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REPUBLIC OF GHANA GHANA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD SCHEDULE (ENGLISH)

IDENTIFICATION

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

URBAN/RURAL

URBAN=1
RURAL=2

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

large city=1
medium city=2
small city=3
town=4
village=5

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 ____
***RESULT CODES:

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

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?

______

* CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:

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

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

YES 1
NO 2

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

YES 1
NO 2

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

M 1
F 2

7. AGE: How old is (NAME)?

IN YEARS ___

MARITAL STATUS AGE 12+

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

MARRIED 1
CONSENSUAL 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
NEVER MARRIED 6

EDUCATION

**IF AGED 6 YEARS OR OLDER

9. Has (NAME) ever been to school?

YES 1
NO 2 (GO TO 11b)

IF ATTENDED SCHOOL

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

LEVEL ____
GRADE ____

** CODES FOR Q 10
LEVEL OF EDUCATION:

1 = PRIMARY
2 = MIDDLE/JSS
3 = SSS/COMMERCIAL/TECHNICAL/4 YEAR IRG. COLLL.
4 = POST SEC./NURSING TRG/POLYTECHNIC
5 = HIGHER
8 = DK

GRADE:

00 = LESS THAN 1 YEAR COMPLETED
98 = DK

IF AGED LESS THAN 25 YEARS

11a. Is (NAME) still in school?

YES 1 (GO TO 12)
NO 2

11b. If no, why?

FINANCIAL CONSTRAINT 1
SCHOOL TOO FAR 2
LACK OF INTEREST 3
DISABILITY 4
NEEDED TO HELP IN FAMILY 5
GRADUATED 6
OTHER 7

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)

DESCRIPTION ____________

13. What kind of industry is it connected with?

TYPE ______

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

OWN ACCOUNT W/O EMPL 1
EMPLOYER 2
UNPAID FAMILY WORKER 2
FOR WAGES/SALARY 4

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?

YES 1
NO 2

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

YES (ENTER EACH)
NO

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 (ENTER EACH)
NO

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

YES (ENTER EACH)
NO

HEALTH

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 21)

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

DOCTOR 01
DENTIST 02
MEDICAL ASSISTANT 03
NURSE 04
MIDWIFE 05
PHARMACIST 06
DRUGGIST 07
TRADITIONAL HEALER 08
TB 09
SPIRITUALIST 10
OTHER (SPECIFY) ___ 96

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

AMOUNT _____

MIGRATION

ALL USUAL RESIDENTS AGED 15 OR OLDER

22. Was (NAME) born in this locality?

YES 1
NO 2 (GO TO 24)

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

YES 1
NO 2

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

City 1
Town 2
Village 3

***(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?

IN YEARS _____

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

FOLLOW/JOIN FAMILY 1
WORK RELATED 2
MARRIAGE 3
SCHOOL 4
ADVENTURE/BRIGHTLIGHTS 5
ESCAPE FAMILY PROBLEMS 6
OTHER (SPECIFY) _____ 7

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.

YEARS ____
MONTHS ___

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

FOLLOW/JOIN FAMILY 1
WORK RELATED 2
MARRIAGE 3
SCHOOLS 4
BRIGHTLIGHT 5
ESCAPE FAMILY PROBLEMS 6
OTHER (SPECIFY) ____ 7

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

WESTERN 01
CENTRAL 02
G/ACCRA 03
VOLTA 04
EASTERN 05
ASHANTI 06
B. AHAFO 07
NORTHERN 08
U. WEST 09
U. EAST 10
NIGERIA 11
C. D'IVORE 12
B. FASO 14
OTHER AFRICA 15
OUTSIDE AFRICA 16

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

CITY 1
TOWN 2
VILLAGE 3

DISABILITY

31. Does (NAME) have difficulty moving?

YES 1
NO 2

32. Does (NAME) have difficulty seeing?

YES 1
NO 2

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

YES 1
NO 2

34. Does (NAME) have difficulty learning?

YES 1
NO 2

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

YES 1
NO 2

36. Does (NAME) have fits?

YES 1
NO 2

37. Does (NAME) behave strangely?

YES 1
NO 2

38. Does (NAME) have any other difficulty?

YES 1
NO 2

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

MOVING 1
SEEING 2
HEARING/SPEAKING 3
LEARNING 4
LOSS OF FEELING IN THE HAND/FOOT 5
FITS 6
BEHAVE STRANGELY 7
OTHER 8

PARENTAL SURVIVORSHIP AND RESIDENCE

FOR PERSONS LESS THAN 15 YEARS OLD***

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

YES 1
NO 2 (GO TO 42)
DK 8 (GO TO 42)

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?

YES 1
NO 2 (GO TO 44)
DK 8 (GO TO 44)

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)

35. 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?

PIPED WATER
PIPED INTO RESIDENCE/YARD/COMPOUND 11 (GO TO 48)
PUBLIC TAP/NEIGHBOUR'S HSE 12
WELL WATER
WELL IN RESIDENCE/YARD/COMP 21 (GO TO 48)
PUBLIC WELL 22
BOREHOLE 23
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/DAM 33
DAM 34
DUGOUT 35
RAINWATER 41 (GO TO 48)
TANKER TRUCK 51
BOTTLED WATER 61 (SKIP TO 48)
OTHER (SPECIFY) ____ 96

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

MINUTES ___
HOURS ___
ON PREMISES 996

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

YES 1 (GO TO 51)
NO 2

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

PIPED WATER
PIPED INTO RESIDENCE/YARD/COMPOUND 11 (SKIP TO 51)
PUBLIC TAP/NEIGHBOUR'S HSE 12
WELL WATER
WELL IN RESIDENCE/YARD/COMP 21 (SKIP TO 51)
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/DAM 33
DAM 34
DUGOUT 35
RAINWATER 41 (GO TO 51)
TANKER TRUCK 51
BOTTLED WATER 61 (SKIP TO 51)
OTHER (SPECIFY) ____ 96

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

HOURS ___
MINUTES ____
ON PREMISES 996

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

FLUSH TOILET
OWN WC 11
SHARED WC 12
PIT TOILET/LATRINE
TRADITIONAL PIT LATRINE 21
VENTILATED IMPROVED PIT (VIP LATRINE) 22
NO FACILITY (BUSH/FIELD) 41
OTHER (SPECIFY) ____ 96

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

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
VIDEO
YES 1
NO 2

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

ROOMS _____

54. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND/MUD 11
MUD MIXED WITH DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
TERRAZO 36
OTHER (SPECIFY) _____ 96

55. Does any member of your household own:

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

BICYCLE
YES 1
NO 2
MOTORCYCLE
YES 1
NO 2
MOTOR VEHICLE
YES 1
NO 2
TRACTOR
YES 1
NO 2
HORSE/CART
YES 1
NO 2