IDENTIFICATION

GOVERNORATE __________
PSU/SEGMENT NO. _____________
KISM/MARKAZ __________
BUILDING NO. ________________
SHIAKHA/VILLAGE __________
HOUSE NO. ___________

URBAN 1
RURAL 2

HOUSEHOLD NUMBER ___________

MATERNAL MRT/ANTHROPOMETRY SUBSAMPLE

NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________

GOVERNORATE ____
PSU/SEGMENT NO. ____
HOUSEHOLD NO. ____
SUBSAMPLE ____

INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________

INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________

INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________

FINAL VISIT
MONTH ____
YEAR ____
TEAM _____
INTERVIEWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES) ____
RESULT*____

TOTAL NUMBER OF VISITS ____
TOTAL IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____

* RESULT CODES:

FIELD EDITOR
NAME _________
DATE _________
SIGNATURE __________

OFFICE EDITOR
NAME _________
DATE _________
SIGNATURE __________

CODER
NAME _________
DATE _________
SIGNATURE __________

DATA ENTRY OPERATOR
NAME _________
DATE _________
SIGNATURE __________

ADDRESSED CHECKED __
HOUSEHOLD REVISITED __

HOUSEHOLD SCHEDULE

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

001. LINE NO.

002. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.

AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT YOU HAVE A COMPLETE LISTING. THEN GO ON TO 006-024.

Just to make sure that I have a complete listing:

003. Are there any other persons such as small children or infants who are not listed?

004. 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?

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

006. RELATIONSHIP TO THE HOUSEHOLD HEAD: What is (NAME)'s relationship to the head of the household?

007. RELATIONSHIP TO THE HOUSEHOLD HEAD:

008. RELATIONSHIP TO THE HOUSEHOLD HEAD:

009. RELATIONSHIP TO THE HOUSEHOLD HEAD:

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

011. RESIDENCE: Was (NAME) present last night?

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

013. AGE: How old was (NAME) at his/her last birthday?

014. MARITAL STATUS, ONLY FOR PERSONS FIFTEEN YEARS AND OLDER: What is (NAME)'s current marital status?

015. ELIGIBLE WOMEN: CIRCLE LINE NUMBER FOR WOMEN ELIGIBLE FOR INTERVIEW, I.E., MARRIED, WIDOWED OR DIVORCED WOMEN 15-49 YEARS OLD PRESENT IN THE HOUSEHOLD LAST NIGHT.

EDUCATION STATUS

016. ONLY FOR THOSE THREE YEARS AND OLDER: Has (NAME) attended school in the past or is he/she currently going to school?

017. ONLY FOR PERSONS ATTENDING SCHOOL IN PAST OR CURRENTLY: What was the highest LEVEL that he/she was admitted to?

018. ONLY FOR PERSONS ATTENDING SCHOOL IN PAST OR CURRENTLY: What was the highest GRADE that he/she successfully completed at that level?

019. ONLY FOR PERSONS NEVER ATTENDING SCHOOL OR NOT COMPLETING PRIMARY: Can (NAME) read a newspaper or a letter, for example?

OCCUPATION

020. ONLY FOR PERSONS TWELVE YEARS AND OLDER: What is the main work that (NAME) does?

021. ONLY FOR PERSONS TWELVE YEARS AND OLDER:
OCCUPATIONAL GROUP (FOR CODER)

WORK STATUS

022. ONLY FOR PERSONS TWELVE YEARS AND OLDER WHO WORK: Did (NAME) work during the last month?

023. Is (NAME) usually paid in cash or kind for the work he/she does?

024. COUNT THE NUMBER OF ELIGIBLE WOMEN FOR WHOM LINE NUMBERS ELIGIBLE NUMBERS ARE CIRCLED IN 015. ENTER THE TOTAL IN THE BOXES AT THE BOTTOM OF THE COLUMN IN 015. THEN GO TO 025.

