DIVISION:
DISTRICT:
UPAZILA OR THANA:
UNION:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE:
SMALL CITY 2
TOWN 3
VILLAGE 4
IS HOUSEHOLD SELECTED FOR HUSBAND SURVEY?
NO 2
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME RO 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
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME RO 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
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME RO 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
FINAL VISIT
DAY
MONTH
FEBRUARY 02
MARCH 03
APRIL 04
MAY 05
JUNE 06
JULY 07
AUGUST 08
SEPTEMBER 09
OCTOBER 10
NOVEMBER 11
DECEMBER 12
YEAR 199_
NAME
RESULT
TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE
FILED EDITED BY
OFFICE EDITED BY
KEYED BY
KEYED BY
HOUSEHOLD SCHEDULE
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 THE HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED OR FOSTER CHILD 10
NOT RELATED 11
DOES NOT KNOW 98
Just to make sure I have a complete listing:
4. Are there any other persons such as small children or infants that we have not listed?
NO
5. 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?
NO
6. Do you have any guest or temporary visitors staying here, or anyone else who slept here last night?
NO
7. RESIDENCE: Does (NAME) usually live here?
NO 2
8. Did (NAME) sleep here last night?
NO 2
9. SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGED 6 YEARS OR OLDER
11. Has (NAME) ever been to school?
NO 2
IF ATTENDED SCHOOL
12. What is the highest level of school (NAME) attended? What is the highest class (NAME) completed?
SECONDARY 2
COLLEGE OR UNIVERSITY 3
DOES NOT KNOW 8
DOES NOT KNOW 98
IF AGED LESS THAN 25 YEARS
13. Is (NAME) still in school?
NO 2
EMPLOYMENT IF AGED 8 YEARS OR OLDER
14. Is (NAME) currently working for money?
NO 2
DON'T KNOW 8
MARITAL STATUS FOR ALL AGED 10 YEARS OR ABOVE
15. Has (NAME) ever been married?
NO 2
16. WOMEN ELIGIBILITY: CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN AGE 10-49 YEARS.
17. HUSBAND'S LINE NUMBER: WRITE THE LINE NUMBER OF THE HUSBAND OR THOSE IN (16).
IF NOT MARRIED OR IF HUSBAND NOT IN HOUSEHOLD, WRITE '00'.
18. HUSBAND ELIGIBILITY: IF HOUSEHOLD CHOSEN FOR HUSBAND SURVEY, CIRCLE LINE NUMBER OF HUSBANDS OF ALL ELIGIBLE WOMEN.
19. What is the source of water your household uses for dishwashing?
PIPED OUTSIDE DWELLING 12
SURFACE WELL OR OTHER WELL 22
RIVER OR STREAM 32
OTHER (SPECIFY) 51
20. How long does it take to go there?
ON PREMISES 996
20A. How long do you usually wait to get water there?
21. Does your household get drinking water from this same source?
NO 2
22. What is the source of drinking water for embers of your household?
PIPED OUTSIDE DWELLING 12
SURFACE WELL OR OTHER WELL 22
RIVER OR STREAM 32
OTHER (SPECIFY) 51
24. Where do adult women in your household usually defecate?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 41
25. Where do children in your household usually defecate?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 41
NO CHILDREN 51
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
27. How many rooms in your household are used for sleeping?
28. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
29. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.
TIN 32
30. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
31. IS THIS HOUSEHOLD IN A BOSTI (SLUM)?
RECORD OBSERVATION
NO 2