CLUSTER NUMBER ___
PROVINCE _________________ ___
DISTRICT _____________________ ___
HOUSEHOLD NUMBER ___
NAME OF HOUSEHOLD HEAD _______________ ___
RURAL 2
LUSAKA/OTHER CITY/TOWN/VILLAGE
OTHER CITY 2
TOWN 3
VILLAGE 4
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
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 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 ___
NAME ___
RESULT ____
TOTAL IN HOUSEHOLD __
TOTAL ELIG. WOMEN __
TOTAL ELIG. MEN __
LINE NUMBER OF RESP. TO HOUSEHOLD SCHEDULE _
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 NO.
(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/STEP CHILD 11
NOT RELATED 12
DON'T KNOW 98
(4) RESIDENCE: Does (NAME) usually live here?
NO 2
(5) RESIDENCE: Did (NAME) stay here last night?
NO 2
(6) SEX: Is (NAME) male or female?
FEMALE 2
(8) EDUCATION IF AGE 6 YEARS OR OLDER: 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 that level?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
(10) IF AGE LESS THAN 25 YEARS: Is (NAME) still in school?
NO 2
(11) MARITAL STATUS IF AGE 12 YEARS OR OLDER: Is (NAME) married, living together, separated, divorced, or never married?
LIVING TOGETHER 2
SEPARATED 3
DIVORCED 4
WIDOWED 5
NEVER MARRIED 6
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 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.
Record 00 if parent not member of household.
(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 FATHER'S LINE NUMBER.
Record 00 if parent not member of household.
(16) ELIGIBILITY WOMEN: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
(16A) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 (IF HOUSEHOLD FALLS IN MEN'S SAMPLE).
TICK HERE IF CONTINUATION SHEET USED __
1) Just to make sure that I have a complete listing: 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
17. What is the main source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC SHALLOW WELL 22
PUBLIC TRADITIONAL WELL 23
PUBLIC BOREHOLE 24
RIVER/STREAM 32
POND/LAKE 33
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 19)
OTHER (SPECIFY) _______ 96
18. How long does it take to go there, get water, and come back?
ON PREMISES 996
19. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) ________ 96
Electricity?
A radio?
A television?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
21. How many rooms in your household are used for sleeping?
22. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
CERAMIC/TERRAZO/MARBLE TILE 32
CEMENT/CONCRETE 33
23. Does any member of your household own:
A bicycle?
A motorcycle?
A car?
NO 2
NO 2
NO 2
24. We would like to check whether the salt used in your household is iodized. May we see a sample of the salt used to cook meal eaten by members of your household last night?
NOT IODIZED 2 (IND. QRE)
NOT TESTED 3 (IND. QRE)
NO SALT AT HOME 4 (IND. QRE)
25 02
50 03
75 04
100 plus 05