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DEMOGRAPHIC AND HEALTH SURVEY
STANDARD HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF GUINEA
NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
ADMINISTRATIVE REGION
NATURAL REGION
SANITATION DISTRICT NUMBER
LOCATION OF HOUSEHOLD

CONAKRY 1
OTHER CITY 2
RURAL 3

Household selected for men's survey/tests/health spending?

YES 1
NO 2

INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT


COMPLETED 1
NO HOUSEHOLD MEMBER AT HOM EOR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DDWELLING 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 2018
INT. NUMBER
RESULT


COMPLETED 1
NO HOUSEHOLD MEMBER AT HOM EOR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DDWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___ 9

TOTAL NO. OF VISITS

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE: FRENCH 01
LANGUAGE OF INTERVIEW

FRENCH 01
SOUSSOU 02
PEUL 03
MALINKE 04
KISSI 05
LOMA 06
KPELE 07
OTHER 08

NATIVE LANGUAGE OF RESPONDENT

FRENCH 01
SOUSSOU 02
PEUL 03
MALINKE 04
KISSI 05
LOMA 06
KPELE 07
OTHER 08

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR
NAME
DATE

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Institute of Statistics. We are conducting a survey about health all over Guinea. 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 to 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 AGREES TO BE INTERVIEWED 1 (GO TO 100)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100) RECORD THE TIME

HOURS
MINUTES

HOUSEHOLD SCHEDULE

1) LINE NO.