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DEMOGRAPHIC AND HEALTH SURVEYS
(E.P.S.F.-2003) - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

REGION _____

PROVINCE OR PREFECTURE ___

CIRCLE ___

MUNICIPALITY/RURAL MUNICIPALITY ____

OTHER CENTER ___

SURVEY DISTRICT _

RABAT-CASA/LARGER CITY/SMALL CITY/RURAL (RABAT CASA=1, LARGE CITY=2, SMALL CITY=3, RURAL=4) ___

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

HOUSEHOLD ADDRESS ____

NAME OF HEAD OF HOUSEHOLD ________

INTERVIEWER VISITS
1
2
3
Date _______

Interviewer’s name and code and 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 of time
4 Postponed
5 Refused
6 Dwelling vacant or address not a dwelling
7 Dwelling destroyed
8 Dwelling not found
9 Other (Specify)

Next visit
Date ____
Time ______

Final visit
Day___
Month ___
Year 200_

Name ______
Result _____

Total number of visits ____

Total persons in household _____
Total eligible women_____
Line no. of surveyed household ____

Supervisor ____
Name _____
Date _____

Field editor ____
Name ____
Date ____

Office Editor _____

Keyed by _____

Household Schedule

I. List of members of household: member characteristics

Record the time at the beginning of the interview

Hour ___
Minutes ___

1. Line number _______

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.

NAME_____________________

3. Sex
Is (NAME) male or female?

MALE 1
FEMALE 2

4. Birth certificate
Please give me the family's civil registration form or (NAME)'s birth certificate.
If NO, PROBE:
Has (NAME's) birth ever been registered with the civil authority?

None 1
Civil registration 2
Birth certificate 3
Other 4

5. Relationship to the head of household
What is the relationship of (NAME) to the head of the household? _____

01 Head of Household
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
10 Other relative
11 Adopted/Foster child
12 Not related
98 Don’t know

6. Residence
Does (NAME) usually live here?

Yes 1
No 2

7. Did (NAME) stay here last night?

Yes 1
No 2

8. Age
How old is NAME?

In years _______

9. Marital status of those 15 years or older
What is (NAME)'s marital status?

Married 1
Widowed 2
Divorced 3
Single 4

Eligibility

10. Circle the line number of all women age 15-49

11. Circle line number of all children under age 6

12. Circle line number of all single men age 15-24

Education

If age 6 years or older

14. Has (NAME) ever attended school?

Yes 1
No 2 (GO TO 18)

15. What is the highest level of school (NAME) has attended?

1 Primary
2 Preparatory, Secondary 1st cycle
3 Secondary/2nd cycle
4 Higher
8 Don’t know

What is the highest grade (NAME) completed at that level?

GRADE _____
00 Less than 1 year completed
98 Don’t know

If age 6-25 years

16. Is (NAME) currently attending school?

Yes 1 (GO TO 18)
No 2

17. What is the reason (NAME) left school?

01 For work
02 For health reasons
03 Failed/Dismissed
04 Doesn’t like school
05 No transportation/too far
06 Costs too much
07 Family against education
08 Marriage
09 Finished studies
96 Other
98 Don’t know

Professional Activity
If age 10 or older

18. Does (NAME) work ?

Yes 1
No 2 (GO TO 21)

19. What is (NAME)'s main job?

Work ______
Code _____

II. List of household members: prevalence of chronic illnesses
Usual residents and visitors
Copy the names of all members of the household listed for question 2

21) Name ____

Morbidity and treatment

22. Now I would like to ask you few questions about your family members’ health. Does (NAME) suffer from any chronic illness (for a long time)?

Yes 1
No 2 (GO TO 32)

23. What is this illness?

1 Blood pressure
2 Diabetes
3 Gastric ulcer
4 Anemia
5 Heart disease
6 Cancer
7 Kidney disease
8 Liver disease
9 Joint disease
10 Paralysis
11 Chronic pain
12 Scalp/skin disease
13 Seizures
14 Asthma
15 Cholesterol
16 Chronic lung disease
17 Hyperthyroid, apart from cancer
18 Hypothyroid, apart from cancer
19 Prostate problem
20 Eye pressure (increased eye pressure)
21 Cataracts
22 Chronic back pain/Spine issues
23 Mental illness
24 Big skin problems
96 Other
98 Do not know

24. Did a doctor or nurse diagnose this illness?

Yes 1
No 2 (GO TO 26)

25. What was (NAME)'s age when the doctor or the nurse diagnosed (NAME)'s illness?

Age _____

26. Is (name) taking or has (name) ever taken a medicine for this illness?

Yes 1
No 2
Don’t know 3

27. Is (name) suffering from another chronic illness (for a long time)?

Yes 1
No 2 (GO TO 32)

