NAME OF HEAD OF HOUSEHOLD__
OTHER COMMUNE 2
OTHER CITIES 3
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
2 NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT.
3 HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME
6 EMPTY DWELLING OR NO DWELLING AT THE ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)__
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
TOTAL IN THE HOUSEHOLD__
TOTAL ELIGIBLE WOMEN__
TOTAL ELIGIBLE MEN__
We would now like information on the persons who usually live in your household and who are currently living with you.
1. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)
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 slept here last night, starting with the head of the household.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDSON OR GRANDDAUGHTER
06 FATHER OR MOTHER
07 FATHER-IN-LAW OR MOTHER --IN-LAW
08 BROTHER OR SISTER
10 OTHER RELATIVE
12 NOT RELATED
98 DOESN'T KNOW
4. RESIDENCE: Does (NAME) usually live here?
5. RESIDENCE: Did (NAME) stay here last night?
6. SEX: Is (NAME) male or female?
EDUCATION. IF 6 YEARS OR MORE:
8. Has (NAME) attended school?
9. What is the highest level of education attained by (NAME)? What is the last grade completed by (NAME) at this level?
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
8 DOESN'T KNOW
98 DOESN'T KNOW
EDUCATION. IF LESS THAN 25 YEARS OLD:
10. Does (NAME) currently attend school?
SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:
11. Is (NAME'S) biological mother still alive?
DOESN'T KNOW 8
12. IF ALIVE: Does the (NAME'S) biological mother live in the household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.
13. Is (NAME'S) biological father still alive?
DOESN'T KNOW 8
14. IF ALIVE: Does the (NAME'S) biological father live in the household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.
15A. CIRCLE THE LINE NUMBER OF ALL WOMEN RESIDENTS OR VISITORS BETWEEN 15-49 YEARS.
15B. CIRCLE THE LINE NUMBER OF ALL MEN RESIDENTS OR VISITORS BETWEEN 15-49 YEARS.
MARK HERE IF ANOTHER SHEET WAS USED___
Just to be sure that I have a complete list:
1) Are there other persons such as small children or infants that we have not recorded on the list?
2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?
3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?
16. What is the main source of water for members of your household?
Piped into public tap 12
In the yard/plot 22
Open public well 23
Covered or borehole wells 23
Bottled water 61 (GO TO 18)
17. How long does it take to go there, get water, and come back?
On site 996
18. What kind of toilet facility do the majority of the members of your household use?
Communal flush 12
Electricity? (EDM or solar panel)
Refrigerator or freezer?
20. How many rooms in your household do you use to sleep in?
21. MAIN MATERIAL OF THE FLOOR.
VINYLE OR LINO/ASPHALT 32
22. Is there anyone in your household who owns:
A scooter or motorcycle?
23. What kind of salt do you usually use for cooking in your household?
PACKAGING SALT (IODINE) 02
SALT FROM ROCK DEPOSITS 03
SALT IN BULK 04
OTHER (SPECIFY) ____ 96