DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE 1998
PLACE NAME ___
NAME OF HOUSEHOLD HEAD ___
COMPOUND NUMBER ___
HOUSEHOLD NUMBER ___
CLUSTER NUMBER ___
DEPARTMENT ___
DISTRICT ___
COUNTY ___
OTHER CITY 2
RURAL 3
NO 2
COMMON AREA 3
HOUSEHOLD SELECTED FOR MEN'S SURVEY:
NO 2
INTERVIEWER:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULTS___
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME
3 ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING EMPTY OR NO DWELLING AT THE ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY): ___
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]:
DATE__
TIME__
FINAL VISIT:
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
2 NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY): ___
TOTAL NUMBER OF RESIDENTS IN HOUSEHOLD ___
TOTAL NUMBER OF ELIGIBLE WOMEN ___
TOTAL NUMBER OF ELIGIBLE HUSBANDS ___
LINE NUMBER OF THE SURVEY OF THE HOUSEHOLD QUESTIONNAIRE___
FIELD EDITED BY:
NAME ___
DATE ___
OFFICE EDITED BY:
NAME ___
DATE ___
KEYED BY:
NAME ___
DATE ___
We would now like information on the persons who usually live in your household and those who are currently living with you.
2) Please give me the names of the persons who usually live in your household and the names of guests of the household who slept here last night, starting with the head of the household.
3) RELATIONSHIP TO THE HEAD OF THE HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDSON OR GRANDDAUGHTER
06 FATHER OR MOTHER
07 STEPFATHER OR STEPMOTHER
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DON'T KNOW
4) RESIDENCE: Does (NAME) usually live here?
NO 2
5) RESIDENCE: Did (NAME) stay here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
8) EDUCATION: IF AGE 6 OR MORE: Has (NAME) ever attended school?
NO 2
9) EDUCATION: IF AGE 6 OR MORE: IF ATTENDED SCHOOL: What is the highest level of education attained by (NAME)?
What is the last class completed by (NAME) at this level?
SECONDARY, FIRST CYCLE 2
SECONDARY, SECOND CYCLE 3
HIGHER 4
DON'T KNOW 8
CP 2
CE1 3
CE2 4
CM1 5
CM2 6
5TH 2
4TH 3
3RD 4
DON'T KNOW 8
1ST YEAR 2
FINAL YEAR 3
DON'T KNOW 8
SECOND YEAR 2
THIRD YEAR 3
FOURTH YEAR AND HIGHER 4
DON'T KNOW 8
10) EDUCATION: IF LESS THAN 25 YEARS OLD: Does (NAME) currently attend school?
NO 2
11) SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:
Is (NAME)'s biological mother still alive?
NO 2
DON'T KNOW 8
12) SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS: IF ALIVE:
Does (NAME)'s biological mother live in the household?
IF YES: What is her name?
RECORD THE MOTHER'S LINE NUMBER.
13) SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:
Is (NAME)'s biological father still alive?
NO 2
DON'T KNOW 8
14) SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS: IF ALIVE: Does (NAME)'s biological father live in the household?
IF YES: What is his name?
RECORD THE FATHER'S LINE NUMBER.
15) ELIGIBILITY OF WOMEN: CIRCLE THE LINE NUMBER OF ALL WOMEN BETWEEN 15-49 YEARS.
15A) ELIGIBILITY OF MEN: CIRCLE THE LINE NUMBER OF ALL THE MEN AGED 15-59 YEARS.
(CHECK TO SEE IF THE HOUSEHOLD WAS CHOSEN FOR A MEN'S SURVEY).
MARK HERE IF A CONTINUATION SHEET WAS USED: ___
Just to be sure that I have a complete list:
1. Are there other persons such as small children or infants that we have not recorded on the list?
NO: ___
2. Are there other persons who maybe are not members of your family, such as domestic workers, renters or friends who usually live here?
NO: ___
3. Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?
NO: ___
16) What is the main source of water for members of your household?
PUBLIC TAP/STANDPIPE 12
COVERED PUBLIC CEMENT WELL 22
OPEN PUBLIC CEMENT WELL 23
TRADITIONAL PUBLIC WELL 24
BOREHOLE 25
RIVER/STREAM/CREEK 32
SWAMP/LAKE 33
DAM 34
TANKER 51 (GO TO 18)
BOTTLED WATER 61 (GO TO 18)
OTHER (SPECIFY): ___96
17) How long does it take to go there, get water, and come back?
ON SITE 996
18) What kind of toilet facilities does the majority of the members of your household use?
COMMUNAL FLUSH 12
IMPROVED 22
OTHER (SPECIFY): ___ 96
Electricity? (NIGELEC, group or solar panel)
A radio?
A television?
A telephone?
A refrigerator or freezer?
NO 2
NO 2
NO 2
NO 2
NO 2
20) In your house, how many rooms do you use for sleeping?
21) MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION
DUNG 12
CEMENT 32
CARPET 33
OTHER (SPECIFY): ___96
22) Is there anyone in your household who owns:
A bicycle?
A moped or a motorcycle?
A car?
A cart?
NO 2
NO 2
NO 2
NO 2
23) What type of salt do you use for cooking in your household?
(ASK TO SEE SALT PACKETS)
PACKAGED SALT (IODIZED) 2
ROCK SALT 3
DOESN'T USE SALT 4
OTHER (SPECIFY): ___ 6
24) RESULT OF TEST OF THE SALT USED IN THE HOUSEHOLD:
NEGATIVE (NON-IODINE SALT) 2
SALT UNAVAILABLE 3
INDETERMINATE TEST 4