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DEMOGRAPHIC AND HEALTH SURVEYS - MOZAMBIQUE 2003 -HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

NAME OF HOUSEHOLD HEAD_____
PLACE NAME_____
PROVINCE_____

URBAN/RURAL:

URBAN 1
RURAL 2

CLUSTER NUMBER _____
HOUSEHOLD NUMBER______

SELECTED HOUSEHOLD FOR MEN'S QUESTIONNAIRE?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_______
INTERVIEWER'S NAME______

RESULT______

COMPLETED 1
ENTIRE HOUSEHOLD ABSENT 2
REFUSED 3
DWELLING VACANT 4
DWELLING DESTROYED 5
DWELLING NOT FOUND 6
OTHER (SPECIFY) _____ 7

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR 2003
CODE _____
RESULT_____

TOTAL NUMBER OF VISITS _____

TOTAL IN HOUSEHOLD_____
TOTAL NUMBER OF WOMEN 15-49_____
TOTAL NUMBER OF MEN 15-64_____
LINE NUMBER OF RESPONDENT______

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____

KEYED BY_____
RE-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
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER CHILD
12 NOT RELATED
98 DOESN'T KNOW

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

MALE 1
FEMALE 2

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

YES 1
NO 2

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

YES 1
NO 2

7. AGE: How old is (NAME)?

AGE IN YEARS _______

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

ELIGIBILITY:
8A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-64

ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

9A. BIRTH PLACE: Where was (NAME) born?

01 NIASSA
02 CABO DELGADO
03 NAMPULA
04 ZAMB?ZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW

PLACE OF PREVIOUS RESIDENCE. ONLY FOR PEOPLE AGE 1 OR MORE:

9B. Where did (NAME) reside during (DATE OF THE INTERVIEW MONTH____ YEAR 2002)?

01 NIASSA
02 CABO DELGADO
03 NAMPULA
04 ZAMB?ZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW

PLACE OF PREVIOUS RESIDENCE. ONLY FOR PEOPLE AGE 5 OR OLDER:

9C. Where did (NAME) reside 5 years ago?

01 NIASSA
02 CABO DELGADO
03 NAMPULA
04 ZAMB?ZIA
05 TETE
06 MANICA
07 SOFALA
08 INHAMBANE
09 GAZA
10 MAPUTO PROVINCE
11 MAPUTO CITY
12 OUTSIDE OF THE COUNTRY
98 DOESN'T KNOW

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS:

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

YES 1
NO 2
DOESN'T KNOW 8

11. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER
RECORD '00' IF NATURAL MOTHER IS NOT PART OF THE LIST OF THE HOUSEHOLD MEMBERS.

LINE NUMBER____

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

YES 1
NO 2
DOESN'T KNOW 8

12A. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name? RECORD FATHER'S LINE NUMBER
RECORD '00' IF NATURAL FATHER IS NOT PART OF THE LIST OF THE HOUSEHOLD MEMBERS.

LINE NUMBER____

EDUCATION. IF AGE 5 YEARS OR OLDER:

13. Does (NAME) know how to read and write?

YES 1
NO 2
DOESN'T KNOW 8

14. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

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

EDUCATION LEVEL ____
00 LITERACY
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
GRADE ____
00 LESS THAN 1 YEAR COMPLETED
98 DOESN'T KNOW

EDUCATION. IF AGE 5-24 YEARS:

16. Is (NAME) still attending school?

YES 1 (GO TO 18)
NO 2

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

YES 1
NO 2 (GO TO 19)

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

EDUCATION LEVEL ____
00 LITERACY
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
GRADE ____
98 DOESN'T KNOW

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

YES 1
NO 2 (GO TO NEXT LINE)

20. During the previous school year, what level and grade did (NAME) attend?

EDUCATION LEVEL ____
00 LITERACY
01 PRIMARY EP1
02 PRIMARY EP2
03 SECONDARY ESG1
04 SECONDARY ESG2
05 TECHNICAL ELEMENTARY
06 TECHNICAL BASIC
07 TECHNICAL ADVANCED
08 TEACHER PREP
09 HIGHER
98 DOESN'T KNOW
GRADE ____
98 DOESN'T KNOW

CHECK 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 were 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

MODULE OF CARDIOVASCULAR ASPECTS

HOUSEHOLD MEMBERS AGE 25-64:

20A. LINE NUMBER:

LINE NO. _____

20B. NAME:

NAME _____

20C. Have you ever smoked or consumed any type of tobacco?

