IDENTIFICATION

STATE _______
DISTRICT ______
TEHSIL/TALUK _______
CITY/TOWN/VILLAGE_______

LARGE CITY/SMALL CITY/TOWN/RURAL AREA _____

PSU NUMBER ______
HOUSEHOLD HUMBER ______
NAME OF HOUSEHOLD HEAD _______
ADDRESS OF HOUSEHOLD _______

INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME _______
RESULT _______

NEXT VISIT
DATE _______
TIME _______

FINAL VISIT
DAY _______
MONTH _______
YEAR 19_____
NAME CODE _______
RESULT CODE _______

TOTAL NUMBER OF VISITS _______

TOTAL PERSONS IN HOUSEHOLD ________
TOTAL ELIGIBLE WOMEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD SCHEDULE _____

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR
NAME ________
DATE ________

KEYED BY ______

HOUSEHOLD SCHEDULE

1. RECORD THE TIME.

Now I would like some information about the people who usually live in your household or who are staying with you now.

2. LINE NUMBER

3. 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.

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

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

6. RESIDENCE: Did (NAME) stay here last night?

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

8. AGE: How old is (NAME)?

9. MARITAL STATUS (IF AGE 10 OR OLDER): What is the current marital status of (NAME)?

ELIGIBILITY
10. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 (EXCLUDE NG AND NM)

11. EDUCATION: Can (NAME) read and write?

12. EDUCATION: Has (NAME) ever been to school?

IF NEVER ATTENDED SCHOOL:

13. What is the main reason (NAME) never went to school?

14. What is the highest standard (NAME) has completed?

IF EVER ATTENDED SCHOOL AND AGE LESS THAN 18 YEARS:

15. Is (NAME) still in school?

16. IF NOT IN SCHOOL: What is the main reason (NAME) is not attending school?

TICK HERE IF CONTINUATION SHEET USED ______
TOTAL NUMBER OF ELIGIBLE WOMEN ______

OCCUPATION: IF AGE 6 YEARS OR OLDER:

17. What kind of work does (NAME) do most of the time?

18. IF WORKING: Does (NAME) earn cash for this work?

AFTER COMPLETING COLUMNS 1-18 FOR ALL LISTED PERSONS, ASK:

19. Does anyone listed suffer from Asthma?

20. Does anyone listed suffer from Tuberculosis?

21. IF SUFFERS FROM TUBERCULOSIS: Has (NAME) received medical treatment for tuberculosis?

22. Did anyone listed suffer from malaria at any time during the last three months?

23. Did anyone listed suffer from jaundice at any time during the last twelve months?

Does anyone listed:

24. Chew paan masala or tobacco?

Does anyone listed:

25. Drink alcohol?

Does anyone listed:

26. Smoke?

27. Has any (other) person listed ever smoked regularly?
RECORD FOR CURRENT NONSMOKERS ONLY

28. Just to make sure that I have a complete listing:

1) Are there any other persons such as small children?

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 stayed here last night?

29. When members of your household get sick, where do they generally go for treatment?

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

31. How long does it take to go there, get water, and come back in one trip?

32. What do you do to purify drinking water, if anything?
RECORD ALL MENTIONED.

33. What kind of toilet facility does your household have?

34. What is the main source of lighting for your household?

35. How many rooms are there in your household?

36. Do you have a separate room which is used as a kitchen?

37. What type of fuel does your household mainly use for cooking?

38. What other types of fuel does your household commonly use for cooking or heating? RECORD ALL MENTIONED.

39. What is the religion of the head of the household?

40. What is the caste or tribe of the head of the household?

41. Is this a scheduled caste, a scheduled tribe, other backward caste, or none of them?

42. Does this household own this house or any other house?

43. Does this household own any agricultural land?

44. How much agricultural land does this household own?

45. Out of this land, how much is irrigated?

46. Does this household own any livestock?

47. Does the household own any of the following:

A mattress?
A pressure cooker?
A chair?
A cot or bed?
A table?
A clock or watch?
An electric fan?
A bicycle?
A radio or transistor?
A sewing machine?
A telephone?
A refrigerator?
A black and white television?
A colour television?
A moped, scooter, or motorcycle?
A car?
A water pump?
A bullock cart?
A thresher?
A tractor?

48. What is the main type of kitchenware this household uses?

49. TYPE OF HOUSE.
RECORD OBSERVATION.

50A. TYPE OF SALT USED FOR COOKING:

50B. TEST COOKING SALT FOR IODINE:

51. Did any usual resident of this household die since January 1996?

52 How many persons died?

53. What (was/were) the name of the person(s) who died?

54. Was (NAME) a male or a female?

55. How old was he/she when he/she died?
RECORD DAYS OF LESS THAN ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR YEARS.

56. In what month and year did (NAME) die?

57. What did (NAME) die of?

58. CHECK 54 AND 55:
DECEASED WAS FEMALE AGED 15-49 AT THE TIME OF DEATH?

59. Was (NAME) pregnant when she died?

60. Did (NAME) die during childbirth?

61. Did (NAME) die within two months after the end of a pregnancy or childbirth?

62. Was the death of (NAME) due to a complication of the pregnancy or childbirth?

63. RECORD THE TIME.