IDENTIFICATION

VILLAGE/PLACE NAME__________

NAME OF HOUSEHOLD HEAD _________

MDHS CLUSTER NUMBER __________

HOUSEHOLD NUMBER ___________

URBAN/RURAL

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME _____
RESULT* ______

NEXT VISIT:
DATE____
TIME____

FINAL VISIT
DAY ___
MONTH____
YEAR ____
NAME ___
RESULT___

TOTAL NUMBER OF VISITS ____

TOTAL PERSONS IN HOUSEHOLD____

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE____

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW:

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR_______

KEYED BY_______

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

1) LINE NO.

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?*

4) SEX: Is (NAME) male or female?

5) RESIDENCE: Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

8) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

8a) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.

9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**:

10) Is (NAME)'s natural mother alive?

11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

12) Is (NAME)'s natural father alive?

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

EDUCATION:

14) IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

15) What is the highest level of school (NAME) has attended?***
What is the highest year (NAME) completed at that level? ***

16) IF AGE 5-24 YEARS: Is (NAME) currently attending school?

17) During the current school year, did (NAME) attend school at any time?

18) During the current school year, what level and class [is/was] (NAME) attending? ***

19) During the previous school year, did (NAME) attend school at any time?

20) During that school year, what level and year did (NAME) attend? ***

**Q. 10 THROUGH Q. 13
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q. 11 AND Q. 13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

TICK HERE IF CONTINUATION SHEET USED ___

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?

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?

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

21. What is the main source of drinking water for members of your household?

22. How long does it take you to go there, get water, and come back?

23. What kind of toilet facility does your household use?

24. Do you share this facility with other households?

25. Does your household have:

26. What type of fuel does your household mainly use for cooking?

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

28. Does any member of your household own:

29. Does your household have any mosquito nets that can be used while sleeping?
IF YES ASK: How many?

30. How many mosquito nets are white in color?

33. Where do you usually wash your hands?

34. ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).

CHILD LABOUR

Now I would like to ask you about any work children in this household may do.

36. LINE NO.
COPY LINE NUMBER OF CHILDREN AGES 5 - 14 YEARS FROM THE HOUSEHOLD LISTING

37. CHILD'S NAME
COPY THE NAMES OF CHILDREN AGES 5 - 14 YEARS FROM THE HOUSEHOLD LISTING

38. During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?

39. Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of the household?*
*IF MORE THAN ONE JOB, INCLUDE ALL HOURS AT ALL JOBS

40. During the past week, did (NAME) help with housekeeping chores such as cooking, shopping, cleaning, washing clothes, fetching water, or caring for children?

41. Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?

42. During the past week, did (NAME) do any other family work on the farm or in a business?

43. Since last (DAY OF THE WEEK), about how many hours did he/she do this work?

WEIGHT AND HEIGHT MEASUREMENT

CHECK COLUMNS (8) AND (9):
RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

WOMEN 15-49/ CHILDREN UNDER AGE 6:

44) LINE NO. FROM COLUMN (8)

45) NAME FROM COLUMN (2)

46) AGE FROM COLUMN (7)

47) What is (NAME)'s date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49/CHILDREN BORN IN 1995 OR LATER:

48) WEIGHT (KILOGRAMS)

49) HEIGHT (CENTIMETERS)

50) MEASURED LYING DOWN OR STANDING UP
[FOR CHILDREN BORN IN 1995 OR LATER ONLY]

51) RESULT

TICK HERE IF CONTINUATION SHEET USED ___