TA/STA/TOWN ___________
ENUMERATION AREA _________
VILLAGE OR PLACE __________
MDHS CLUSTER NUMBER __________
HOUSEHOLD NUMBER ___________
URBAN/RURAL ________
RURAL 2
NUMBER OF DWELLING UNITS USED BY HOUSEHOLD __________
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME ____
RESULT*** _____
NO HOUSEHOLD MEMBER AT HOME AT TIME OF VISIT OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ______ 9
FINAL VISIT
DAY ___
MONTH____
YEAR ____
NAME ___
RESULT___
TOTAL NUMBER OF VISITS ____
TOTAL IN HOUSEHOLD ___
TOTAL NUMBER-ELIGIBLE WOMEN ___
TOTAL NUMBER-ELIGIBLE MEN ___
LINE NUMBER OF HOUSEHOLD RESPONDENT ___
FIELD EDITED BY
NAME ____
DATE ____
OFFICE EDITED BY
NAME ____
DATE ____
KEYED BY
NAME ____
DATE ____
KEYED BY ___
Now we would like some information about the people who usually live in your household or who are staying with you now.
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.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD*: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER CHILD 10
NOT RELATED 11
DO NOT KNOW 98
4) RESIDENCE: Does (NAME) usually live here?
NO 2
5) Did (NAME) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION AND LITERACY IF AGED 5 YEARS OR OLDER:
8) Has (NAME) ever been to school?
NO 2
9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended?
How many years did (NAME) complete at that level? **
SECONDARY 2
HIGHER 3
DO NOT KNOW 8
DON'T KNOW 98
10) Is (NAME) still in school?
NO 2
IF AGED 5 YEARS OR OLDER AND IF LESS THAN SECONDARY SCHOOL:
11) Is (NAME) able to read and write in English or Chichewa?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD***:
12) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
13) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
14) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
15) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUBMER
16) ELIGIBILITY: CIRCLE LINE NUMBER OF ELIGIBLE WOMEN.
"ROOF" LINE NUMBER OF ELIGIBLE MEN.
TICK HERE IF CONTINUATION SHEET USED ___
TOTAL NUMBER OF ELIGIBLE WOMEN (15-49 YEARS) ___
TOTAL NUMBER OF ELIGIBLE MEN (20-54 YEARS) ___
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO 2
2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here, but that were not already listed?
NO
3) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night that we have not already listed?
NO
***These questions refer to the biological parents of the child. Record 00 if parent not member of household.
BIRTHS AND DEATHS IN LAST 12 MONTHS
Now we would like some information about all the births and deaths that occurred in this household to usual residents during the last 12 months. First, let's talk about all of the births.
17) NAME OF CHILD: Please give me the names of all the children born in this household over the past 12 months, that is, since (MONTH OF INTERVIEW) 1991.
PROBE: Have you included all births, even if the child lived only a few moments, days, or weeks?
18) SEX: Was (NAME) born a boy or a girl?
FEMALE 2
19) MONTH: In what month was (NAME) born?
PROBE: In what season?
20) YEAR: In what year was (NAME) born?
PROBE: This year? Or last year?
21) CHILD: Is (NAME) still alive?
NO 2
22) MOTHER: Is the mother of (NAME) still alive?
NO 2
Now we would like some information about all of the deaths that occurred in this household to usual residents during the last 12 months.
23) NAME OF PERSON: Please give me the names of all the persons who were usual residents of this household and died during the last 12 months, that is, since (MONTH OF INTERVIEW) 1991.
CHECK CONSISTENCY WITH Q. 21
24) SEX: Was (NAME) born a male or female?
FEMALE 2
25) AGE AT DEATH: How old was (NAME) when he/she died?
RECORD IN COMPLETED YEARS.
26) MONTH: In what month did (NAME) die?
PROBE: During what season?
27) YEAR: In what year did (NAME) die?
PROBE: This year? Or last year?
28) PLACE OF DEATH: Where did (NAME) die?
HOSPITAL/CLINIC 2
ON WAY TO HOSPITAL/CLINIC 3
OUTSIDE HOUSEHOLD 4
29) What is the main source of water your household uses for handwashing and dishwashing?
PIPED INTO YARD/PLOT 12 (GO TO 31)
PUBLIC TAP 13
UNPROTECTED WELL 22
RIVER/STREAM 32
POND/DAM 33
LAKE 34
OTHER (SPECIFY) ____ 71
30) How long does it take to go there, get water, and come back?
ON PREMISES 996
DON'T KNOW 998
31) Does your household get drinking water from this same source?
NO 2
32) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12
PUBLIC TAP 13
UNPROTECTED WELL 22
RIVER/STREAM 32
POND/DAM 33
LAKE 34
OTHER (SPECIFY) ____ 71
33) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP LATRINE) 22
OTHER (SPECIFY) ____ 41
NO 2
NO 2
NO 2
35) How many rooms in all of the dwelling units of this household are used for sleeping?
36) Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
37A) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
NOTE: IF THE HOUSEHOLD LIVES IN MORE THAN ONE DWELLING UNIT AND THE DWELLING UNITS DIFFER IN FLOOR MATERIALS, RECORD YOUR OBSERVATION ON THE FLOOR OF THE DWELLING OF THE HEAD OF HOUSEHOLD.
BRICKS 32
WOOD 33
TILES 34
37B) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
NOTE: IF THE HOUSEHOLD LIVES IN MORE THAN ONE DWELLING UNIT AND THE DWELLING UNITS DIFFER IN ROOF MATERIALS, RECORD YOUR OBSERVATION ON THE ROOF OF THE DWELLING OF THE HEAD OF HOUSEHOLD.
IRON SHEETS 2
IRON AND TILES 3
ASBESTOS 4
CEMENT 5
WOOD 6
OTHER (SPECIFY) ____ 7