REGION ___________________ ___
DISTRICT __________________ ___
WARD __________________ ___
E.A. NUMBER ___
TRCHS CLUSTER NUMBER ___
HOUSEHOLD NUMBER___
DAR ES SALAAM, SMALL CITY, TOWN, RURAL/VILLAGE
SMALL CITY* 2
TOWN 3
RURAL/VILLAGE 4 ___
*SMALL CITIES ARE: MWANZA, ARUSHA, MOROGORO, DODOMA, MOSHI, TANGA, IRINGA, MBEYA, AND TABORA. ALL OTHER URBAN AREAS ARE TOWNS.
NAME OF HOUSEHOLD HEAD _____________________
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT*
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
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
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE ______
TIME _____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
INTER. ID NO. ____
RESULT* ____
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 PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE MEN __
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ___
SUPERVISOR:
NAME ________
DATE ________
FIELD EDITOR:
NAME ________
DATE ________
OFFICE EDITOR: ____
KEYED BY____
1. 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 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?
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
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 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
8. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
8A. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.
9. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 5.
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 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 PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.
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 PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.
EDUCATION IF AGE 3 YEARS OR OLDER:
14. Has (NAME) ever attended school?
NO 2
15. What is the highest standard or form (NAME) has completed?
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
OTHER 96
DOES NOT KNOW 98
EDUCATION IF AGE LESS 3-24 YEARS:
16. Is (NAME) currently attending school (including pre-school)?
NO 2
17. During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 19)
18. During the current school year, what standard or form is (NAME) attending?
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 = DOES NOT KNOW
19. During the previous school year, did (NAME) attend school at any time?
NO 2
20. During that school year, what standard or form did (NAME) attend?
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 = DOES NOT KNOW
TICK HERE IF CONTINUATION SHEET USED __
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) 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 YARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
BOREHOLE OR TUBEWELL 32
UNPROTECTED SPRING 42
POND, RIVER, STREAM 43
TANKER TRUCK 61
BOTTLED WATER 71
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 facility do most members of your household use?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) ________ 96
24. Do you share this facility with other households?
NO 2
Electricity?
A radio?
A television?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
CERAMIC TILES, CARPET 33
CEMENT 34
28. Does any member of your household own:
A bicycle?
A motorcycle or motor scooter?
A car or truck?
NO 2
NO 2
NO 2
29. Does your household have any bednets that can be used while sleeping?
NO 2 (GO TO 34)
30. CHECK COLUMNS (6) AND (7):
NUMBER OF CHILDREN UNDER AGE 5 WHO SLEPT IN THE HOUSEHOLD LAST NIGHT
NONE (GO TO 34)
31. Did any of the children under age 5 who slept in the household last night sleep under a bednet?
IF YES: Did all or only some sleep under a bednet?
SOME CHILDREN 2
NONE 3 (GO TO 34)
32. Were any of these bednets ever treated with a chemical (dawa) to avoid mosquito bites?
NO 2 (GO TO 34)
DOES NOT KNOW 8 (GO TO 34)
33. How long ago was the bednet last treated?
DOES NOT KNOW 98
34. ASK RESPONDENT FOR A TEASPOONFUL OF SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).
25 PPM 2
50 PPM 3
75 PPM 4
100 PPM 5
NOT TESTED 8