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DEMOGRAPHIC AND HEALTH SURVEY

HOUSEHOLD QUESTIONNAIRE

Ministry of Territory Planning and Development
Republic of Cameroon
"Peace-Work-Country"

IDENTIFICATION

PROVINCE __________
DEPARTMENT __________
URBAN DISTRICT/DISTRICT __________
CITY/COUNTY/GROUP __________
VILLAGE __________
NEIGHBORHOOD/TOWN __________
NAME OF RESPONDENT __________

PROVINCE ____
STRATUM NUMBER _______
URBAN DISTRICT/DISTRICT _________
CLUSTER NUMBER _____
STRUCTURE NUMBER _________
HOUSEHOLD NUMBER ________
NUMBER OF COUNTING ZONE_______

HUSBAND SURVEY?

YES 1
NO 2

INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___

RESULTS___

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

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__

RESULT__

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

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___

LINE NO. OF SURVEYED HOUSEHOLD ___
NO. OF QUESTIONNAIRE ___
NO. OF QUESTIONNAIRES ___

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

HOUSEHOLD QUESTIONNAIRE

0) RECORD TIME

HOUR ___
MINUTE ___

HUSBAND SURVEY

YES 1
NO 2

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

2) FIRST AND LAST NAME:
Please give me the name of the people 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 THE HOUSEHOLD:
What is the relationship of (name) to the head of 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 UNCLE OR AUNT
10 COUSIN/NIECE/NEPHEW
11 OTHER RELATIVE
12 NOT RELATED
13 DK

4) RESIDENCE STATUS: Does (name) usually live here?

YES 1
NO 2

5) RESIDENCE STATUS: Did (name) sleep here last night?

YES 1
NO 2

6) SEX: Is (name) male or female?

MALE 2
FEMALE 2

7) AGE: How old is (name)?

IN YEARS: ___

8) EDUCATION: Does (name) know how to read and write?

YES 1
NO 2

9) EDUCATION: Has (name) ever been to school?

YES 1
NO 2 (GO TO 12)

10) EDUCATION:

What is the highest level of school (name) attended?
What is that highest grade (name) completed) at this level?

IF THE LEVEL IS NURSERY SCHOOL, DO NOT WRITE ANYTHING FOR GRADE.

LEVEL

NURSERY SCHOOL 0
PRIMARY 1
HIGHER 2
SUPERIOR 3
DK 4

GRADE

PRIMARY
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
SECONDARY
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7

IF AGED LESS THAN 25 YEARS:
11) EDUCATION: Is (name) still in school?

YES 1
NO 2

FOR THOSE LESS THAN 15 YEARS OF AGE:
12) SUPERVISION OF CHILDREN: Is (name)'s natural mother alive?

YES 1
NO 2 (GO TO 14)
DK 8 (GO TO 14)

13) IF ALIVE:

Does (name)'s natural mother live in this household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.

THIS QUESTION REFERS TO THE BIOLOGICAL PARENTS OF THE CHILD. RECORD '00' IF THE PARENT IS NOT A MEMBER OF THE HOUSEHOLD.

____

14) Is (name)'s natural father alive?

YES 1
NO 2 (GO TO 16)
DK 8 (GO TO 16)

15) IF ALIVE:

Does (Name)'s natural father live in this household?
IF YES: what is his name?

RECORD FATHER'S LINE NUMBER.

THIS QUESTION REFERS TO THE BIOLOGICAL PARENTS OF THE CHILD. RECORD '00' IF THE PARENT IS NOT A MEMBER OF THE HOUSEHOLD.

____

16) WOMEN IN A UNION:
Is (name) married or currently living with partner?

(FOR WOMEN AGES 15 TO 49)

YES 1
NO 2

17) ELIGIBILITY OF WOMEN: CIRCLE THE ORDER NUMBER OF THE WOMEN (SEE 7) WHO SLEPT IN THE HOUSEHOLD LAST NIGHT (YES TO 5).

18) ELIGIBILITY OF HUSBANDS:
Does the husband/partner normally live in this household?
IF YES: what is his name?

(FOR EACH ELIGIBLE WOMAN IN A UNION)
RECORD THE LINE NUMBER OF THE HUSBAND IN FRONT OF THAT OF HIS WIFE. IF NONE, RECORD '00' IN FRONT OF THE LINE NUMBER OF HIS WIFE.

___

TICK HERE IF 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?

YES ___ (ENTER EACH IN TABLE)
NO ___

2. In addition, are there any other people who may not be members of your family, such as domestic servants or friends who normally live in your household?

YES___ (ENTER EACH IN TABLE)
NO ___

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

YES __ (ENTER EACH IN TABLE)
NO __

19) What is the source of water to wash the dishes, to wash clothes, and to bathe?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 21)
PIPED INTO YARD 12 (GO TO 21)
PIPED INTO NEIGHBOR'S YARD 13
PUBLIC TAP 14
WELL WATER
MANUAL WELL PUMP 21
WELL WITHOUT PUMP 22
SURFACE WATER
RIVER/BACKWATER/MARSHLAND/UNPROTECTED WELL 31
RAINWATER 41
OTHER (SPECIFY): ___ 51

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

IF 90 MINUTES OR LESS, RECORD THE MINUTES. IN OTHER CASES, RECORD IN HOURS.

MINUTES: ___ 1
HOURS: ___ 2
ON PREMISES 996

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 members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (go to 24)
PIPED INTO YARD 12 (go to 24)
PIPED INTO NEIGHBOR'S YARD 13
PUBLIC TAP 14
WELL WATER
MANUAL PUMP WELL 21
WELL WITHOUT PUMP 22
SURFACE WATER
RIVER/BACKWATER/MARSHLAND/UNPROTECTED SPRING 31
RAINWATER 41
OTHER (SPECIFY): ___ 51

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

IF 90 MINUTES OR LESS, RECORD IN MINUTES. IN OTHER CASES, RECORD IN HOURS.

MINUTES: ___ 1
HOURS: ___ 2
ON THE PREMISES 996

24) What kind of toilet facility does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD
OUTSIDE 31
RIVER 32
NO TOILET 33
OTHER (SPECIFY) 41

25) Does your household have:

Electricity?
A radio?
A television?
A refrigerator?
A gas or electric stove?
A gas ring or a hotplate?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
GAS OR ELECTRIC STOVE
YES 1
NO 2
GAS RING OR HOTPLATE
YES 1
NO 2

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

ROOMS: ___

27) How many people sleep in the room that sleeps the most people?

NUMBER OF PEOPLE: ___

28) MAIN MATERIAL OF THE FLOOR.

(RECORD OBSERVATION)

NATURAL FLOOR
SOIL 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
CEMENT 31
TILE 32
OTHER (SPECIFY): ___ 41

29) Does someone in your household own:

A bicycle?
A motorcycle?
A car?

BICYCLE
YES 1
NO 2
MOTORCYCLE
YES 1
NO 2
CAR
YES 1
NO 2

30) RECORD THE TIME:

HOUR: ___
MINUTES: ___