28. What is this illness?

1 Blood pressure
2 Diabetes
3 Gastric ulcer
4 Anemia
5 Heart disease
6 Cancer
7 Kidney disease
8 Liver disease
9 Joint disease
10 Paralysis
11 Chronic pain
12 Scalp/skin disease
13 Seizures
14 Asthma
15 Cholesterol
16 Chronic lung disease
17 Hyperthyroid, apart from cancer
18 Hypothyroid, apart from cancer
19 Prostate problem
20 Eye pressure (increased eye pressure)
21 Cataracts
22 Chronic back pain/Spine issues
23 Mental illness
24 Big skin problems
96 Other
98 Do not know

29. Did a doctor or nurse diagnose this illness?

Yes 1
No 2 (GO TO 31)

30. What was (NAME)'s age when the doctor or the nurse diagnosed this illness?

Age _____

31. Is (name) taking or has ever taken a medicine for this illness?

Yes 1
No 2
Don’t know 3

32. Is (NAME) covered by social welfare or health insurance?

Yes 1
No 2
Don’t know 3

33. Does (NAME) smoke cigarettes or pot or tobacco?

Yes 1 (GO TO next person)
No 2
Don’t know 3

34.

Yes 1
No 2
Don’t know 3

III. List of members of the household: Disability
Usual residents and visitors

Copy the names of all members of the household listed in question 2
41) Name ____

42. Is (name) disabled?
Does (name) suffer from a physical, mental, or health condition that limits his ability to live his daily life in a normal way for a person of his age?

Yes 1
No 2 (GO TO next person)
Don’t know 3

If 42=1, ask questions 43 to 46

43. Does (name) have any of the following problems:
Read each item on the list and circle the codes for all positive ('Yes') responses

Blind A
Deaf B
Mute C
Limping or disabled from his hands or feet D
Crazy or simple-minded E
Paralyzed F
Something else G
Do not know H

44. How did (name) get this problem?
Read the corresponding conditions, one by one, and see which best describes the cause of this problem.

1 Inherited
2 Born with (congenital)
3 Got it at time of birth (delivery problem)
4 Accident
5 Contagious
6 Envy/witchcraft
7 Something else
8 Do not know

45. How old was (name) when this condition started?

Age ____
Since birth 96
Don’t know 98

46. Did (name) take any medication or treatment for the problem or did someone else, apart from you, take care of him?

Yes 1
No 2
Don’t know 3

IV. Dwelling characteristics

51. Observe and record the type of dwelling

Independent house/villa 01
Apartment in a building 02
Room 03
Group quarters/barracks 04 (GO TO 57)
Tent 05 (GO TO 57)
Temporary shelter 06 (GO TO 57)
Other (specify) _______ 96 (GO TO 57)

52. Do you own the housing unit in which you live or do you rent it or do you live in it for free?

Owner 1
Renter 2
Free usage 3
Other (specify) ______ 6

53. Main material of the floor

Record observation

Natural floor
Earth/sand 11
Manure 12
Rudimentary floor
Wood planks 21
Palm 22
Finished floor
Tiles/cement 31
Stone/brick 32
Vinyl 33
Polished wood 34
Carpet 35
Other (specify) 96

54. How many rooms are there in this house only for your family's use?

Number of rooms _______

55. How many of these rooms are used for sleeping?

Number of rooms ______

56. Of what material are the windows of the house made?

Window panes 1
Shutters 2
Window panes and shutters 3
Curtains 4
Other (specify) 6
No windows 8

57. Do you have any animals (such as livestock or hens) inside the house?

Yes 1
No 2 (GO TO 59)

58. Where do you let them sleep at night?

Inside the dwelling 1
Outside the dwelling 2

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

Piped water
Piped into dwelling 11
Piped into yard 12
Public tap 13
Unprotected well
Unprotected well into dwelling 21
Unprotected well into yard 22
Public unprotected well 23
Protected well or borehole
Protected well in dwelling 31
Protected well in yard 32
Public protected well 33
Surface water
Spring 41
River/Stream 42
Pond/lake 43
Dam 44
Rainwater 51
Tanker truck 61
Bottled water 71
Other (specify) 96

60. Do you pay for this water, to the government or someone else, or is it free?

Government 1
Private source 2
Free 3

61. Do you store the water that you drink?
IF YES: What do you use to store it?

Water reservoir 1
Plastic container 2
Bottle 3
Can 4
Other (specify) 6
Water not stored 8

