IDENTIFICATION

PLACE NAME __________
NAME OF HOUSEHOLD HEAD ____________
EA NUMBER _____________
STRUCTURE NUMBER ___________
HOUSEHOLD NUMBER ___________
REGION ____________________

URBAN/RURAL

LARGE CITY/MEDIUM CITY/SMALL CITY/TOWN/VILLAGE ____________

FOR OFFICE USE
Large city 1,000,000 and over
Medium city 500,000 - 999,999
Small city 50,000 - 499,999
Town 5,000 - 49,999
Village under 5,000

INTERVIEWER 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
DAY ____
MONTH ____
YEAR ____
NAME ____

TOTAL NUMBER OF VISITS _____

***RESULT CODES:

TOTAL IN HOUSEHOLD ____

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ____

LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ____

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. (1)

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.

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

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

5. RESIDENCE: Did (NAME) sleep here last night?

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

7. AGE: How old is (NAME)?

MARITAL STATUS AGE 12+

8. What is (NAME)'S current marital status?

EDUCATION

**IF AGED 6 YEARS OR OLDER

9. Has (NAME) ever been to school?

IF ATTENDED SCHOOL

10. What is the highest level of school (NAME) attended?
What is the highest grade (NAME) completed at that level?

LEVEL OF EDUCATION:

GRADE:

IF AGED LESS THAN 25 YEARS

11a. Is (NAME) still in school?

11b. If no, why?

OCCUPATION

FOR THOSE AGED 7 YEARS AND ABOVE

12. What work did (NAME) do during the past 7 days, even if (NAME) was not paid for it?
Describe what (NAME) did in this work?

IF ONLY STUDENT/HOMEMAKER/UNEMPLOYED (SKIP TO Q17)

13. What kind of industry is it connected with?

14. In this work did (NAME) work on own account, as an employer, as unpaid family worker or for wages/salary?

15. For how many days during the past 7 days did (NAME) do this work?

16. During these days how many hours per day did (NAME) do this work? (16)
RECORD HOURS WORKED AND SKIP TO Q18.

17. Did (NAME) look for work during the past 7 days?

1) Are there any other persons such as small children or infants that we have not listed?

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?

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

HEALTH

18. During the past 2 weeks has (NAME) suffered from either an illness or an injusry?

19. Has (NAME) had a health consultation in the past 2 weeks?

20. In the past 2 weeks whom did (NAME) consult?

21. Did (NAME) pay anything for medical supplies or consultation in the past 2 weeks? (21)
IF YES: How much?
IF NO: ENTER "0"

MIGRATION

ALL USUAL RESIDENTS AGED 15 OR OLDER

22. Was (NAME) born in this locality?

23. Has (NAME) lived anywhere else for at least 6 months?

24. At the time of (NAME'S) birth, was his/her birthplace a:

***(Q24) CHECK IF YES IN Q22 AND NO IN Q23 THEN SKIP TO Q31.

25. How old was (NAME) when he/she left his/her place of birth for the first time to live somewhere else?

26. What was the main reason (NAME) moved the first time?

MIGRATION

ALL USUAL RESIDENTS AGED 15 OR OLDER

27. How long has (NAME) lived in (PRESENT PLACE OF RESIDENCE) since his/her last move?
TIME IN YEARS
IN MONTHS IF LESS THAN 1 YEAR.

28. What was the main reason (NAME) came to (PRESENT PLACE OF RESIDENCE)?

29. Which region or country did (NAME) move from?

30. Was the place where (NAME) was living before coming here a city, town or village?

DISABILITY

31. Does (NAME) have difficulty moving?

32. Does (NAME) have difficulty seeing?

33. Does (NAME) have difficulty hearing/speaking?

34. Does (NAME) have difficulty learning?

35. Has (NAME) loss of feeling in the hand/foot?

36. Does (NAME) have fits?

37. Does (NAME) behave strangely?

38. Does (NAME) have any other difficulty?

39. IF MORE THAN ONE "YES": Which is the main difficulty (NAME) has?

PARENTAL SURVIVORSHIP AND RESIDENCE

FOR PERSONS LESS THAN 15 YEARS OLD***

40. Is (NAME)'s natural mother alive?
.

41. IF MOTHER ALIVE: Does (NAME)'S natural mother live in this household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER

42. Is (NAME)'S natural father alive?

43. IF FATHER ALIVE: Does (NAME)'S natural father live in this household?
IF YES: What is his name?

RECORD FATHER'S LINE NUMBER.

44. ELIGIBILITY (WOMAN)
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.
(15-49 YEARS)

45. ELIGIBILITY (MAN)
CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INTERVIEW.
(15-49 YEARS)

46. What is the source of water your household uses for laundry and dishwashing?

47. How long does it take to go there, get water, and come back?
RECORD RESPONSE

48. Does your household get drinking water from this same source?

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

50. How long does it take to go there, get water, and come back?
RECORD RESPONSE

51. What kind of toilet facility does your household use?

52. Does your household have:
Electricity?
A functioning radio?
A functioning television?
A functioning refrigerator?
A functioning video?

53. How many rooms in your household are used for sleeping?

54. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

55. Does any member of your household own:

A bicycle?
A motorcycle?
A motor vehicle?
A tractor?
A horse/cart?