025. CHECK THE COVER TO DETERMINE IF THE HOUSEHOLD IS INCLUDED IN THE MATERNAL MORTALITY/ANTHROPOMETRY SUBBAMPLE AND MARK THE APPROPRIATE RESPONSE BELOW. THEN FOLLOW THE SKIP INSTRUCTIONS.

MATERNAL MORTALITY

ASK QUESTIONS OF ALL PERSONS AGED 15 YEARS AND OLDER PRESENT IN THE HOUSEHOLD THE DAY OF THE INTERVIEW. AFTER COMPLETING THE QUESTIONS FOR ALL ELIGIBLE RESPONDENTS, GO OR TO QUESTION 034.

026. CIRCLE LINE NO. AND RECORD NAMES OF ALL PERSONS AGED 15 AND OLDER. IF PRESENT IN HOUSEHOLD, COMPLETE 027-033A AS APPROPRIATE. IF THE ELIGIBLE PERSON IS NOT PRESENT, OBTAIN INFORMATION FROM ANOTHER HOUSEHOLD MEMBER IF POSSIBLE. IF CANNOT OBTAIN INFORMATION FROM ANYONE ELSE, ENTER '97' IN 027 AND CONTINUE WITH NEXT ELIGIBLE PERSON.

027. How many sisters have you (he/she) ever had who were born to the same mother? IF NONE, ENTER '00' AND SKIP TO 033A.

028. How many of these sisters born to the same mother were married at any time? IF NONE, ENTER '00' AND SKIP TO 033A.

029. How many of these ever-married sisters are still alive? IF NONE, ENTER '00'.

030. How many of these ever-married sisters have died? IF NONE, ENTER '00' AND SKIP TO 033A.

031. How many of these ever-married sisters died while they were pregnant? IF NONE, ENTER '00'.

032. How many of these ever-married sisters died while they giving birth?

033. How many of these ever-married sisters died within six weeks after the end of a pregnancy? IF NONE, ENTER '00'.

033A. ENTER THE CODE IN THE BOX FOR THE PERSON ANSWERING QUESTIONS 027-033.

034. What type of dwelling unit does your household live in?

035. Is your dwelling owned by your household or not?

036. MAIN MATERIAL OF THE FLOOR.

037. How many rooms are there in your dwelling (excluding the bathroom(s), kitchen, and stairway areas)?

038. Is there a special room used only for cooking inside or outside your dwelling?

039. Is the place used for cooking shared with other households?

040. Does the dwelling unit have electrical connections in all or only part of the dwelling unit?

041. What is the major source of drinking water for members of your household?

042. Where is the major source of the water that you use for drinking located?

043. Do you buy your drinking water from the government or from a private source?

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

045. Do you obtain water for household use other than drinking (e.g., handwashing, cooking, etc) from the same source?

046. What is the major source of water for household use other than drinking?

047. Where is the major source of the water that you use for household use other than drinking located?

048. Does your household use water which you have stored for regular use?

049. What kind of toilet facilities does the household have?

050. Is the toilet linked to a public sewer, a canal (river) or a pit?

051. Where are the toilet facilities located?

052. Do you share the toilet facilities with any other household?

053. Are any of the following items found in the dwelling unit:

054. Are any of the following appliances found in the dwelling unit:

055. Do you or any member of your household own any of the following:

OBSERVATIONS

THANK THE RESPONDENT FOR PARTICIPATING IN THE SURVEY. FILL IN THE APPROPRIATE RESPONSES IN QUESTIONS 056-057. BE SURE TO REVIEW THE QUESTIONNAIRE FOR COMPLETENESS BEFORE LEAVING THE HOUSEHOLD.

056. RECORD THE LINE NUMBER OF THE RESPONDENT FOR THE HOUSEHOLD INTERVIEW.

057. DEGREE OF COOPERATION

058. INTERVIEWER'S COMMENTS:
_________________________________

059. FIELD EDITOR'S COMMENTS:
_________________________________

060. SUPERVISOR'S COMMENTS:
_________________________________

061. OFFICE EDITOR'S COMMENTS:
________________________________