62. Do you usually do something to the water before drinking it?
IF YES:
What do you do to it?

Boil 1
Add bleach 2
Filter 3
Other (specify) 6
No treatment 8

63. Do you have any space in the dwelling that you use as a toilet?

Yes, inside 1 (GO TO 65)
Yes, outside 2 (GO TO 65)
No toilet 3

64. Where do you go or what do you use to relieve yourself?

Outside 1 (go to 67)
Bucket 2 (go to 67)
Latrine 3 (go to 67)
Pit 4 (go to 67)
Public toilet 5 (go to 67)
Other (specify) _____6 (go to 67)

65. Do you share your toilet facility with another family?

Private 1
Communal 2

66. What kind of toilet facilities does your household have?

Toilet connected to sewer 1
Toilet not connected to sewer 2
Other (specify) _____ 6

67. Do you have soap to wash your hands?

Yes 1
No 2

68. What type of lighting does your household mainly use?

Electricity 1
Oil lamp 2
Gas 3
Oil lamp/candle 4
Other (specify) ____ 6
No lighting 8

69. Do you have a separate room which is used as a kitchen?
IF YES: Is it inside or outside the house?

Yes, inside 1
Yes, outside 2
No kitchen 3 (GO TO 71)

70. Do you share that space for cooking with someone else?

Private 1
Communal 2

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

Wood 01
Coal 02
Charcoal 03
Kerosene 04
Electricity 05
Liquid gas 06
Gas 07
Other (specify) ____ 96

72. Where do you collect trash before throwing it out?

Trashcan with cover 1
Trashcan without cover 2
Plastic bag 3
Old newspapers 4
Throw in the street 5
Other (specify) 6

73. Where do you put the trash container?

In the kitchen 1
Outside of the kitchen but inside the dwelling 2
Outside the dwelling 3

74. What do you do with the trash you gathered?

Put in bin for garbage collection 1
Throw away in a special place 2
Burn 3
Throw in the street 4 (GO TO 76)
Other (specify) ______6

75. How often do you throw out trash?

Every day 1
At least twice a week 2
Once a week 3
Other (specify) ____ 6

76. Does your household have:

Radio
Yes 1
No 2
Large color TV
Yes 1
No 2
Small color TV
Yes 1
No 2
Video
Yes 1
No 2
Satellite dish
Yes 1
No 2
Refrigerator
Yes 1
No 2
Stove
Yes 1
No 2
Water heater
Yes 1
No 2
Dishwasher
Yes 1
No 2
Vacuum cleaner
Yes 1
No 2
Microwave
Yes 1
No 2
Telephone
Yes 1
No 2
Washing machine
Yes 1
No 2
Air conditioner
Yes 1
No 2

77. Does any member of your household own:

Bicycle
Yes 1
No 2
Motorbike/scooter
Yes 1
No 2
Car
Yes 1
No 2
Livestock
Yes 1
No 2
Poultry
Yes 1
No 2
Agricultural land
Yes 1
No 2
Non-agricultural land
Yes 1
No 2
Tractor/agricultural machinery
Yes 1
No 2
Real estate other than dwelling
Yes 1
No 2
Commercial buildings
Yes 1
No 2
Factories
Yes 1
No 2
Industrial machinery and equipment
Yes 1
No 2
Commercial transportation vehicles
Yes 1
No 2

78. Observe and circle the appropriate answer. Is the space around the dwelling clean and dry, or is there garbage and stagnant water?

Space clean and dry 1
Space dirty (trash) 2
Stagnant water 3
Space flooded 4

79. Record the time

Hours _____
Minutes _____

Measurement of height and weight

Check columns 8 and 10: record the line number, name and age of all women 15-49 and copy responses from questions 8 and 11 for all children age 6 or under.

Women 15-49

81. Line number from column 10

___________

82. Name from column 2

__________

83. Age from column 8

Years __________
Birth date _____

Weight and height of women age 15-49

85. Weight (kilograms) ____

86. Height (centimeters) ___________

87. Arm circumference (centimeters) _____

88. Results

Measured 1
Absent 2
Refused 3
Other 4

Children age 6 or under

81. Line number from column 11 ____

82. Name from column 2 ____

83. Age from column 8 _____

84. In which month and year was he/she born? (Name)

Day ____
Month ____
Year _____

Weight and height of children born 1998 or later

85. Weight (kilograms) ______

86. Height (Centimeters) ____

87. Measured lying down or standing

Lying down 1
Standing 2

88. Result

Measured 1
Absent 2
Refused 3
Other 6

Tick here if continuation sheet used