1999 ZIMBABWE DEMOGRAPHIC AND HEALTH SURVEY
NAME OF HOUSEHOLD HEAD __________
WARD NAME __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE ___
RURAL 2
LARGE CITY/SMALL CITY/TOWN/RURAL
SMALL CITY 2
TOWN 3
RURAL 4
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 ___
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) __________
TOTAL PERSONS IN HOUSEHOLD ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE ___
NDEBELE 2
ENGLISH 3
OTHER 4
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 ___
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? *
* CODES FOR QUESTION 3
RELATIONSHIP TO THE HEAD OF HOUSEHOLD:
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DON'T KNOW
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) stay here last night?
NO 2
6) Is (NAME) male or female?
FEMALE 2
7) How old is (NAME)?
AGE IN COMPLETED YEARS
8)
"CIRCLE" LINE NUMBER OF ALL WOMEN AGE 15-49
"ROOF" LINE NUMBER OF ALL MEN AGE 15-54
"BOX" LINE NUMBER OF ALL CHILDREN UNDER AGE 6
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS 0-14 YEARS OLD **
** QUESTION 9 THROUGH QUESTION 12
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. IN QUESTION 10 AND QUESTION 12, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE
9) Is (NAME)'s natural mother alive?
NO 2
DK 8
10) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
11) Is (NAME)'s natural father alive?
NO 2
DK 8
12) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
13) Has (NAME) ever been to school?
NO 2 (SKIP TO NEXT LINE)
14) What is the highest level of school (NAME) attended or attending? ***
What is the highest grade (NAME) completed at that level? ***
*** CODES FOR QUESTIONS 14, 15C AND 15F
EDUCATION LEVEL:
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW
EDUCATION GRADE:
98 DON'T KNOW
15A) Is (NAME) currently attending school?
NO 2
15B) Was (NAME) ever in attendance in school at any point during this school year?
NO 2 (SKIP TO 15D)
15C) During this school year, what level and grade [is (NAME) attending / was (NAME) enrolled in]? ***
GRADE ___
15D) Did (NAME) attend school during the previous school year?
NO 2
15E) Was (NAME) ever in attendance in school at any point during the previous school year?
NO 2 (SKIP TO NEXT LINE)
15F) During the previous school year, what level and grade [did (NAME) attend / was (NAME) enrolled in]? ***
GRADE ___
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 ___
16) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (SKIP TO 18)
PUBLIC TAP 13
UNPROTECTED WELL 22
BOREHOLE 23
RIVER/STREAM 32
POND/LAKE/DAM 33
OTHER (SPECIFY) __________ 96 (SKIP TO 18)
17) How long does it take you to go there, get water, and come back?
ON PREMISES 996
18) What kind of toilet or sanitation facility do most members of your household use?
VENTILATED IMPROVED PIT (VIP) LATRINE/BLAIR TOILET 22
OTHER (SPECIFY) __________ 96
18A) With how many other households do you share this facility?
RECORD "00" IF TOILET NOT SHARED
NO 2
NO 2
NO 2
NO 2
NO 2
19A) What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE/PARAFFIN 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) __________ 96
21) MAIN MATERIAL ON THE FLOOR.
RECORD OBSERVATION.
DUNG 12
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
22) Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
22A) Does your household have any bednets that are used while sleeping?
NO 2 (SKIP TO 22E)
22B) CHECK 5 AND 7:
NUMBER OF CHILDREN UNDER AGE 5 WHO SLEPT IN THE HOUSEHOLD LAST NIGHT
ONE ___
TWO OR MORE ___ (SKIP TO 22D)
22C) Did (NAME) sleep under a bednet last night?
NO 2 (SKIP TO 22E)
22D) Did all, some or none of the children under age 5 who slept in the household last night sleep under a bednet?
SOME CHILDREN 2
NONE 3
22E) Does your household have any place which is used for hand washing?
NO 2 (SKIP TO 23)
22F) ASK TO SEE THE PLACE USED MOST OFTEN AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT
NO 2
NO 2
NO 2
23) TYPE OF SALT
TEST OF IODINE.
01-14 PPM 2
15+ PPM 3
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT
CHECK COLUMNS (8): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
HEIGHT AND WEIGHT MEASUREMENT OF WOMEN 15-49
2 NOT PRESENT
3 REFUSED
6 OTHER
27) What is (NAME)'s date of birth?
WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1994 OR LATER
30) MEASURED LYING DOWN OR STANDING UP
STANDING 2
2 NOT PRESENT
3 REFUSED
6 OTHER
TICK HERE IF CONTINUATION SHEET USED ___
HEMOBGLOBIN MEASUREMENT OF WOMEN 15-49
AGE 18-49 2 (SKIP TO 34)
33) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
34) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT *
CIRCLE CODE (AND SIGN)
SIGN __________
REFUSED 2 (SKIP TO NEXT LINE)
2 NOT PRESENT
3 REFUSED
6 OTHER
HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN JANUARY 1994 OR LATER
33) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
34) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT *
CIRCLE CODE (AND SIGN)
REFUSED 2 (SKIP TO NEXT LINE)
2 NOT PRESENT
3 REFUSED
6 OTHER
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem which results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in January 1994 or later) participate in the anemia testing part of this survey and give a sample of blood from a finger or heel. The test uses disposable sterile instruments that are clean and completely safe. 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 results will be kept confidential.
May I now ask that you [and NAME OF CHILD(REN)] participate in the anemia 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.