainly use for cooking?
BOTTLED GAS/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, BROWN COAL (LIGNITE), PEAT 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY)____ 96
27) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
DUNG 12
PALM LEAVES/BAMBOO 22
VINYL OR LINOLEUM/ASPHALT 32
TILE OR STONE SLABS 33
CEMENT 34
CARPET 35
28) Does any member of your household own:
NO 2
NO 2
NO 2
29) In your household, do you have mosquito nets that can be used while sleeping?
NO 2 (GO TO 33)
30) CHECK COLUMNS 6 AND 7:
NUMBER OF CHILDREN UNDER 5 YEARS OLD WHO SLEPT IN THE HOUSEHOLD LAST NIGHT
ONE (GO TO 31)
TWO OR MORE (GO TO 32)
31) Did (NAME) sleep under a mosquito net last night?
NO 2 (GO TO 33)
32) Among the children under 5 years old who slept in the household last night, did all of them, some of them, or none of them sleep under a mosquito net?
SOME 2
NONE 3
33) In your household, is there a place to wash hands?
NO 2 (GO TO 35)
34) ASK TO SEE THE PLACE MOST FREQUENTLY USED TO WASH HANDS AND VERIFY IF THE FOLLOWING OBJECTS ARE THERE
NO 2
NO 2
NO 2
35) ASK RESPONDENT FOR A SPOONFUL OF SALT. TEST THE SALT TO CHECK FOR THE PRESENCE OF IODINE.
RECORD THE PPM (PARTS PER MILLION)
7 PPM 2
15 PPM 3
30 PPM 4
HEIGHT AND WEIGHT MEASUREMENTS
CHECK COLUMNS 8 AND 9: RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN 15-49 YEARS OLD AND CHILDREN UNDER 6 YEARS OLD:
36) LINE NUMBER FROM COLUMN 8
39) What is (NAME)'s birthday?
[FOR CHILDREN UNDER AGE 6 ONLY]
WEIGHT AND HEIGHT OF WOMEN 15-49 AND CHILDREN BORN IN OR AFTER 1995:
40) WEIGHT (KILOGRAMS)
42) MEASURED LYING DOWN OR STANDING UP?
[FOR CHILDREN BORN IN OR AFTER 1995 ONLY]
STANDING 2
ABSENT 2
REFUSED 3
OTHER 6