[NAME OF COUNTRY]

[NAME OF ORGANIZATION]

IDENTIFICATION *

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

REGION

URBAN/RURAL

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE **

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT***

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT***

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT***

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TOTAL NUMBER OF VISITS

***RESULT CODES:

TOTAL IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __________

FIELD EDITOR BY
NAME
DATE

OFFICE EDITOR BY
NAME
DATE

KEYED BY
NAME
DATE

* THIS SECTION SHOULD BE ADAPTED FOR COUNTRY-SPECIFIC SURVEY DESIGN.
** The following guidelines should be used to categorize urban sample points:
"Large cities" are national capitals and places with over 1 million population; "small cities" are places with between 50,000 and 1 million population; remaining urban sample points are "towns".

HOUSEHOLD SCHEDULE

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?

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

RESIDENCE

4) Does (NAME) usually live here?

5) Did (NAME) stay here last night?

6) SEX

Is (NAME) male or female?

7) AGE
How old is (NAME)?

EDUCATION

IF AGED 6 YEARS OR OLDER

8) Has (NAME) ever been to school?

9) IF ATTENDED SCHOOL
What is the highest level of school (NAME) attended?
What is the highest grade (NAME) completed at that level? **

CODES FOR Q. 9
LEVEL OF EDUCATION:

GRADE:

10) IF ATTENDED SCHOOL AND IF LESS THAN 25 YEARS
Is (NAME) still in school?

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD***

*** These questions refer to the biological parents of the child. Record 00 if parent not member of household.

11) Is (NAME)'s natural mother alive?

12) IF ALIVE
Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

13) Is (NAME)'s natural father alive?

14) IF ALIVE
Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

ELIGIBILITY

15) CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW

TICK HERE IF AN CONTINUATION SHEET USED _____
TOTAL NUMBER OF ELIGIBLE WOMEN ____

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?

2) In addition, are there any other people who may not be members of you family, such as domestic servants, lodgers or friends who usually live here?

3) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?

16) What is the main source of water your household uses for handwashing and dishwashing?

17) How long does it take to go there, get water, and come back?

18) Does your household get drinking water from this same source?

19) What is the source of drinking water for members of your household? *

20) What kind of toilet facility does your household have?*

*Coding categories to be developed locally and revised based on pretest, however the large categories must be maintained.

21) Does your household have:

Electricity?
A radio?
A television?
A refrigerator?

.

22) How many rooms in your household are used for sleeping?

23) MAIN MATERIAL OF THE FLOOR. **
RECORD OBSERVATION.

**Coding categories to be developed locally and revised based on pretest, however the large categories must be maintained. The material of walls or ceilings may be a better measure in some countries.

24) Does any member of this household own:
A bicycle?
A motorcycle?
A car?