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Demographic and health surveys 1987
Household schedule

IDENTIFICATION

DISTRICT/SEGMENT________

SUB DISTRICT/SEGMENT________
HOUSEHOLD_________

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER’S NAME
RESULT

1COMPLETED
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _______

SECOND VISIT
DATE
INTERVIEWER’S NAME
RESULT

1COMPLETED
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _______

THIRD VISIT
DATE
INTERVIEWER’S NAME
RESULT

1COMPLETED
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _______

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR 87
INT. NUMBER

RESULT CODE

1COMPLETED
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _______

NO. OF VISITS_______

NAME________
DATE___________
FIELD EDITED BY__________
OFFICE EDITED BY____________
KEYED BY___________
KEYED BY_________

Now I would like some information about the people who usually live in your household or who are staying with you now.

001) HOUSEHOLD NO.

_________

002) LINE NO.

_________

003) FIRST NAMES AND LAST NAMES OF USUAL RESIDENTS AND VISITORS

NAME___________

004) RELATIONSHIP

_______________

005) MARITAL STATUS

SINGLE 1
MARRIED 2
WIDOW 3
DIVORCED 4
SEPARATED 5

006) SEX

MALE 1
FEMALE 2

007) AGE IN COMPLETED YEARS

AGE______________

008) RESIDENCE

RP=1
RA=2
VI=3
[##translator note: The document only had these codes, and not enough information to tell what they mean. VI is most likely for visitor, and RP may be for permanent resident, while RA may be for absent resident, although these are only guesses]

009) NATIONALITY OF HEAD OF HOUSEHOLD

BURUNDI 1
RWANDA 2
ZAIRE 3
TANZANIA 4
OTHER AFRICAN COUNTRY 5
OTHER 6

010) SELECTION OF ELIGIBLE PEOPLE (X)

WOMEN
MEN
CHILDREN

1) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

2) Are there any other people who many not be members of your family, such as domestic servants or lodgers who usually live here?

YES (ADD TO TABLE)
NO

3) Are there any guests or temporary visitors staying here, or anyone else who stayed here?

YES (ADD TO TABLE)
NO