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NIGERIA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD SCHEDULE--ENGLISH

IDENTIFICATION
PLACE NAME _________________________
NAME OF RESPONDENT __________________________
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
STATE __

URBAN/RURAL __

URBAN L
RURAL 2

CITY/TOWN/RURAL __

CITY L
TOWN 2
RURAL(VILLAGE) 3

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER’S NAME ___________
RESULT _____________

COMPLETED 1
HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME 2
HOUSEHOLD ABSENT 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___________ 9

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER’S NAME ____
RESULT _____

COMPLETED 1
HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME 2
HOUSEHOLD ABSENT 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___________ 9

TOTAL NUMBER OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN__

FIELD EDITED BY
NAME ________
DATE ________

OFFICE EDITED BY
NAME ________
DATE ________

KEYED BY
NAME ________ __
DATE ________

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 NO. (1) (01-26) (*THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

(2) USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household or are staying with you now, 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?

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER CHILD 10
NOT RELATED 11
DON’T KNOW 98

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

YES 1
NO 2

(5) RESIDENCE: Did (NAME) sleep here last night?

YES 1
NO 2

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

MALE 1
FEMALE 2

(7) AGE: How old is he/she?

IN YEARS __

(8) EDUCATION: Has (NAME) ever been to school?

YES 1
NO 2

(9) EDUCATION: What is the highest level and grade of schooling** he/she completed?

LEVEL ____
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE ____
LESS THAN ONE YEAR COMPLETED 00
DON'T KNOW 98

(10) EDUCATION FOR ALL AGED LESS THAN 25 YEARS: Is he/she still in school?

YES 1
NO 2

FOSTERING FOR EVERYONE AGED LESS THAN 15 YEARS:

(11) Does his/her natural mother live here?
IF YES: What is her name?
RECORD MOTHER’S LINE NUMBER.
RECORD ‘00’ IF PARENT NOT MEMBER OF HOUSEHOLD.

LINE NUMBER_______

(12) Does his/her natural father live here?
IF YES: What is his name?
RECORD FATHER’S LINE NUMBER.
RECORD ‘00’ IF PARENT NOT MEMBER OF HOUSEHOLD.

LINE NUMBER_______

(13) ELIGIBILITY: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.

TICK HERE IF CONTINUATION SHEET USED. __

TOTAL NUMBER OF ELIGIBLE WOMEN ___

Just to make sure that I have a 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) In addition, 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) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?

YES (ENTER EACH IN TABLE)
NO