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NEPAL FAMILY HEALTH SURVEY HOUSEHOLD SCHEDULE

IDENTIFICATION
DISTRICT NAME AND NUMBER

VILLAGE/MUNICIPALITY NAME AND NUMBER

WARD NUMBER

CLUSTER NUMBER

HOUSEHOLD NUMBER

CITY/TOWN/COUNTRYSIDE (city=1, town=2, countryside=3)

NAME OF HOUSEHOLD

NAME OF RESPONDENT

INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT

TOTAL NUMBER OF VISITS _________________

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME 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 IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NUMBER OF RESPONDENT IN HOUSEHOLD SCHEDULE

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

KEYED BY

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 NUMBER

LINE NO. ___

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?

YES 1
NO 2

5. Did (NAME) stay here last night?

YES 1
NO 2

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

M 1
F 2

7. AGE: How old is (NAME)?

IN YEARS___

EDUCATION IF AGED 6 YEARS OR OLDER:

8. Has (NAME) ever been to school?

YES 1
NO 2

9. IF ATTENDED SCHOOL: What is the highest grade** completed by (NAME)?

GRADE____

IF AGE LESS THAN 25 YEARS:
10. Is (NAME) still in school?

YES 1
NO 2

MARITAL STATUS IF AGE 10 YEARS OR OLDER:

11. Has (NAME) ever been married?

YES 1
NO 2

IF EVER-MARRIED AND AGE LESS THAN 20:

12. Has (NAME) started living with his/her spouse?

YES 1
NO 2

ELIGIBILITY:
13. CIRCLE LINE NUMBER OF ALL ELIGIBLE WOMEN: IF FEMALE AGE 15-49 AND YES TO COL (11) AND COL (12) IS YES OR NOT ASKED.

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

PIPED WATER
PIPED INTO RESIDENCE/YARD/PLOT 11 (GO TO 16)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 16)
PUBLIC WELL 22
HAND PUMP
RESIDENCE/YARD/PLOT 31 (GO TO 16)
PUBLIC 32
SURFACE WATER
SPRING/KUWA 41
RIVER/STREAM 42
POND/LAKE 43
STONE TAP (DHARA) 44
OTHER (SPECIFY) ___ 96

15. How long does it take to get there, get water, and come back?

MINUTES ____
ON PREMISES 996

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

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENILATED IMPROVED PIT 22
PAN 31
NO FACILITY/BUSH/FIELD 41
OTHER (SPECIFY) 96 ___

17. Does your household have:
Electricity?
A radio?
A television?
A telephone?
A bicycle?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
BICYCLE
YES 1
NO 2

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

ROOMS ___

19. What is the religion of the head of the household?

HINDU 01
BUDDHIST 02
MUSLIM 03
CHRISTIAN 04
OTHER (SPECIFY) ___ 96

20. What is the caste of the head of the household?
WRITE CASTE IN SPACE PROVIDED. CODE WILL BE ENTERED BY FIELD EDITOR

CASTE ___

21. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION

NATURAL FLOOR
MUD/DUNG 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
POLISHED WOOD 31
CEMENT 32
LINOLEUM 33
MARBLE CHIPS 34
CARPET 35
OTHER (SPECIFY) ___ 96

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

PACKAGED
IODIZED 11
NOT IODIZED 12
NOT PACKAGED
CRYSTAL SALT 21
LOOSE SALT 22
OTHER (SPECIFY) __ 96

23. TEST THE SALT AND WRITE THE RESULT.

IODINE READING (PPM) ___