UNITED REPUBLIC OF TANZANIA
BUREAU OF STATISTICS, PLANNING COMMISSION
TANZANIA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD SCHEDULE
IDENTIFICATION
NAME OF HOUSEHOLD HEAD ______________________
CLUSTER NUMBER ___
HOUSEHOLD NO. ___
REGION ___________________ ___
DISTRICT __________________ ___
WARD __________________ ___
ENUMERATION AREA _______________ ___
RURAL 2
LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE ___
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
HOUSEHOLD SELECTED FOR MALE SURVEY? ___
NO 2
INTERVIEWER VISITS
INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
INTERVIEWER VISIT 2
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
INTERVIEWER VISIT 3
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
NEXT VISIT:
DATE ______
TIME _____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
ID NO. ____
RESULT ____
TOTAL NUMBER OF VISITS __
TOTAL IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE MEN __
HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME 2
HOUSEHOLD ABSENT 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _________ 9
FIELD EDITED BY
NAME ________
DATE ________
OFFICE EDITED BY
NAME ________
DATE ________
KEYED BY
NAME ________
DATE ________
KEYED BY
Now we would like some information about the people who usually live in your household or who are staying with you now.
(2) 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.
(3) RELATIONSHIP TO HEAD OF HOUSEHOLD*
What is the relationship of (NAME) to the head of the household?*
(4) SEX: Is (NAME) male or female?
FEMALE 2
RESIDENCE
(5) Does (NAME) usually live here?
NO 2
(6) Did (NAME) sleep here last night?
NO 2
EDUCATION
IF AGE 5 YEARS OR OLDER
(8) Has (NAME) ever been to school?
NO 2
(9) What is the highest formal school (NAME) completed?**
(10) (IF AGED LESS THAN 25 YEARS) Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
(11) Is (NAME)'s natural mother alive?
NO 2
DK 8
(12) (IF ALIVE) Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.***
(13) Is (NAME)'s natural father alive?
NO 2
DK 8
(14) (IF ALIVE) Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.***
(15) (WOMEN) CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.
(16) (MEN) CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.
TICK HERE IF CONTINUATION SHEET USED __
TOTAL NUMBER OF ELIGIBLE WOMEN __
TOTAL NUMBER OF ELIGIBLE MEN__
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE: __
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) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO __
*CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD:
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER CHILD 10
NOT RELATED 11
DK 98
**CODES FOR Q.9 HIGHEST FORMAL SCHOOL:
01 STANDARD 1
02 STANDARD 2
03 STANDARD 3
04 STANDARD 4
05 STANDARD 5
06 STANDARD 6
07 STANDARD 7
08 STANDARD 8
09 FORM 1
10 FORM 2
11 FORM 3
12 FORM 4
13 FORM 5
14 FORM 6
15 UNIVERSITY
96 OTHER
98 DON'T KNOW
***QUESTIONS 12 AND14: RECORD '00' IF THE NATURAL (BIOLOGICAL) PARENT IS NOT A MEMBER OF THE HOUSEHOLD.
17. What is the source of water your household uses for handwashing and dishwashing?
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 18)
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 18)
TANKER TRUCK 51
OTHER (SPECIFY) _______ 71
18. How long does it take to go there, get water, and come back?
ON PREMISES 996
19. Does your household get drinking water from this same source?
NO 2
20. What is the source of drinking water for members of your household?
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 21)
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 21)
TANKER TRUCK 51
OTHER (SPECIFY) _______ 71
21. How long does it take to go there, get water, and come back?
ON PREMISES 996
22. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
TRADITIONAL PIT TOILET 21
VENTILATED PIT LATRINE 22
NO FACILITY/BUSH/FIELD 31
NO 2
NO 2
NO 2
NO 2
24. How many rooms in your household are used for sleeping?
25. MAIN MATERIAL OF THE FLOOR.
WOOD PLANKS 21
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
OTHER (SPECIFY) _____________ 41
26. Does any member of your household own:
NO 2
NO 2
NO 2