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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

DATE _______

INTERVIEWER'S NAME AND CODE AND RESULT* ____

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 NUMBER OF HOUSEHOLD SURVEY RESPONDENT ____

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?

HEAD OF HOUSEHOLD 01
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

RESIDENCE

6. 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?

PRIMARY 1
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?

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

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?

FOR WORK 01
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

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

21. USUAL RESIDENTS AND VISITORS: COPY THE NAMES OF ALL MEMBERS OF THE HOUSEHOLD LISTED FOR QUESTION 2

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?

BLOOD PRESSURE 01
DIABETES 02
GASTRIC ULCER 03
ANEMIA 04
HEART DISEASE 05
CANCER 06
KIDNEY DISEASE 07
LIVER DISEASE 08
JOINT DISEASE 09
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
DON'T KNOW 98

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?

BLOOD PRESSURE 01
DIABETES 02
GASTRIC ULCER 03
ANEMIA 04
HEART DISEASE 05
CANCER 06
KIDNEY DISEASE 07
LIVER DISEASE 08
JOINT DISEASE 09
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
DON'T KNOW 98

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

IF AGE 15 OR OLDER:

TOBACCO

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

YES 1 (GO TO NEXT PERSON)
NO 2
DON'T KNOW 3

34. Did (NAME) smoke and stopped?

YES 1
NO 2
DON'T KNOW 3

III. LIST OF MEMBERS OF THE HOUSEHOLD: DISABILITY

41. USUAL RESIDENTS AND VISITORS: COPY THE NAMES OF ALL MEMBERS OF THE HOUSEHOLD LISTED IN QUESTION 2.

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
DON'T 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.

INHERITED 1
BORN WITH (CONGENITAL) 2
GOT IT AT TIME OF BIRTH (DELIVERY PROBLEM) 3
ACCIDENT 4
CONTAGIOUS 5
ENVY/WITCHCRAFT 6
SOMETHING ELSE 7
DON'T KNOW 8

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. HOUSEHOLD 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:

A radio or transistor?
YES 1
NO 2
A large color TV?
YES 1
NO 2
A small color TV?
YES 1
NO 2
A video?
YES 1
NO 2
A satellite dish?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A stove?
YES 1
NO 2
A water heater?
YES 1
NO 2
A dishwasher?
YES 1
NO 2
A vacuum cleaner?
YES 1
NO 2
A microwave?
YES 1
NO 2
A telephone?
YES 1
NO 2
A washing machine?
YES 1
NO 2
An air conditioner?
YES 1
NO 2

77. Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorbike or scooter?
YES 1
NO 2
A 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
A 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

LINE NUMBER ___________

82. NAME FROM COLUMN 2

NAME __________

83. AGE FROM COLUMN 8

YEARS __________

84. 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

LINE NUMBER ____

82. NAME FROM COLUMN 2

NAME __________

83. AGE FROM COLUMN 8

AGE ____

84. In which month and year was (NAME) born?

DAY ____
MONTH ____
YEAR _____

WEIGHT AND HEIGHT OF CHILDREN BORN 1998 OR LATER:

85. WEIGHT (KILOGRAMS)

0____.__

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