(E.P.S.F.-2003) - HOUSEHOLD QUESTIONNAIRE
REGION _____
PROVINCE OR PREFECTURE ___
CIRCLE ___
MUNICIPALITY/RURAL MUNICIPALITY ____
OTHER CENTER ___
SURVEY DISTRICT _
RABAT-CASA/LARGER CITY/SMALL CITY/RURAL
LARGE CITY 2
SMALL CITY 3
RURAL 4
CLUSTER NUMBER __
HOUSEHOLD NUMBER ___
HOUSEHOLD ADDRESS ____
NAME OF HEAD OF HOUSEHOLD ________
Date _______
INTERVIEWER'S NAME AND CODE AND RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING 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 200_
NAME ______
RESULT _____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN_____
LINE NO. OF SURVEYED HOUSEHOLD ____
SUPERVISOR ____
NAME _____
DATE _____
FIELD EDITOR ____
NAME ____
DATE ____
OFFICE EDITOR _____
KEYED BY _____
I. LIST OF MEMBERS OF HOUSEHOLD: MEMBER CHARACTERISTICS
RECORD THE TIME AT THE BEGINNING OF THE INTERVIEW
MINUTES ___
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. SEX: Is (NAME) male or female?
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?
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?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 10
ADOPTED/FOSTER CHILD 11
NOT RELATED 12
DON'T KNOW 98
Does (NAME) usually live here?
NO 2
7. Did (NAME) stay here last night?
NO 2
9. MARITAL STATUS OF THOSE 15 YEARS OR OLDER: What is (NAME)'s marital status?
WIDOWED 2
DIVORCED 3
SINGLE 4
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?
NO 2 (GO TO 18)
15. What is the highest level of school (NAME) has attended?
PREPARATORY, SECONDARY 1ST CYCLE 2
SECONDARY/2ND CYCLE 3
HIGHER 4
DON'T KNOW 8
What is the highest grade (NAME) completed at that level?
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98
16. Is (NAME) currently attending school?
NO 2
17. What is the reason (NAME) left school?
FOR HEALTH REASONS 02
FAILED/DISMISSED 03
DOESN'T LIKE SCHOOL 04
NO TRANSPORTATION/TOO FAR 05
COSTS TOO MUCH 06
FAMILY AGAINST EDUCATION 07
MARRIAGE 08
FINISHED STUDIES 09
OTHER 96
DON'T KNOW 98
IF AGE 10 OR OLDER
18. Does (NAME) work ?
NO 2 (GO TO 21)
19. What is (NAME)'s main job?
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 ____
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)?
NO 2 (GO TO 32)
DIABETES 2
GASTRIC ULCER 3
ANEMIA 4
HEART DISEASE 5
CANCER 6
KIDNEY DISEASE 7
LIVER DISEASE 8
JOINT DISEASE 9
PARALYSIS 10
CHRONIC PAIN 11
SCALP/SKIN DISEASE 12
SEIZURES 13
ASTHMA 14
CHOLESTEROL 15
CHRONIC LUNG DISEASE 16
HYPERTHYROID, APART FROM CANCER 17
HYPOTHYROID, APART FROM CANCER 18
PROSTATE PROBLEM 19
EYE PRESSURE (INCREASED EYE PRESSURE) 20
CATARACTS 21
CHRONIC BACK PAIN/SPINE ISSUES 22
MENTAL ILLNESS 23
BIG SKIN PROBLEMS 24
OTHER 96
DO NOT KNOW 98
24. Did a doctor or nurse diagnose this illness?
NO 2 (GO TO 26)
