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DEMOGRAPHIC AND HEALTH SURVEY- BANGLADESH 1993-94 - HOUSEHOLD QUESTIONNAIRE (ENGLISH)

BANGLADESH

IDENTIFICATION

DIVISION:
DISTRICT:
UPAZILA OR THANA:
UNION:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE:

1 DHAKA OR CHITTAGONG
2 SMALL CITY
3 TOWN
4 VILLAGE

NAME OF HOUSEHOLD HEAD:

IS HOUSEHOLD SELECTED FOR HUSBAND SURVEY?

YES 1
NO 2

INTERVIEWER VISITS:

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME RO NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ___

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH

01 JANUARY
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER

YEAR 199_
NAME
RESULT

TOTAL NUMBER OF VISITS

TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE

NAME
DATE

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?

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED OR FOSTER CHILD
11 NOT RELATED
98 DOES NOT KNOW

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?

YES (ENTER EACH IN TABLE)
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?

YES (ENTER EACH IN TABLE)
NO

6. Do you have any guest or temporary visitors staying here, or anyone else who slept here last night?

YES (ENTER EACH IN TABLE)
NO

7. RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

8. Did (NAME) sleep here last night?

YES 1
NO 2

9. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

10. AGE: How old is (NAME)?

IN YEARS ___

EDUCATION IF AGED 6 YEARS OR OLDER

11. Has (NAME) ever been to school?

YES 1
NO 2

IF ATTENDED SCHOOL
12. What is the highest level of school (NAME) attended? What is the highest class (NAME) completed?

LEVEL
1 PRIMARY
2 SECONDARY
3 COLLEGE OR UNIVERSITY
8 DOES NOT KNOW
CLASS
00 LESS THAN 1 YEAR COMPLETED
98 DOES NOT KNOW

IF AGED LESS THAN 25 YEARS

13. Is (NAME) still in school?

YES 1
NO 2

EMPLOYMENT IF AGED 8 YEARS OR OLDER
14. Is (NAME) currently working for money?

YES 1
NO 2
DON'T KNOW 8

MARITAL STATUS FOR ALL AGED 10 YEARS OR ABOVE
15. Has (NAME) ever been married?

YES 1
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 WATER
PIPED INSIDE DWELLING 11 (GO TO 21)
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SURFACE WELL OR OTHER WELL 22
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41 (GO TO 21)
OTHER (SPECIFY) 51

20. How long does it take to go there?

MINUTES ___
ON PREMISES 996

20A. How long do you usually wait to get water there?

MINUTES ___

21. Does your household get drinking water from this same source?

YES 1 (GO TO 24)
NO 2

22. What is the source of drinking water for embers of your household?

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SURFACE WELL OR OTHER WELL 22
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 51

24. Where do adult women in your household usually defecate?

SEPTIC TANK OR MODERN TOILET 11
PIT TOILET OR LATRINE
WATER SEALED OR SLAB LATRINE 21
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
NO FACILITY OR BUSH OR FIELD 31
OTHER (SPECIFY) 41

25. Where do children in your household usually defecate?

SEPTIC TANK OR MODERN TOILET 11
PIT TOILET OR LATRINE
WATER SEALED OR SLAB LATRINE 21
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
NO FACILITY OR BUSH OR FIELD 31
OTHER (SPECIFY) 41
NO CHILDREN 51

26. Does your household have:

Almirah (wardrobe)?
YES 1
NO 2
A table, chair or bench?
YES 1
NO 2
A cot or bed?
YES 1
NO 2
Electricity?
YES 1
NO 2
A radio that is working?
YES 1
NO 2
A television that is working?
YES 1
NO 2
A bicycle?
YES 1
NO 2
Agricultural land?
YES 1
NO 2

27. How many rooms in your household are used for sleeping?

ROOMS ___

28. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOF
KATCHA (BAMBOO OR THATCH) 11
RUDIMENTARY ROOF
TIN 21
FINISHED ROOF
CEMENT OR CONCRETE 31
OTHER (SPECIFY) 41

29. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.

NATURAL WALLS
JUTE OR BAMBOO OR MUD (KATCHA) 11
RUDIMENTARY WALLS
WOOD 21
FINISHED WALLS
BRICK OR CEMENT 31
TIN 32
OTHER (SPECIFY) 41

30. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH OR BAMBOO (KATCHA) 11
RUDIMENTARY FLOOR
WOOD 21
FINISHED FLOOR (PUKKA)
CEMENT OR CONCRETE 31
OTHER (SPECIFY) 41

31. IS THIS HOUSEHOLD IN A BOSTI (SLUM)?
RECORD OBSERVATION

YES 1
NO 2