HOUSEHOLD SCHEDULE COVER SHEET
CENTRAL STATISTICAL OFFICE
PLACE NAME __________
PROVINCE __________
STRATA ___
DHS SEGMENT NUMBER _____
HOUSEHOLD NUMBER ___
FIRST VISIT
INTERVIEWER'S NAME __________
RESULT * __________
NEXT VISIT:
TIME _____
SECOND VISIT
INTERVIEWER'S NAME __________
RESULT * __________
NEXT VISIT:
TIME
THIRD VISIT
INTERVIEWER'S NAME __________
RESULT * __________
FINAL VISIT
YEAR _____
INTERVIEWER'S NAME __________
RESULT * __________
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ___________
NDEBELE 2
ENGLISH 3
OTHER 4 __________
DATE _____
OFFICE EDITOR
DATE _____
KEYED BY
DATE _____
Now we would like some information about the people who usually live in your household or who are staying with you now.
NUMBER
1) ___
2) Please give me the names of the persons who usually live in your household and visitors who stayed with you last night starting with the head of household.
3) Does (NAME) usually live here?
NO 2
4) Did (NAME) sleep here last night?
NO 2
5) Is (NAME) male or female?
Female 2
6) How old was (NAME) at his/her last birthday?
7) CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW:
SLEPT HERE LAST NIGHT, FEMALE 15 - 49
TICK HERE IF CONTINUATION SHEET USED ___
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET __
Just to make sure 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 such as domestic servants, lodgers or friends who usually live here and cook with your household?
NO ___
3. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO ___
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET ___
TOTAL NUMBER OF ELIGIBLE WOMEN ON BOTH SHEETS ___
To find the person's age, locate the decade of their year of birth on the left hand column, and the last number of their year of birth in the row which goes across the top. If that person has had a birthday already this year before the date of the interview, their age is the number in the left corner of the box. If they have not yet had a birthday in the year of the interview, their age is the lower of the two numbers in the box.
FIRST THREE DIGITS OF THE YEAR OF BIRTH (193- to 198- ) _____
LAST DIGIT OF THE YEAR OF BIRTH (0-9) ___