2000 UGANDA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE
IDENTIFICATION
REGION __________
DISTRICT __________
COUNTY __________
SUBCOUNTY/TOWN __________
PARISH/LC2 NAME __________
EA NAME __________
UDHS NUMBER __________
RURAL 2
LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
HOUSEHOLD NUMBER ___
NAME OF HOUSEHOLD HEAD __________
Household selected for male survey?
NO 2
Household selected for Vitamin A testing?
NO 2
INTERVIEWER VISITS (FOR 1, 2, 3 AND FINAL VISITS)
INTERVIEWER'S NAME __________
RESULT __________
TIME __________
MONTH __________
YEAR _____
NAME __________
RESULT __________
TOTAL NUMBER OF VISITS ___
TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR AN 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
SUPERVISOR:
NAME __________
DATE _____
FIELD EDITOR:
NAME __________
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.
1. LINE NUMBER (1-20) ___
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 (FIRST AND LAST NAME IN CAPITAL LETTERS).
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.
9. ELIGIBILITY: Circle line number of all children under age 6.
10. ELIGIBILITY: Circle line number of all men age 15-54.
11. ELIGIBILITY: Circle line number of all children age 5-17.
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD:
12. Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
13. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
NO 2
LINE NUMBER ___
14. Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
15. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD MOTHER'S LINE NUMBER.
NO 2
LINE NUMBER ___
16. IF AGE 4 YEARS OR OLDER: Has (NAME) ever attended school?
NO 2
17. IF AGE 4 YEARS OR OLDER: What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?
LEVEL
PRIMARY 1
SECONDARY 2
POST SECONDARY 3
DON'T KNOW 8
GRADE
DON'T KNOW 98
18. IF AGE 4-24 YEARS: Is (NAME) currently attending school?
NO 2
19. IF AGE 4-24 YEARS: During the current school year (2000), did (NAME) attend school at any time?
NO (GO TO 21)
20. IF AGE 4-24 YEARS: During the current school year (2000), what level and grade (is/was) (NAME) attending?
LEVEL
PRIMARY 1
SECONDARY 2
POST SECONDARY 3
DON'T KNOW 8
GRADE
DON'T KNOW 98
21. IF AGE 4-24 YEARS: During the previous school year (1999), did (NAME) attend school at any time?
NO 2
22. IF AGE 4-24 YEARS: During that school year (1999), what level and grade did (NAME) attend?
LEVEL
PRIMARY 1
SECONDARY 2
POST SECONDARY 3
DON'T KNOW 8
GRADE
DON'T KNOW 98
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 ___
23. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 25)
PUBLIC TAP 13
OPEN PUBLIC WELL 22
PROTECTED PUBLIC WELL 32
BOREHOLD PUBLIC 34
RIVER/STREAM 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 25)
GRAVITY FLOW SCHEME 81
24. How long does it take you to go there, get water, and come back?
25. What kind of toilet facility does your household have?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
26. Do you share this facility with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
28. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
OTHER (SPECIFY) __________ 96
29. What type of fuel does your household mainly use for lighting?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
OTHER (SPECIFY) __________ 96
30. Main material of the floor. RECORD OBSERVATION.
EARTH/SAND 11
DUNG 12
FINISHED FLOOR
PARQUET AND POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
31. Main material of the roof. RECORD OBSERVATION.
IRON SHEETS 02
ASBESTOS 03
TILES 04
TIN 05
CEMENT 06
OTHER (SPECIFY) __________ 96
32. Main material of the wall. RECORD OBSERVATION.
MUD AND POLE 02
UNBURNT BRICKS 03
BURNT BRICKS WITH MUD 04
BURNT BRICKS WITH CEMENT 05
TIMBER 06
CEMENT BLOCKS 07
STONE 08
OTHER (SPECIFY) __________ 96
33. DOES ANY MEMBER OF YOUR HOUSEHOLD OWN:
NO 2
NO 2
NO 2
NO 2
NO 2
34 Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 38)
35. CHECK COLUMNS 6 AND 7: Number of children under age 5 who slept in the household last night.
ONE ___
TWO OR MORE ___ (GO TO 37)
36 Did (NAME) sleep under a mosquito net last night?
NO 2 (GO TO 38)
37. Did all, some or none of the children under age 5 who slept in the household last night sleep under a mosquito net?
SOME CHILDREN 2
NONE 3
38 Where do you usually wash your hands?
SOMEWHERE ELSE 2 (GO TO 40)
NOWHERE 3 (GO TO 40)
39. ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.
