REGION ___________________
DISTRICT ___________________
COUNTY ___________________
SUB-COUNTY/TOWN ___________________
PARISH/RC2 NAME ___________________
EA NAME ___________________
UDHS NUMBER
URBAN/RURAL
RURAL 2
CITY/MUNICIPALITY/TOWN/COUNTRYSIDE
MUNICIPALITY 2
TOWN 3
COUNTRYSIDE 4
HOUSEHOLD NUMBER
NAME OF HOUSEHOLD HEAD ___________________
HOUSEHOLD SELECTED FOR MALE SURVEY?
NO 2
FIRST VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE __________
TIME __________
SECOND VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE __________
TIME __________
THIRD VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
TOTAL NUMBER OF VISITS
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____________ 9
TOTAL WOMEN 15 - 49
MEN 15 - 54
LINE NUMBER OF REPONDENT OF HOUSEHOLD SCHEDULE
LANGUAGE OF QUESTIONNAIRE: ENGLISH
DATE ___________
FIELD EDITOR
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.
LINE NUMBER
1) USUAL RESIDENTS AND VISITORS
2) 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?
SPOUSE 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 CHILD/STEP CHILD 11
NOT RELATED 12
DOES NOT KNOW 98
4) RESIDENCE: Does (NAME) usually live here?
NO 2
5) RESIDENCE: Did (NAME) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
8) Has (NAME) ever been to school?
NO 2
9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at the level?
GRADE
CODES FOR QUESTION 9
JUNIOR 2
SECONDARY 3
UNIVERSITY 4
DOES NOT KNOW 8
2
3
4 [for all except junior]
5 [for all except junior]
6 [for primary and secondary only]
7 [for primary only]
8 DOES NOT KNOW
10) IF AGE IS 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
DON'T KNOW 8
12) IF ALIVE: Does (NAME)'s natural mother live in this household? IF YES: What is her name?
13) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 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) CIRCLE LINE NUMBER OF ALL WOMEN AGED 15-49
16) WRITE LINE NUMBER OF THE HUSBAND OF EACH ELIGIBLE WOMAN
WRITE 00 IF NOT MARRIED OR IF HUSBAND NOT IN HOUSEHOLD
17) CIRCLE LINE NUMBER OF ALL MEN AGED 15-54 (IF HOUSEHOLD FALLS IN MAN SAMPLE)
TICK HERE IF CONTINUATION SHEET USED
TOTAL NUMBER OF ELIGIBLE WOMEN
TOTAL NUMBER OF ELIGIBLE MEN
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 that have not been listed?
NO
18A) What is the main source of drinking water for members of your household?
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 20)
PUBLIC WELL 22
BOREHOLE 23
SPRING 31
RIVER/STREAM 32
POND/LAKE/DAM 33
GRAVITY FLOW SCHEME 34
RAINWATER 41 (GO TO 20)
BOTTLED WATER 51 (GO TO 20)
OTHER ___________________ 96
18B) Where do you store the drinking water?
JERRY CAN 2
PAN 3
KALABASH 4
OTHER __________ 6
18C) How much water is used in this household every day?
19) How long does it take to go there, get water, and come back?
ON PREMISES 996
20) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
IMPROVED PIT LATRINE 22
OTHER __________ 96
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
22) How many rooms in your household are used for sleeping?
23) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
COW DUNG 12
PARQUET OR POLISHED WOOD 21
VINYL OR ASPHALT STRIPS 22
CERAMIC TILES 23
CEMENT 24
OTHER (SPECIFY) _________ 96
24) Does any member of your household own:
NO 2
NO 2
NO 2
25) What type of salt is usually used for cooking in your household?
(ASK TO SEE SALT PACKAGE)
PACKAGED SALT (IODIZED) 2
PACKAGED SALT (NOT IODIZED) 3
SALT FOR ANIMALS 4
OTHER SALT 6
25A) TEST THE SALT AND WRITE THE RESULT.
26) How many meals did the household have yesterday?
(MEALS: OTHER THAN TEA AND SNACKS)
27) In terms of household consumption, do you think that your household is:
NEITHER SURPLUS NOR DEFICIT 2
OCCASIONALLY DEFICIT 3
ALWAYS DEFICIT 4
DOES NOT KNOW 8