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GHANA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD SCHEDULE

GHANA STATISTICAL SERVICE

IDENTIFICATION

PLACE NAME ______
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD________

INTERVIEW VISITS

INTERVIEW 1
DATE ____
INTERVIEWER'S NAME _____
RESULT** ______

NEXT VISIT:
DATE ____
TIME ____

INTERVIEW 2
DATE ____
INTERVIEWER'S NAME _____
RESULT** ______

NEXT VISIT:
DATE ____
TIME ____

INTERVIEW 3
DATE ____
INTERVIEWER'S NAME _____
RESULT** _______

FINAL VISIT
MONTH ____
YEAR ____
INTERVIEWER'S NAME ____

TOTAL NUMBER OF VISITS ____

RESULT** ____
**RESULT CODES:

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

TOTAL IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____

FIELD EDITED BY
NAME _____
DATE _____

OFFICE EDITED BY
NAME _____
DATE _____

KEYED BY
NAME _____
DATE _____

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.

2. 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 you now, starting with the head of the household.

_______

RESIDENCE

3. Does (NAME) usually live here?

YES 1
NO 2

4. Did (NAME) sleep here last night?

YES 1
NO 2

5. SEX
Is (NAME) male or female?

YES 1
NO 2

6. AGE
How old is he/she?

IN YEARS _____

FOSTERING
ONLY FOR CHILDREN UNDER 15 YEARS OLD:

7. Do any of his/her parents usually live in this household?

YES 1
NO 2

8. ELIGIBILITY
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW

9. WOMAN SUCCESSFULLY INTERVIEWED?
TICK IF YES

YES 1
NO 2

10. HUSBAND'S ELIGIBILITY
CIRCLE LINE NUMBER OF HUSBAND'S ELIGIBLE FOR INTERVIEW

TICK HERE IF CONTINUATION SHEET USED ____

TOTAL NUMBER OF ELIGIBLE WOMEN ____

TOTAL NUMBER OF ELIGIBLE HUSBANDS ____

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 1 (ENTER EACH IN TABLE)
NO 2

2) 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?

YES 1 (ENTER EACH IN TABLE)
NO 2

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

YES 1 (ENTER EACH IN TABLE)
NO 2