YES 1
NO 2
SOAP, ASH OR OTHER CLEANSING AGENT
YES 1
NO 2
BASIN
NO 2
40. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).
BELOW 15 PPM 2
15 PPM+ 3
NO SALT 4
CHILD LABOUR MODULE FOR CHILDREN AGES 5-17
1. LINE NUMBER (FROM COLUMN 11) ___
2. NAME (FROM COLUMN 2) __________
3. At any time during the past year, did (NAME) do any kind of work for someone who is not a member of this household?
NO 2 (GO TO 10)
4. WORKED AT ANY TIME IN THE PAST YEAR: Describe briefly the main work of job that (NAME) did.
5. WORKED AT ANY TIME IN THE PAST YEAR: Was (NAME) a regular paid employee, a casual labourer, paid per piece or unpaid?
6. WORKED AT ANY TIME IN THE PAST YEAR: Where did (NAME) carry out the work?
7. Since last (DAY OF THE WEEK) did (NAME) do any kind of work for someone who is not a member of this household?
No 2 (GO TO 10)
8. Describe briefly the main work or job that (NAME) did.
9. Since last (DAY OF THE WEEK) how many hours did (NAME) do this work?
10. Since last (DAY OF THE WEEK) did (NAME) regularly help with household chores such as cooking, shopping, cleaning, washing cloths, fetching water or caring for animals?
No 2 (GO TO 12)
11. Since last (DAY OF THE WEEK), how many hours a week did (NAME) spend doing these chores?
12. Since last (DAY OF THE WEEK), did (NAME) do any other family work (ON THE FARM OR IN A BUSINESS)?
NO 2
13. Since last (DAY OF THE WEEK), how many hours did (NAME) do this work?
TICK HERE IF CONTINUATION SHEET USED ___
CODES FOR COLUMN 4 AND 8
UNSKILLED MANUAL 02
HOUSEHOLD/DOMESTIC 03
CROP FARMING 04
LIVESTOCK REARING 05
FISHING 06
MANUFACTURING 07
OTHER 08
CASUAL LABOURER 2
PAID AT PIECE RATE 3
UNPAID 4
AT EMPLOYER'S HOUSE 02
ON THE STREET 03
SHOP/MARKET/KIOSK 04
INDUSTRY/FACTORY 05
PLANTATION/FARM/GARDEN 06
CONSTRUCTION/QUARRYING SITES 07
OTHER 08
Weight, Height and Hemoglobin Measurement
41. CHECK COLUMNS 8 AND 9: RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WOMEN 15-49: LINE NUMBER FROM COLUMN 8
LINE NUMBER ___
CHILDREN UNDER AGE 6: LINE NUMBER FROM COLUMN 9
LINE NUMBER ___
MEN AGE 15-54: LINE NUMBER FROM COLUMN 10
42.
WOMEN 15-49: NAME FROM COLUMN 2
CHILDREN UNDER AGE 6: NAME FROM COLUMN 2
MEN AGE 15-54: NAME FROM COLUMN 2
43.
WOMEN 15-49: AGE FROM COLUMN 7
AGE ___
CHILDREN UNDER AGE 6: AGE FROM COLUMN 7
AGE ___
MEN AGE 15-54: AGE FROM COLUMN 7
44.
WOMEN 15-49: What is (name)'s date of birth?
MONTH __________
YEAR _____
CHILDREN UNDER AGE 6: What is (name)'s date of birth?
MONTH __________
YEAR _____
45. WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49: Weight (KILOGRAMS)
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1995 OR LATER: Weight (KILOGRAMS)
46. WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49: Height (CENTIMETERS)
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1995 OR LATER: Height (CENTIMETERS)
47. WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49: MEASURED LYING DOWN OR STANDING UP
STANDING UP 2
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1995 OR LATER: MEASURED LYING DOWN OR STANDING UP
STANDING UP 2
48. WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49: Result
NOT PRESENT 2
REFUSED 3
DISABLED 4
OTHER 6
Weight and height measurement of children born in 1995 or later: Result
NOT PRESENT 2
REFUSED 3
DISABLED 4
OTHER 6
TICK HERE IF CONTINUATION SHEET USED ___
*RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
**CONSENT STATEMENT
As part of this survey, we are studying anemia (and vitamin A deficiency) among women, men and children. This (these) problem(s) often result from poor nutrition.