YES 1
NO 2 (GO TO 20H)
DOESN'T KNOW 8 (GO TO 20H)

20D. Do you currently smoke or consume any type of tobacco?

YES 1
NO 2 (GO TO 20H)
DOESN'T KNOW 8 (GO TO 20H)

20E. What type of tobacco do you usually consume?

CIGARETTES 1
PIPE 2 (GO TO 20G)
HAND-ROLLED CIGARETTES 3 (GO TO 20G)
CIGARS 4 (GO TO 20G)
SNUFF 5 (GO TO 20G)
OTHER (SPECIFY) ___ 6 (GO TO 20G)

20F. During the last 24 hours, how many cigarettes have you smoked?

NUMBER OF CIGARETTES____

NONE 00
DOESN'T KNOW 98

20G. Approximately, how old were you when you started to smoke/consume tobacco regularly?

AGE IN YEARS____
DOESN'T KNOW 98

20H. Have you ever consumed an alcoholic beverage?

YES 1
NO 2 (GO TO 20L)
DOESN'T KNOW 8 (GO TO 20L)

20I. Currently, are you consuming alcohol?

YES 1
NO 2 (GO TO 20L)
DOESN'T KNOW 8 (GO TO 20L)

20J. What type of alcoholic beverages do you usually consume?

BEER 1
WINE 2
DISTILLED LIQUOR (GIN, WHISKY, VODKA, ETC.) 3
TRADITIONAL ALCOHOLIC BEVERAGES 4
OTHER (SPECIFY) _____ 6

20K. How many days a week do you consume alcohol?

NUMBER OF DAYS A WEEK _____

NONE 0
DOESN'T KNOW 8

20L. How many days a week do you consume fruit?

NUMBER OF DAYS A WEEK ______
NONE 0

20M. How many days a week do you consume vegetables?

NUMBER OF DAYS A WEEK ______
NONE 0

SECTION OF TRAUMATISM

TRAUMATISM CAN BE CAUSED BY: A TRANSIT/CAR ACCIDENT, A FALL, BURN INJURY, PHYSICAL AGGRESSION, SEXUAL ABUSE, POISONING, CUT OR STAB, INTOXICATION, GUN INJURY, HANGING/STRANGLING.

29. During the last 30 days, has any member of the household suffered from traumatism?

YES 1
NO 2 (GO TO 41)
DOESN'T KNOW 8 (GO TO 41)

30. RECORD THE NAME AND LINE NUMBER OF HOUSEHOLD MEMBER:

NAME_____
LINE NUMBER______

31. During the last 30 days, how many times has (NAME) experienced traumatism?

ONE TIME 1
TWO TIMES 2
THREE OR MORE TIMES 3
DOESN'T KNOW 8

32. During the last 30 days, when was the last time (NAME) suffered a traumatic event?
HOW LONG AGO DID (NAME) SUFFER A TRAUMATIC EVENT?

LESS THAN A WEEK 1
ONE TO TWO WEEKS 2
THREE WEEKS OR MORE 3

33. What was the cause of (NAME)'s traumatism? Is there another cause?
RECORD ALL ANSWERS.

TRANSIT/CAR ACCIDENT A
FALL B
STRIKE/PHYSICAL AGGRESSION/ATTACK C
CUT/STAB D
HANGING/STRANGLING E
GUNSHOT INJURY F
POISONING/INTOXICATION G
SEXUAL ABUSE H
BITE I
BURN J
LAND MINE K
OTHER (SPECIFY) ____X

