PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
INTERVIEWER VISITS
DATE
INTERVIEWER'S NAME
RESULT
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) ___
FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT
TOTAL NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
01 AMARIGNA
02 OROMIGNA
03 TIGRIGNA
04 ENGLISH
06 OTHER
LANGUAGE OF INTERVIEW
02 OROMIGNA
03 TIGRIGNA
04 ENGLISH
06 OTHER
NATIVE LANGUAGE OF RESPONDENT
02 OROMIGNA
03 TIGRIGNA
04 ENGLISH
06 OTHER
TRANSLATOR USED
NO 2
FIELD EDITOR
OFFICE EDITOR
KEYED BY
Hello, My name is _____ . I am working with the Ethiopian Public Health Institute. We are conducting a survey about health and other topics all over Ethiopia. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15-20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card.
GIVE CARD WITH CONTACT INFORMATION
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ________
DATE _______
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES ___
1. LINE NO. ____
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.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON. ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTION IN COLUMNS 5-20 FOR EACH PERSON.
2A. Just to make sure that I have a complete listing: are there any other people such as small children or infants that we have not listed?
NO
2B. Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
NO
2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night who have not been listed?
NO
3. RELATIIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of household?
WIFE OR HUSBAND 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
NIECE/NEPHEW 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
7. AGE: How old is (NAME)?
IF LESS THAN 1 YEAR, RECORD 00. IF 95 OR MORE, RECORD 95.
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.
16. EVER ATTENDED SCHOOL: Has (NAME) ever attended school?
NO 2 (SKIP TO NEXT)
17. EVER ATTENDED SCHOOL: What is the highest level of school (NAME) has attended? What is the highest grade or year (NAME) completed at that level?
PRIMARY 1
SECONDARY 2
TECHNICAL/VOCATIONAL 3
HIGHER 4
DON'T KNOW 98
18. CURRENT/RECENT SCHOOL ATTENDANCE: Did (NAME) attend school at any time during the 2011 E.C. school year?
NO 2 (SKIP TO NEXT)
19. CURRENT/RECNET SCHOOL ATTENDANCE: During this/that school year, what level and grade or year is/was (NAME) attending?
PRIMARY 1
SECONDARY 2
TECHNICAL/VOCATIONAL 3
HIGHER 4
DON'T KNOW 98
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 109)
PIPED TO NEIGHBOR 13 (SKIP TO 109)
PUBLIC TAP/STANDPIPE 14
DUG WELL
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTELD WATER 91 (SKIP TO 109)
OTHER _____ 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 109)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
109. What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 113)
OTHER ____ 96
110. Do you share this toilet facility with other households?
NO 2 (SKIP TO 112)
111. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
112. Where is this toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
113. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP 09
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95 (SKIP TO 116)
OTHER ___ 96
114. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (SKIP TO 116)
OUTDOORS 3 (SKIP TO 116)
OTHER ____ 6 (SKIP TO 116)
115. Do you have a separate room which is used as a kitchen?
NO 2
116. How many rooms in this household are used for sleeping?
117. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 119)
118. How many of the following animals does this household own?
IF NONE, RECORD 00
IF 95 OR MORE RECORD 95
IF UNKNOWN RECORD 98
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950.
95 OR MORE HECTARES 950
DON'T KNOW 998
121. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
122. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
123. Does any member of this household have a bank account or microfinance savings account?
NO 2
124. Is your household receiving cash or food from the Safety Net Program?
NO 2
125. Is your household enrolled in a Community Based Health Insurance scheme?
NO 2
126. Does your household own this dwelling, occupy this dwelling free of charge (or subsidized ????), or rent this dwelling form the kebele, an agency, an employer, or from individuals?
FREE OF CHARGE OR SUBSIDIZED 2
RENTED FROM KEBELE/AGENCY/EMPLOYER/INDIVIDUALS 3
OTHER ___ 6
ADDITIONAL HOUSEHOLD CHARACTERISTICS
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
CANE/PALM/TRUNKS/BAMBOO/REED 12
DIRT 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
MINUTES ___