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DEMOGRAPHIC AND HEALTH SURVEY-ETHIOPIA 2000-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

REGION _____________

ZONE _______________

WOREDA _____________

TOWN _______________

KEBELE _____________

ENUMERATION AREA __________

CLUSTER NUMBER

URBAN/RURAL:

URBAN 1
RURAL 2

TYPE OF PLACE:

LARGE CITY 1
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4

HOUSEHOLD NUMBER ______________

NAME OF HEAD OF HOUSEHOLD _________________

HOUSEHOLD SELECTED FOR MALE INTERVIEW?

YES 1
NO 2

INTERVIEW VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 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___

FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INTERVIEWER NUMBER ______
RESULT ___

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ___ ___

TOTAL ELIGIBLE WOMEN ___ ___

TOTAL ELIGIBLE MEN ___ ___

TOTAL ELIGIBLE CHILDREN ___ ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___ ___

SUPERVISOR
NAME _________________
DATE _________________ ___ ___

FIELD EDITOR
NAME _________________
DATE _________________ ___ ___

OFFICE EDITOR ___ ___

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 NO.

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.

NAME ___________________________________

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

HEAD 01
WIFE OR HUSBAND OR PARTNER 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
ADOPTED/FOSTER/STEPCHILD 10
OTHER RELATIVE 11
NOT RELATED 12
DON'T KNOW 98

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is (NAME)?

IN YEARS ___ ___

ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

9A) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OF AGE

Q.10 THROUGH Q.13:
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

10) Is (NAME)'s natural mother alive?

YES 1
NO 2
DON'T KNOW 8

11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

LINE NUMBER ___ ___

12) Is (NAME)'s natural father alive?

YES 1
NO 2
DON'T KNOW 8

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

LINE NUMBER ___ ___

IF AGE 5 YEARS OR OLDER:

14) LITERACY: Is (NAME) able to read and write a simple sentence?

YES 1
NO 2
DON'T KNOW 8

15) EDUCATION: Has (NAME) ever had any formal education?

YES 1
NO 2 (GO TO NEXT LINE)

16) What is the highest grade (NAME) completed?

GRADE ___ __
LESS THAN 1 YEAR COMPLETED 00
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98

CURRENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

17) Is (NAME) currently attending school?

YES 1 (GO TO 19)
NO 2

18) During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 20)

19) During the current school year, what grade [is/was] (NAME) attending?

GRADE ___ ___
LESS THAN 1 YEAR COMPLETED 00
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98

20) During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO NEXT LINE)

20A) During that school year, what grade did (NAME) attend?

GRADE ___ ___
LESS THAN 1 YEAR COMPLETED 00
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98

TICK HERE IF CONTINUATION SHEET USED___

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 may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

YES (ENTER EACH IN TABLE)
NO

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

YES (ENTER EACH IN TABLE)
NO

21. What is the main source of drinking water for members of your household?

PIPED (TAP)
PIPED INTO DWELLING 11 (GO TO 23)
PIPED INTO COMPOUND 12 (GO TO 23)
PIPED OUTSIDE COMPOUND 13
OPEN WELL/SPRING
OPEN WELL 22
OPEN SPRING 23
COVERED WELL/SPRING
COVERED WELL 31
COVERED SPRING 32
SURFACE WATER
RIVER 42
POND/LAKE/DAM 43
RAINWATER 51 (GO TO 23)
OTHER (SPECIFY)___________ 96

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

MINUTES ___ ___ ___

ONE DAY OR LONGER 995
ON PREMISES 996


23. What kind of toilet facility do most members of your household use?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT LATRINE (VIP) 22
NO FACILITY/BUSH/FIELD 31 (GO TO 25)
OTHER (SPECIFY)____________ 96


24. Do you share this facility with other households?

YES 1
NO 2

25. Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A telephone?
YES 1
NO 2
An electric mitad?
YES 1
NO 2
A kerosene lamp/pressure lamp?
YES 1
NO 2
A bed/table?
YES 1
NO 2

25A. Does your household:

Own the house it is living in?
YES 1
NO 2
Have crop land?
YES 1
NO 2
Have cattle/camels?
YES 1
NO 2
Have horse/mule/donkey?
YES 1
NO 2
Have sheep/goats?
YES 1
NO 2
Grow cash crops?
YES 1
NO 2

26. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
OTHER (SPECIFY)__________________ 96

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

EARTH/SAND 11
DUNG 12
WOOD PLANKS 21
REED/BAMBOO 22
PARQUET OR POLISHED WOOD 31
VINYL SHEETS/TILES 32
CEMENT 33
CEMENT TILES/BRICK 34
CARPET 35
OTHER (SPECIFY)___________ 96

27A. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

CORRUGATED IRON 01
CEMENT/CONCRETE 02
WOOD AND MUD 03
THATCH 04
REED/BAMBOO 05
PLASTIC SHEET 06
MOBILE ROOFS OF NOMADS 07
OTHER (SPECIFY)__________ 96

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

ROOMS ___ ___

28. Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A horse or mule for human transport only?
YES 1
NO 2

29. Has any member of your household received any of the following services at a health facility at any time in the past 12 months:

Treatment for a sick child?
YES 1
NO 2
Immunization?
YES 1
NO 2
Family planning education or services?
YES 1
NO 2
Prenatal/postnatal/delivery care?
YES 1
NO 2
Information on prevention of STD/HIV/AIDS?
YES 1
NO 2
Information on breast feeding and infant feeding practices?
YES 1
NO 2

29A. CHECK 29:

AT LEAST ONE "YES" (GO TO 29B)
NOT A SINGLE "YES" (GO TO 29C)

29B. From what facilities have members received these services?
PROBE: Anywhere else?
RECORD BELOW TYPE AND/OR LOCATION OF ALL FACILITIES VISITED BY HOUSEHOLD MEMBERS IN PAST 12 MONTHS. THEN CIRCLE CODE FOR EACH TYPE OF FACILITY MENTIONED.

TYPE/LOCATION____
GOVERNMENT
HOSPITAL A
HEALTH CENTER B
HEALTH STATION/CLINIC C
HEALTH POST D
COMMUNITY-BASED OUTLET E
OTHER GOVERNMENT (SPECIFY)___________F
NONGOVERNMENTAL ORGANIZATION (NGO)
HEALTH FACILITY G
COMMUNITY-BASED OUTLET H
OTHER NGO (SPECIFY) _____________ I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL J
PRIVATE DOCTOR/CLINIC K
OTHER PRIVATE (SPECIFY)_____________ L
OTHER SOURCE (SPECIFY) ___________X

29C. Has any member of your household bought any drugs during the last 12 months?

YES 1
NO 2 (GO TO 29F)

29D.Where were the drugs mainly bought?

PHARMACY/OTHER MEDICAL FACILITY A
NON MEDICAL FACILITY B

29F. Does your household have any bednets that can be used while sleeping?

YES 1
NO 2 (GO TO 35)

29G. Was the bednent ever treated with a product to kill mosquitoes?

YES 1
NO 2

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
30 PPM 4

HEIGHT AND WEIGHT MEASUREMENT

CHECK COLUMN (8): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 IN Q.36 TO Q.38 IN THE HEIGHT AND WEIGHT GRID FOR WOMEN BELOW. THEN CHECK COLUMN (9) AND RECORD THE LINE NUMBER,
NAME AND AGE OF ALL CHILDREN UNDER AGE 6 IN COLUMNS Q.44-Q.46 IN THE HEIGHT AND WEIGHT GRID FOR CHILDREN.

36) LINE NO. FROM COL (8)/(9)

LINE NUMBER___ ___

37) NAME FROM COL. (2)

NAME ___________________

38) AGE FROM COL. (7)

YEARS___ ___

39) What is (NAME)'s date of birth?
[ONLY FOR CHILDREN UNDER AGE 6]

DAY___
MONTH___
YEAR___

40) WEIGHT (KILOGRAMS)

WEIGHT ___ ___ ___ . ___

41) HEIGHT (CENTIMETERS)

HEIGHT ___ ___ ___.___

42) MEASURED LYING DOWN OR STANDING UP
[ONLY FOR CHILDREN UNDER AGE 6]

LYING 1
STANDING 2

43) RESULT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 4