34. Was (NAME)'s traumatism accidental or intentional?
IF INTENTIONAL, ASK: Suicide or homicide?

ACCIDENTAL 1
INTENTIONAL (SUICIDE) 2
INTENTIONAL (HOMICIDE) 3
LEGAL INTERVENTION 4
OTHER (SPECIFY) ___ 6
DOESN'T KNOW 8

35. What is the relationship between (NAME) and the person who caused the traumatic experience?

PARTNER (CURRENT OR PAST) 01
PARENTS (STEP-FATHER OR STEP-MOTHER) 02
OTHER RELATIVE 03
KNOWN PERSON 04
STRANGER 05
LEGAL AUTHORITY 06
HIM/HERSELF 07
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98

36. Where did (NAME)'s traumatic experience occur?

HOME 01
SCHOOL/DAYCARE/EDUCATIONAL INSTITUTION 02
WORK 03
PUBLIC STREET 04
PUBLIC SPACE (CHURCH, MARKET, ETC.) 05
BAR/STAND/RESTAURANT 06
SEA/RIVER/POND 07
PLANTATION 08
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98

37. What was (NAME) doing, when the traumatic experience happened?

WORKING 01
TRAVELING 02
PLAYING SPORTS 03
DURING LEISURE TIME 04
WHILE STUDYING 05
SLEEPING/EATING/RESTING 06
WHILE DOING NOTHING IN PARTICULAR 07
OTHER (SPECIFY) ____ 96
DOESN'T KNOW 98

38. Has (NAME) been treated at a health facility for trauma?

YES 1
NO 2
DOESN'T KNOW 8

39. Is (NAME) handicapped/disabled because of his/her trauma?

YES 1
NO 2 (GO TO NEXT PERSON OR QUESTION 41)
DOESN'T KNOW 8 (GO TO NEXT PERSON OR QUESTION 41)

39A. RECORD THE NAME AND LINE NUMBER OF HOUSEHOLD MEMBER

NAME_____
LINE NUMBER______

40. What type of disability does (NAME) have?

AMPUTATION 01
LIMPS 02
LOSS OF HEARING 03
LOSS OF SIGHT 04
INCAPACITY TO REMEMBER 05
INCAPACITY TO CHEW 06
OTHER (SPECIFY) ___ 96
DOESN'T KNOW 98

DEATH CAUSED BY TRAUMATISM:

41. During the last 12 months, have any of the household members died due to traumatism?

YES 1
NO 2 (GO TO 48)

42. How many members of the household have died due to traumatism?

NUMBER OF MEMBERS______

SEX AND AGE OF DEAD PERSONS DUE TO TRAUMATISM:

42A. SEX:

MALE 1
FEMALE 2

42B. AGE:

AGE IN YEARS____

43. What was (NAME)'s death cause?
Any other accident?
RECORD ALL ANSWERS.

TRANSIT/CAR ACCIDENT A
FALL B
STROKE/PHYSICAL AGGRESSION/ATTACK C
CUT/STAB D
HANGING/STRANGLING E
GUN INJURY F
POISONING/INTOXICATION G
SEXUAL ABUSE H
BITE I
BURN J
LAND MINE K
OTHER (SPECIFY) _____ X

44. Was (NAME)'s traumatism accidental or intentional?
IF INTENTIONAL, ASK: Suicide or homicide?

ACCIDENTAL 1
INTENTIONAL (SUICIDE) 2
INTENTIONAL (HOMICIDE) 3
LEGAL INTERVENTION 4
OTHER (SPECIFY) _____ 6
DOESN'T KNOW 8

45. Where did (NAME)'s traumatic experience occur?

HOME 01
SCHOOL/DAYCARE/EDUCATIONAL INSTITUTION 02
WORK 03
PUBLIC STREET 04
PUBLIC SPACE (CHURCH, MARKET, ETC.) 05
BAR/STAND/RESTAURANT 06
SEA/RIVER/POND 07
PLANTATION 08
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

46. How long after the traumatic experience did the person die?

LESS THAN 1 HOUR 1
BETWEEN 1 AND 24 HOURS 2
DURING THE FIRST WEEK OF THE TRAUMATIC EXPERIENCE 3
MORE THAN 1 WEEK AFTER THE TRAUMATIC EXPERIENCE 4
DOESN'T KNOW 8

47. Was (NAME) treated at a health facility before dying?

YES 1
NO 2
DOESN'T KNOW 8

48. During the last 12 months, has anyone else died in this household besides those that were declared dead due to a traumatic experience?

