REPUBLIC OF MOZAMBIQUE
NATIONAL INSTITUTE OF STATISTICS
MINISTRY OF HEALTH

IDENTIFICATION

PLACE NAME______
NAME OF HOUSEHOLD HEAD_______
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
PROVINCE______

URBAN/RURAL?

LARGE CITY/SMALL CITY/RURAL AREA?

SELECTED HOUSEHOLD FOR MEN'S QUESTIONNAIRE______

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 IN HOUSEHOLD______
TOTAL NO. OF WOMEN______
TOTAL NO. OF MEN______

LINE NO. OF RESPONDENT______

LANGUAGE OF SURVEY: PORTUGUESE 01

LANGUAGE OF THE INTERVIEW_______

WAS IT NECESSARY TO HAVE AN INTERPRETER?

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 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?

4. RESIDENCE: Does (NAME) usually live here?

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

6. SEX: Is (NAME) male or female?

7. AGE: How old is (NAME)?

EDUCATION IF AGE 6 YEARS OR OLDER:

8. Has (NAME) ever attended school?

9. IF ATTENDED SCHOOL: What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

10. IF LESS THAN 25 YEARS: Is (NAME) still attending school?

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS YOUNGER THAN 15 YEARS:

11. Is (NAME)'s natural mother alive?

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

13. Is (NAME)'s natural father alive?

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

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

ELIGIBILITY:
16. CIRCLE LINE NUMBER OF ALL MEN AGE 15-64

CHECK HERE IF CONTINUATION SHEET USED______

Just to make sure that I have complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

2) 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 other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

17. What is the principal source of drinking water for members of your household?

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

18A. How much did you pay for that water in the last month?

19. What kind of toilet facility does your household have?

19A. Is the bathroom used by only the members of your household or other people?

20. Does your household have:

Electricity?
A radio?
A television?
A telephone?
A refrigerator?

21. How many rooms in your household are used for sleeping?

22. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

23. Does any member of your household own:

A bicycle?
A motorcycle?
A car?

24. What type of salt do you use to cook?
ASK TO SEE SALT PACKAGE.