IDENTIFICATION

STATE NAME ___
LOCAL GOVT. AREA ___
LOCALITY NAME ___
ENUMERATION AREA ___

URBAN/RURAL:

BUILDING NUMBER ___
HOUSEHOLD NAME/NUMBER ___

LARGE TOWN/MEDIUM TOWN/SMALL TOWN/VILLAGE:

INTERVIEWER'S VISITS

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

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

FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT _____

TOTAL NO. OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN__

TOTAL ELIGIBLE MEN __

LINE NO. OF RESPONDENTS TO HOUSEHOLD SCHEDULE __

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY____

HOUSEHOLD SCHEDULE

Now we would like to have some information about the people who usually live in this household or who are staying with you now.

(1) LINE NO. (1) (01-14)

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

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

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

(7) AGE: How old is (NAME) as of last birthday?

EDUCATION IF AGE 6 YEARS OR OLDER:

(8) Can (NAME) read and write in any language with understanding?

(9) Has (NAME) ever been to school?

(10) IF ATTENDED SCHOOL: Which is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at that level?**

(11) Is (NAME) still in school? (For Age less than 25 Years)

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD: Q.12 THROUGH Q.15: THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. RECORD 00 IF PARENT NOT MEMBER OF HOUSEHOLD.

(12) Is (NAME)'s natural mother alive?

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

(14) Is (NAME)'s natural father alive?

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

(16) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGED 10-49.

(17) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGED 15-64.

TICK HERE IF CONTINUATION SHEET USED __

Tick here if Household has more than 14 persons __

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?

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?

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

18. What is the main source of drinking water for members of your household?

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

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

21. Does your household have:

22. How many rooms are in your household?

22B. How many rooms are used for sleeping in your household?

23. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

24. Does any member of your household own:

25. What type of salt is usually used for cooking in your household?
(ASK TO SEE SALT PACKAGE).

26. How do you hold this accommodation?

27. If you rent it or if it is rent-free, who owns the accommodation?

28. MAIN MATERIAL USED FOR OUTER WALLS.
RECORD OBSERVATION

29. MAIN MATERIAL USED FOR ROOF.
RECORD OBSERVATION

30. MAIN SOURCE OF LIGHT

31. TYPE OF KITCHEN FACILITY

32. TYPE OF BATHING FACILITY