YES 1
NO 2 (GO TO 51)

49. Specify sex, age and cause of death:

LINE NUMBER _____
SEX:
MALE 1
FEMALE 2
AGE____
CAUSE OF DEATH_____
CODE ____

51. What is the principle source of drinking water for members of your household?

PIPED WATER
IN RESIDENCE/YARD 11 (GO TO 53)
IN NEIGHBOR'S RESIDENCE/YARD 12
PUBLIC TAP 13
WELL WATER
WELL IN YARD/PLOT 21 (GO TO 53)
WELL IN NEIGHBOR'S YARD/PLOT 22
PROTECTED PUBLIC WELL 23
OPEN PUBLIC WELL 24
SURFACE WATER
RIVER/LAKE 31
RAINWATER 41 (GO TO 53)
OTHER (SPECIFY) _____ 96

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

MINUTES ______
ON PREMISES 996

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

FLUSH TOILET 01
TOILET WITHOUT FLUSHING SYSTEM 02
LATRINE 03
NO FACILITY/BUSH 04 (GO TO 54)
OTHER (SPECIFY) ____ 96

53A. Is the bathroom used by only the members of your household or other people?

ONLY BY MEMBERS 1
OTHER FAMILIES 2

54. Does your household have:

A. Electricity?
B. A radio?
C. A television?
D. A telephone (land line)?
E. A refrigerator/freezer?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE (LAND LINE)
YES 1
NO 2
REFRIGERATOR/FREEZER
YES 1
NO 2

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

ROOMS______

56. Does your house have windows?

YES 1
NO 2

56A. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
NATURAL GAS 02
PETROLEUM/PARAFFIN/KEROSENE 03
COAL 04
CHARCOAL 05
FIREWOOD 06
ANIMAL DUNG 07
OTHER (SPECIFY) _____96

57. 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

58. Does any member of your household own:

A. A bicycle?
B. A motorcycle?
C. A car?

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

58A. What type of salt do you use to cook with?
(ASK TO SEE SALT TO TEST)

LOCAL SALT 1
SALT (IODIZED) 2
SALT (NON IODIZED) 3
OTHER (SPECIFY) _____ 6

WEIGHT AND HEIGHT OF CHILDREN AND WOMEN

RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

60. WOMEN AGE 15-49: LINE NUMBER FROM COLUMN 8:

LINE NUMBER_____

61. WOMEN AGE 15-49: NAME FROM COLUMN 2:

NAME______

62. WOMEN AGE 15-49: AGE FROM COLUMN 7:

AGE___

63. WOMEN AGE 15-49: What is (NAME)'s date of birth?

DATE OF BIRTH_____

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49:

64. WEIGHT (KILOGRAMS):

WEIGHT______

65. HEIGHT (CENTIMETERS):

HEIGHT____

67. RESULT:

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

CHILDREN UNDER AGE 6:

60. LINE NUMBER FROM COLUMN 8:

LINE NUMBER___

61. NAME FROM COLUMN 2:

NAME___

62. AGE FROM COLUMN 7:

AGE___

63. What is (NAME)'s date of birth? ______

DAY _____
MONTH _____
YEAR _____

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER:

64. WEIGHT (KILOGRAMS):

WEIGHT____

65. HEIGHT (CENTIMETERS):

HEIGHT____

66. MEASURED LYING DOWN OR STANDING UP:

LYING DOWN 1
STANDING UP 2

67. RESULT:

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

68. Did (NAME) sleep under a hammock/bed-net last night?

YES 1
NO 2

TICK HERE IF CONTINUATION SHEET USED ______

INTERVIEWER'S OBSERVATIONS

TO BE FILLED OUT AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS _____

SUPERVISOR'S OBSERVATIONS_____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS_____
NAME _____
DATE _____