1)GOUVERNORAT [##translator note: unable to find translation, may be something related to government or governing]
2) NAME AND CLUSTER NUMBER
3) HOUSEHOLD NUMBER
4) NAME OF HEAD OF HOUSEHOLD
5)HOUSEHOLD ADDRESS
FIRST VISIT
6) DATE OF VISIT____
7) NAME OF INTERVIEWER____
8) RESULT
ABSENCE OF PERSON ABLE TO RESPOND 2
ABSENT THE NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT 6
DWELLING DEMOLISHED 7
OTHER 8
9) NEXT VISIT
TIME____
SECOND VISIT
6) DATE OF VISIT____
7) NAME OF INTERVIEWER____
8) RESULT
ABSENCE OF PERSON ABLE TO RESPOND 2
ABSENT THE NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT 6
DWELLING DEMOLISHED 7
OTHER 8
9) NEXT VISIT
TIME____
THIRD VISIT
6) DATE OF VISIT____
7) NAME OF INTERVIEWER____
8) RESULT
ABSENCE OF PERSON ABLE TO RESPOND 2
ABSENT THE NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT 6
DWELLING DEMOLISHED 7
OTHER 8
9) NEXT VISIT
TIME____
INTERVIEWER CODE
NUMBER OF VISITS
NAME ____
DATE ____
FIELD EDITED BY ____
OFFICE EDITED BY ____
KEYED BY ____
CODE KEYED ____
HOUSEHOLD SCHEDULE
Now we would like some information about the people who usually live in your household or who are staying with you now.
LINE NUMBER____
1) FIRST NAMES AND LAST NAMES OF USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.
2) Relationship to head of household
What is the relationship of (NAME) to the head of the household?
3) RESIDENCE
A) LIVES
Does (NAME) usually live here or not?
NO 2
b) VISITOR
Did (NAME) sleep here last night or not?
NO 2
4) SEX
Is (NAME) male or female?
FEMALE 2
6) IF 15 YEARS OR OLDER, MARITAL STATUS
Is he/she married, widowed, divorced, separated or single/
WIDOW/WIDOWER 2
DIVORCED 3
SEPARATED 4
SINGLE 5
OTHER 6
7) EDUCATION LEVEL FOR WOMEN 15 YEARS AND OLDER
A) Did she go to school?
NO 2
b) What is the highest level of school (NAME) has attended?
SECONDARY, PROFESSIONAL 2
HIGHER 3
OTHER 4
C) GRADE
What is the highest grade (NAME) completed at that level?
Are there any other persons such as small boy or girl that we have not listed?
NO
In addition, are there any other people who may not be members of your family, such as domestic servants, or friends who usually live here?
NO
Do you have any guests or temporary visitors staying here with you?
NO