NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES/CENTRAL STATISTICAL OFFICE
CENSUS DISTRICT ____
CENSUS EA CODE_____
HOUSEHOLD SCHEDULE
PLACE NAME_______
NAME OF RESPONDENT_______
LANGUAGE OF QUESTIONNAIRE_______
P.S.U. NUMBER_____
HOUSEHOLD NUMBER_______
REGION
NORTHWEST 1
NORTHEAST 2
CENTRAL 3
SOUTH 4
Rural 2
INTERVIEWER VISIT 1 (REPEAT FOR INTERVIEW VISITS 2 AND 3)
DATE____
INTERVIEWER'S NAME______
RESULT____
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY____
MONTH______
YEAR_____
NAME_____
RESULT_____
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 IN HOUSEHOLD____
TOTAL ELIGIBLE WOMEN____
FIELD EDITED BY
NAME____
DATE____
OFFICE EDITED BY
NAME____
DATE____
KEYED BY
NAME_____
DATE_____
KEYED BY____
Now we would like some information about the people who usually live in your household or who are staying with you now.
1) NO.
02) 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 household.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) sleep here last night?
NO 2
6) SEX
Is (NAME) male or female?
F 2
IF AGED 6 OR OLDER
8) Has (NAME) ever been to school?
NO 2
9) What is the highest level of school (NAME) attended?
What is the highest grade (NAME) completed at that level?
GRADE_____
10) IF AGED LESS THAN 25 YEARS
I (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE
IF AGES LESS THAN 15 YEARS
11) Is (NAME)'s natural mother alive?
NO 2
DK 8
12) IF ALIVE
Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
13) Is (NAME)'s natural father alive?
NO 2
DK 8
14) IF ALIVE
Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
15) 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___
CODES FOR Q. 3
RELATIONSHIP TO HEAD OF HOUSEHOLD
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
DK 98
SECONDARY 2
HIGHER 3
DK 8
DK 98
16) What is the source of water your household uses for hand washing and dishwashing?
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (SKIP TO 18)
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (SKIP TO 18)
TANKER TRUCK 51
OTHER (SPECIFY)____71
17) How long does it take to go there, get water, and come back?
ON PREMISES 996
18) Does your household get drinking water from this same source?
NO 2
19) What is the source of drinking water for members of your household?
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41
TANKER TRUCK 51
OTHER (SPECIFY)_____71
20) What kind of toilet facility does your household have?
TRADITIONAL PIT LATRINE 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
BUCKET 23
NO FACILITY/NUSG/FIELD 31
OTHER (SPECIFY)_____ 41
Electricity?
A radio?
A television?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
22) How many rooms in your household are used for sleeping?
23) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
WOOD PLANKS 21
PALMS/BAMBOO 22
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)______41
24) Does any member of your household own:
A donkey cart or horse?
A bicycle?
A motorcycle?
A car?
NO 2
NO 2
NO 2
NO 2