With Commentary
For Low Contraceptive Prevalence Countries
Macro International Inc.
Demographic and Health Surveys, Phase III
Basic Documentation, Number 2
December 1995
Name of country __________
Name of organization __________
Identification
Place name __________
Name of household head __________
Cluster number ___
Household number ___
Region ___
Rural 2
City or country?
Note: Large cities are national capitals and places with a population of over 1 million; small cities are places with a population between 50,000 and 1 million; remaining urban sample points are considered towns.
Small city 2
Town 3
Countryside 4
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
Not at home 2
Postponed 3
Refused 4
Partly completed 5
Incapacitated 6
Other (specify) __________ 7
TOTAL ELIGIBLE WOMEN ____
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ____
No 2
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 (the number of persons listed by the respondent)
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 slept 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 2
Son or daughter 3
Son-in-law or daughter-in-law 4
Grandson or granddaughter 5
Father or mother 6
Father-in-law or mother-in-law 7
Brother or sister 8
Co-wife 9
Other relative 10
Adopted/foster/stepchild 11
Not related 12
Doesn'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
Questions 8, 9 and 10 are for ages 6 and over (if under 6 skip to Question 11)
8 Education
Has (name) ever been to school?
No 2 (skip to 11)
9 Education
What is the highest level of school (name) attended?
What is the highest grade (name) completed at that level?
Secondary
Higher
Don't know
Don't know
Question 10 is for ages less than 25
10 Education
Is (name) still in school?
No 2
Questions 11 through 14 refer to the biological parents of the child
11 Parental survivorship and residence for persons less than 15 years old
Is (name)'s natural mother alive?
No 2
Doesn't know 8
Parent not member of household 00
12 Parental survivorship and residence for persons less than 15 years old
If alive, does (name)'s natural mother live in this household? If yes, what is her name?
Record the mother's line number in addition. Record '00' if the parent is not member of the household.
Line number ___
13 Parental survivorship and residence for persons less than 15 years old
Is (name)'s natural father alive?
No 2
Doesn't know 3
14 Parental survivorship and residence for persons less than 15 years old
If alive, does (name)'s natural father live in this household? If yes, what is his name?
Record the father's line number in addition. Record '00' if the parent is not member of the household.
Line number ___
15 Eligibility
Circle the line number of all women ages 15-49.
Tick here if a continuation sheet was 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 that have not been listed?
No
16 What is the main source of drinking water for members of your household?
Public tap 12
Public well 22
River/stream 32
Pond/lake 33
Dam 34
Tanker truck 51
Bottled water 61
17 How long does it take to go there, get water, and come back?
On premises 996
18 What kind of toilet facility does your household have?
Shared flush toilet 12
Ventilated improved pit (VIP) latrine 22
No 2
No 2
No 2
No 2
No 2
20 How many rooms in your household are used for sleeping?
21 Main material of the floor.
Record observation
Dung 12
Palm/bamboo 22
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
23 What type of salt is usually used for cooking in your household?
(Ask to see salt package).
Packaged salt (iodized) 02
Packaged salt (not iodized) 03
Salt for animals 04
Loose salt 05