IDENTIFICATION

NAME OF HOUSEHOLD HEAD_____
PLACE NAME_____
PROVINCE_____

URBAN/RURAL:

CLUSTER NUMBER _____
HOUSEHOLD NUMBER______

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 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?

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

7. AGE: How old is (NAME)?

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?

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

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

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

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

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS:

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
RECORD '00' IF NATURAL MOTHER IS NOT PART OF THE LIST OF THE HOUSEHOLD MEMBERS.

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

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.

EDUCATION. IF AGE 5 YEARS OR OLDER:

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

14. Has (NAME) ever attended school?

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

EDUCATION. IF AGE 5-24 YEARS:

16. Is (NAME) still attending school?

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

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

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

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

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?

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?

MODULE OF CARDIOVASCULAR ASPECTS

HOUSEHOLD MEMBERS AGE 25-64:

20A. LINE NUMBER:

20B. NAME:

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

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

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

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

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

20H. Have you ever consumed an alcoholic beverage?

20I. Currently, are you consuming alcohol?

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

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

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

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

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?

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

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

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?

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

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

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

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

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

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

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

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

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

DEATH CAUSED BY TRAUMATISM:

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

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

SEX AND AGE OF DEAD PERSONS DUE TO TRAUMATISM:

42A. SEX:

42B. AGE:

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

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

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

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

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

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

49. Specify sex, age and cause of death:

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

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

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

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

54. Does your household have:

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

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

56. Does your house have windows?

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

57. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.

58. Does any member of your household own:

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

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

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:

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

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

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

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49:

64. WEIGHT (KILOGRAMS):

65. HEIGHT (CENTIMETERS):

67. RESULT:

CHILDREN UNDER AGE 6:

60. LINE NUMBER FROM COLUMN 8:

61. NAME FROM COLUMN 2:

62. AGE FROM COLUMN 7:

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

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

64. WEIGHT (KILOGRAMS):

65. HEIGHT (CENTIMETERS):

66. MEASURED LYING DOWN OR STANDING UP:

67. RESULT:

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

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 _____