25. What was (NAME)'s age when the doctor or the nurse diagnosed (NAME)'s illness?
26. Is (NAME) taking or has (NAME) ever taken a medicine for this illness?
NO 2
DON'T KNOW 3
27. Is (NAME) suffering from another chronic illness (for a long time)?
NO 2 (GO TO 32)
DIABETES 2
GASTRIC ULCER 3
ANEMIA 4
HEART DISEASE 5
CANCER 6
KIDNEY DISEASE 7
LIVER DISEASE 8
JOINT DISEASE 9
PARALYSIS 10
CHRONIC PAIN 11
SCALP/SKIN DISEASE 12
SEIZURES 13
ASTHMA 14
CHOLESTEROL 15
CHRONIC LUNG DISEASE 16
HYPERTHYROID, APART FROM CANCER 17
HYPOTHYROID, APART FROM CANCER 18
PROSTATE PROBLEM 19
EYE PRESSURE 20
CATARACTS 21
CHRONIC BACK PAIN/SPINE ISSUES 22
MENTAL ILLNESS 23
BIG SKIN PROBLEMS 24
OTHER 96
DO NOT KNOW 98
29. Did a doctor or nurse diagnose this illness?
NO 2 (GO TO 31)
30. What was (NAME)'s age when the doctor or the nurse diagnosed this illness?
31. Is (NAME) taking or has ever taken a medicine for this illness?
NO 2
DON'T KNOW 3
32. Is (NAME) covered by social welfare or health insurance?
NO 2
DON'T KNOW 3
33. Does (NAME) smoke cigarettes or pot or tobacco?
NO 2
DON'T KNOW 3
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?
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
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.
BORN WITH (CONGENITAL) 2
GOT IT AT TIME OF BIRTH (DELIVERY PROBLEM) 3
ACCIDENT 4
CONTAGIOUS 5
ENVY/WITCHCRAFT 6
SOMETHING ELSE 7
DO NOT KNOW 8
45. How old was (NAME) when this condition started?
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?
NO 2
DON'T KNOW 3
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?
RENTER 2
FREE USAGE 3
OTHER (SPECIFY) ______ 6
53. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
MANURE 12
PALM 22
STONE/BRICK 32
VINYL 33
POLISHED WOOD 34
CARPET 35
54. How many rooms are there in this house only for your family's use?
55. How many of these rooms are used for sleeping?
56. Of what material are the windows of the house made?
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?
NO 2 (GO TO 59)
58. Where do you let them sleep at night?
OUTSIDE THE DWELLING 2
59. What is the main source of drinking water for members of your household?
PIPED INTO YARD 12
PUBLIC TAP 13
UNPROTECTED WELL INTO YARD 22
PUBLIC UNPROTECTED WELL 23
PROTECTED WELL IN YARD 32
PUBLIC PROTECTED WELL 33
RIVER/STREAM 42
POND/LAKE 43
DAM 44
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?
PRIVATE SOURCE 2
FREE 3
61. Do you store the water that you drink?
IF YES: What do you use to store it?
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?
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, OUTSIDE 2 (GO TO 65)
NO TOILET 3
64. Where do you go or what do you use to relieve yourself?
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?
COMMUNAL 2
66. What kind of toilet facilities does your household have?
TOILET NOT CONNECTED TO SEWER 2
OTHER (SPECIFY) _____ 6
67. Do you have soap to wash your hands?
NO 2
68. What type of lighting does your household mainly use?
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, OUTSIDE 2
NO KITCHEN 3 (GO TO 71)
70. Do you share that space for cooking with someone else?
COMMUNAL 2
71. What type of fuel does your household mainly use for cooking?
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 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?
OUTSIDE OF THE KITCHEN BUT INSIDE THE DWELLING 2
OUTSIDE THE DWELLING 3
74. What do you do with the trash you gathered?
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?
AT LEAST TWICE A WEEK 2
ONCE A WEEK 3
OTHER (SPECIFY) ____ 6
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
77. Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
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 DIRTY (TRASH) 2
STAGNANT WATER 3
SPACE FLOODED 4
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.
81. LINE NUMBER FROM COLUMN 10
BIRTH DATE _____
WEIGHT AND HEIGHT OF WOMEN AGE 15-49
85. WEIGHT (KILOGRAMS) ____
86. HEIGHT (CENTIMETERS) ___________
87. ARM CIRCUMFERENCE (CENTIMETERS) _____
ABSENT 2
REFUSED 3
OTHER 4
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)
MONTH ____
YEAR _____
WEIGHT AND HEIGHT OF CHILDREN BORN 1998 OR LATER
85. WEIGHT (KILOGRAMS) ______
86. HEIGHT (CENTIMETERS) ____
87. MEASURED LYING DOWN OR STANDING
STANDING 2
ABSENT 2
REFUSED 3
OTHER 6