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DEPARTMENT OF CENSUS AND STATISTICS OF SRI LANKA
DEMOGRAPHIC AND HEALTH SURVEY

HOUSEHOLD SCHEDULE


IDENTIFICATION

ZONE____
DISTRICT____
SECTOR:

URBAN
RURAL
ESTATE

WARD/GS DIV/ESTATE____
SURVEY BLOCK NUMBER____
HOUSING UNIT NUMBER____
HOUSEHOLD NUMBER____

INTERVIEWER VISITS

FIRST VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*

COMPLETED 1
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9

NEXT VISIT
DATE____
TIME____

SECOND VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*

COMPLETED 1
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9

NEXT VISIT
DATE____
TIME____

FINAL VISIT
DATE____
INTERVIEWERÆS NAME____
RESULT*

COMPLETED 1
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT/ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9

TOTAL NUMBER OF VISITS____

FIELD EDITED BY
NAME____
DATE____

OFFICE EDITED BY
NAME____
DATE____

KEYED BY
NAME____
DATE____

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

1) NAMES: Please give me the names of the persons who usually live in your household or who are staying with you now. (RECORD NAME OF HEAD OF HOUSEHOLD FIRST)

NAME____

RESIDENCE

2) Does (NAME) usually live here?

YES 1
NO 2

3) Did (NAME) usually sleep here last night?

YES 1
NO 2

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5) AGE: How old is he/she?

AGE IN YEARS____

6) MARRIAGE STATUS

FORMERLY MARRIED 1
CURRENTLY 2
NEVER MARRIED 3

7) ELIGIBILITY: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW

LINE NUMBER____

TICK HERE IF CONTINUATION SHEET USED____
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET____

Just to make sure that I have this right:

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

YES (CORRECT AND ENTER NAMES IN TABLE)
NO

2) In addition, are there any other people who usually live here but are not members of your family, such as domestic servants, lodgers or friends whom we have not listed?

YES (CORRECT AND ENTER NAMES IN TABLE)
NO

3) Are there any guests or visitors who are temporarily staying with the family and who spent last night here that are not listed?

YES (CORRECT AND ENTER NAMES IN TABLE)
NO