This survey will assist the government to develop programs to prevent and treat anemia (and vitamin A deficiency).
We request that you (and all children born in 1995 or later) participate in the anemia (and vitamin A deficiency) testing as part of this survey and give a few drops of
blood from a finger. The tests use disposable sterile instruments that are clean and completely safe. For anemia test, the blood will be analyzed with new equipment
and the results of the test will be given to you right after the blood is taken. (The vitamin A test has to be done in a laboratory so you will not be given the results). The
results of the (both) test(s) will be kept confidential.
May I now ask that you (and name of child(ren)) participate in the anemia (and vitamin A deficiency test). However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6
49. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49: CHECK COLUMN 43
AGE 18-49 2 (GO TO 51)
HEMOGLOBIN MEASUREMENT OF MEN 15-54: CHECK COLUMN 43
AGE 18-54 2 (GO TO 51)
50. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49: LINE NUMBER OF PARENT/RESPONSIBLE ADULT *
HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF CHILDREN BORN IN 1995 OR LATER: LINE NUMBER OF PARENT/RESPONSIBLE ADULT
HEMOGLOBIN MEASUREMENT OF MEN 15-54: LINE NUMBER OF PARENT/RESPONSIBLE ADULT
51. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT **
CIRCLE CODE (AND SIGN)
REFUSED 2
HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF CHILDREN BORN IN 1995 OR LATER
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT **
CIRCLE CODE (AND SIGN)
REFUSED 2
HEMOGLOBIN MEASUREMENT OF MEN 15-54
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT **
CIRCLE CODE (AND SIGN)
REFUSED 2
52. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49
TESTED FOR VITAMIN A DEFICIENCY
NO 2
NA 3
HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF CHILDREN BORN IN 1995 OR LATER
TESTED FOR VITAMIN A DEFICIENCY
YES 1
NO 2
NA 3
53. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49
HEMOGLOBIN LEVEL (G/DL)
HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF CHILDREN BORN IN 1995 OR LATER
HEMOGLOBIN LEVEL (G/DL)
HEMOGLOBIN MEASUREMENT OF MEN 15-54
HEMOGLOBIN LEVEL (G/DL)
54. HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF WOMEN 15-49: Currently pregnant?
NO/DON'T KNOW 2
55. Hemoglobin and Vitamin A Measurements of women 15-49
NOT PRESENT 2
REFUSED 3
DISABLED 4
OTHER 6
Hemoglobin and Vitamin A Measurements of children born in 1995 or later
NOT PRESENT 2
REFUSED 3
DISABLED 4
OTHER 6
Hemoglobin Measurement of Men 15-54
NOT PRESENT 2
REFUSED 3
DISABLED 4
OTHER 6
55. CHECK 52 AND 53: Number of persons with hemoglobin level below the cutoff point *
NONE ___ (GIVE EACH WOMAN/MAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END THE INTERVIEW)
56. We detected a low level of hemoglobin in (YOUR BLOOD/THE BLOOD OF NAME OF CHILD(REN)). This indicates that (YOU/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem.
You should seek medical assistance for this problem. We will give you a letter of referral which you can take to the doctor or health facility you consult. It provides information on the results of your test that will help the doctor or health facility.
* THE CUTOFF POINT IS 9 G/DL FOR PREGNANT WOMEN AND 7 G/DL FOR CHILDREN, WOMEN WHO ARE NOT PREGNANT (OR WHO DON.T KNOW IF THEY ARE
PREGNANT), AND MEN.
** IF MORE THAN ONE WOMAN, MAN OR CHILD IS BELOW THE CUTOFF POINT, READ THE STATEMENT IN Q.56 TO EACH WOMAN WHO IS BELOW THE CUTOFF POINT
AND EACH WOMAN/PARENT/RESPONSIBLE ADULT FOR WHOM A CHILD IS BELOW THE CUTOFF POINT.
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT MEASUREMENT
__________
__________