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REPUBLIC OF MALI
DEMOGRAPHIC AND HEALTH SURVEY IN MALI HOUSEHOLD QUESTIONNAIRE 1987

IDENTIFICATION

NX__
OF__

NUMBER OF HOUSEHOLD QUESTIONNAIRE__
REGION__
CLUSTER__
ARRONDISSEMENT/COMMUNE__
VILLAGE CODE__
VILLAGE NEIGHBORHOOD__
NAME OF HEAD OF COMPOUND__
NAME OF HEAD OF HOUSEHOLD__

INTERVIEWER VISITS

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
MONTH__
YEAR 1987
INTERVIEWER NAME____

RESULTS___

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 OTHER (SPECIFY)__

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

CHARACTERISTICS OF HOUSEHOLD MEMBERS:

HOUSEHOLD SCHEDULE:

We would now like information on the persons who usually live in your household and who are currently living with you.

LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

____

1. LAST AND FIRST NAME (S)

__________

2. AGE IN COMPLETED YEARS

_______

3. RELATIONSHIP

________

4. GENDER

MALE 1
FEMALE 2

5. HAS (NAME) LIVED THERE:

6 MONTHS OR MORE 1
6 MONTHS AND INTENDS TO STAY 1
OTHER 2

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

YES 1
NO 2

7. SELECTION OF PEOPLE

_____