Data Cart

IDENTIFICATION

NAME AND CODE OF REGION* ______________
NAME OF VILLAGE/TOWN/CITY ________________
URBAN/RURAL

LARGE CITY/SMALL CITY/TOWN/RURAL

HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD _____________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY?

INTERVIEWER VISIT 1

DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____

INTERVIEWER VISIT 2
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____

INTERVIEWER'S VISIT 3
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____

FINAL VISIT
DAY ___
MONTH___
YEAR 200__
INT. NUMBER___
RESULT___

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD___
TOTAL WOMEN 15-49___
TOTAL MEN 15-49___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

**RESULT CODES:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9

LANGUAGE OF QUESTIONNAIRE:

RESPONDENT'S LANGUAGE:

LANGUAGE OF INTERVIEW:

TRANSLATOR USED

SUPERVISOR
NAME ___
DATE ___

FIELD EDITOR
NAME ___
DATE ___

OFFICE EDITOR ____
KEYED BY ___

*REGION CODES:

CAPRIVI 01
ERONGO 02
HARDAP 03
KARAS 04
KHOMAS 05
KUNENE 06
CHANGWENA 07
KAVANGO 08
OMAHEKE 09
OMUSATI 10
OSHANA 11
OSHIKOTO 12
OTJOZONDJUPA 1

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ and I am working with the Ministry of Health and Social Services.

We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ________ Date:_______

HOUSEHOLD SCHEDULE

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.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

SEE CODES BELOW.

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

RESIDENCE
5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

IF AGE 15 OR OLDER:
8) MARITAL STATUS: What is (NAME'S) current marital status?

MARRIED OR LIVING TOGETHER 1
DIVORCED/ SEPARATED 2
WIDOWED 3
NEVERMARRIED AND NEVER LIVED TOGETHER 4