DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF CHAD
MINISTRY OF PLANNING AND COOPERATION
DIRECTORATE OF STATISTICS, ECONOMIC STUDIES, AND DEMOGRAPHICS
CENTRAL CENSUS BUREAU
LOCALITY NAME ___
NAME OF HEAD OF HOUSEHOLD ___
ADMINISTRATIVE DISTRICT ___
ADMINISTRATIVE SUB-DISTRICT ___
CLUSTER NUMBER (ENUMERATION DISTRICT) ___
STRUCTURE NUMBER ___
HOUSEHOLD NUMBER ___
ABECHE/MOUNFOU/SARH 2
SMALL TOWNS 3
RURAL 4
HOUSEHOLD SELECTED FOR MEN'S SURVEY:
NO 2
INTERVIEWER 1:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING EMPTY 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 __
NAME__
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING EMPTY OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY): ___
TOTAL NUMBER OF RESIDENTS IN HOUSEHOLD ___
TOTAL NUMBER OF ELIGIBLE WOMEN ___
TOTAL NUMBER OF ELIGIBLE MEN ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___
FIELD EDITED BY:
NAME ___
DATE ___
OFFICE EDITED BY:
NAME ___
DATE ___
KEYED BY:
NAME ___
DATE ___
Now we would like some information on the people who usually in your household or who are staying with you now.
1) LINE NUMBER
USUAL RESIDENTS AND VISITORS:
2) Please give the name of those persons usually living in your household or currently living with you, starting with the head of household.
AFFILIATION WITH THE HEAD OF HOUSEHOLD:
3) What is the relationship between (NAME) and the head of household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDSON OR GRANDDAUGHTER 05
FATHER OR MOTHER 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEP CHILD 11
NO FAMILY RELATIONSHIP 12
DK 98
RESIDENCE:
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) sleep here last night?
NO 2
SEX:
6) Is (NAME) male or female?
F 2
RECORD '95' FOR 95 AND OLDER.
SCHOOLING (IF AGE 6 YEARS OR OLDER):
8) Did (NAME) attend school?
NO 2
9) What is the highest level of education (NAME) attained?
What was the last class that he or she successfully completed at this level?
LEVEL: ___
1 CP1
2 CP2
3 CE1
4 CE2
5 CM1
6 CM2
8 DK
1 6TH
2 5TH
3 4TH
4 3RD
5 2ND
6 1ST
7 FINAL YEAR
8 DK
1 FIRST YEAR
2 SECOND YEAR
3 THIRD YEAR
4 FOURTH YEAR AND +
8 DK
1 6TH OR 1ST YEAR
2 5TH OR 2ND YEAR
3 4TH OR 3RD YEAR
4 3RD OR 4TH YEAR
5 2ND OR 5TH YEAR
6 1ST OR 6TH YEAR
7 FINAL YEAR OR 7TH YEAR
8 DK
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR OR +
8 DK
10) IF AGE LESS THAN 30 YEARS:
Does (NAME) still go to school?
NO 2
QUESTIONS 11 TO 14 ARE FOR THE BIOLOGICAL PARENTS. RECORD '00' IF PARENTS ARE NOT MEMBERS OF THE HOUSEHOLD.
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15:
11) Is (NAME)'s natural mother still living?
NO 2
DK 8
12) Is (NAME)'s natural mother living in the household?
IF YES: What is her name?
WRITE THE MOTHER'S LINE NUMBER.
13) Is (NAME)'s natural father still living?
NO 2
DK 8
14) Is (NAME)'s natural father living in the household?
IF YES: What is his name?
WRITE THE FATHER'S LINE NUMBER.
CIRCLE THE LINE NUMBER OF ALL WOMEN BETWEEN AGE 15-49.
MEN'S SURVEY?
NO: ___
CIRCLE THE LINE NUMBER OF ALL MEN BETWEEN AGE 15-59.
Just to make sure that I have a complete list:
1. Are there any other people, for instance small children or infants we have not placed on the list?
NO: ___
2. In addition, are there other people who are perhaps not members of your family, such as servants or friends, who usually live here?
NO: ___
3. Do you have any guests or temporary visitors staying at your house, or other people who slept here last night?
NO: ___
16) Where does the water your household uses for drinking come from?
PUBLIC TAP 12
MODERN WELL/BOREHOLE IN RESIDENCE/YARD/ALLOTMENT 22 (GO TO 18)
PUBLIC/COMMUNITY TRADITIONAL WELL 23
PUBLIC/COMMUNITY WELL/BOREHOLE 24
POND/LAKE/BACKWATER POOL 32
TANK TRUCK 51
WATER VENDOR 61 (GO TO 18)
OTHER (SPECIFY): ___ 96
17) How long does it take to go there, get water, and come back?
ON PREMISE 996
18) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY): ___ 96
Grid power?
Personal electricity: (power generator, solar panel, batteries)?
A radio?
A television?
Telephone?
A refrigerator/freezer?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
19A) In your household, what kind of lighting do you mainly use?
GAS LAMP 2
KEROSENE LAMP 3
FLASHLIGHT (BATTERIES) 4
WOOD/PLANT STEMS/STRAW 5
OTHER (SPECIFY): ___ 6
20) In your household, how many rooms are used for sleeping?
21) Is there someone in your household who owns:
A bicycle?
A scooter/motorcycle?
A car?
A canoe?
A cart?
A camel/horse/donkey?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
22) MAIN MATERIAL OF THE FLOOR (RECORD OBSERVATION):
CEMENT 22
23) MAIN ROOF MATERIAL (RECORD OBSERVATION):
BANCO 12
CONCRETE 22
24) MAIN WALL MATERIAL (RECORD OBSERVATION):
BANCO 12
SEMI HARD WALL 13
25) What type of salt is usually used for cooking in your household?
(FOR SALT IN BOX/PACKET, ASK TO SEE BOX/PACKET)
ASH SALT (NON-IODIZED) 02
IODIZED SALT IN BOX/PACKET 03
NON-IODIZED SALT IN BOX/PACKET 04
BLOCK OF ROCK SALT (NATRON) 05
OTHER (SPECIFY): ___ 96
26) RECORD THE RESULT OF THE IODIDE AND POTASSIUM IODATE TEST.
RECORD OBSERVATION.
TEST NEGATIVE (NON IODIZED SALT) 2
SALT IODIZED AND NON-IODIZED 3
SALT UNAVAILABLE 6
TEST INDETERMINATE 8