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DEMOGRAPHIC AND HEALTH SURVEYS - MOZAMBIQUE 1997 - HOUSEHOLD QUESTIONNAIRE

REPUBLIC OF MOZAMBIQUE
NATIONAL INSTITUTE OF STATISTICS
MINISTRY OF HEALTH

IDENTIFICATION

PLACE NAME______
NAME OF HOUSEHOLD HEAD_______
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
PROVINCE______

URBAN/RURAL?

URBAN 1
RURAL 2

LARGE CITY/SMALL CITY/RURAL AREA?

LARGE CITY 1
SMALL CITY 2
VILLAGE 3
RURAL AREA 4

SELECTED HOUSEHOLD FOR MEN'S QUESTIONNAIRE______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME_______

RESULT_______

1 COMPLETED
2 ABSENCE OF QUALIFIED PERSON / NO COMPETENT RESPONDENT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______

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?

YES 1
NO 2

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

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.

NAME_____

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

01 HEAD
02 HUSBAND OR WIFE
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 CHILDREN ADOPTED/BEING TAKEN CARE OF
12 NOT RELATED
98 DOESN'T KNOW

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

YES 1
NO 2

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

YES 1
NO 2

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

MALE 1
FEMALE 2

7. AGE: How old is (NAME)?

AGE IN YEARS _______

EDUCATION IF AGE 6 YEARS OR OLDER:

8. Has (NAME) ever attended school?

YES 1
NO 2

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

LEVEL ____
1 PRIMARY
2 SECONDARY
3 HIGH SCHOOL
4 HIGHER
5 TECHNICAL ELEMENTARY
6 TECHNICAL BASIC
7 TECHNICAL ADVANCED
8 DOESN'T KNOW
GRADE ____
LESS THAN ONE YEAR 00
DOESN'T KNOW 98

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

YES 1
NO 2

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS YOUNGER THAN 15 YEARS:

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

YES 1
NO 2
DOESN'T KNOW 8

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

LINE NUMBER___

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

YES 1
NO 2
DOESN'T KNOW 8

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

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?

YES (ENTER EACH IN TABLE)
NO

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?

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

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

PIPED WATER
INTO RESIDENCE/YARD 11 (GO TO 18A)
INTO NEIGHBOR'S RESIDENCE/YARD 12
PUBLIC TAP 13
WELL WATER
WELL IN YARD/PLOT 21 (GO TO 18A)
WELL IN NEIGHBOR'S YARD/PLOT 22
PUBLIC WELL 23
SURFACE WATER
CREEK 31
RIVER 32
LAKE 33
DAM 34
RAINWATER 41 (GO TO 18A)
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18A)
OTHER (SPECIFY)___ 96

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

MINUTES ______
ON PREMISES 996

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

COST (BY 1000 M) 1 ____

FREE 9996
DOESN'T KNOW 9998

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

FLUSH TOILET 1
TOILET WITHOUT FLUSHING SYSTEM 2
LATRINE 3
NO FACILITY/BUSH 31 (GO TO 20)
OTHER (SPECIFY) _____ 96

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

ONLY BY MEMBERS 1
OTHER FAMILIES 2

20. Does your household have:

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

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

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

ROOMS______

22. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

NATURAL FLOOR
EARTH 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
ADOBE 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
OTHER (SPECIFY) _____ 96

23. Does any member of your household own:

A bicycle?
A motorcycle?
A car?

BICYCLE
YES 1
NO 2
MOTORCYCLE
YES 1
NO 2
CAR
YES 1
NO 2

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

LOCAL SALT 01
PACKAGED SALT (IODIZED) 02
PACKAGED SALT (NOT IODIZED) 03
OTHER (SPECIFY) _____ 96