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NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2001
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

NAME AND CODE OF DISTRICT ______________

NAME AND CODE OF VILLAGE MUNICIPALITY __________________

WARD NUMBER _______

CLUSTER NUMBER _________

CITY/TOWN/COUNTRYSIDE

CITY 1
TOWN 2
COUNTRYSIDE 3

NAME OF HOUSEHOLD HEAD _______________

NAME OF RESPONDENT ______________

IS HOUSEHOLD SELECTED FOR MAN'S SURVEY

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DAY __
MONTH __
YEAR ____

INTERVIEWER'S NAME __________
INT. CODE __

RESULT **

** 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 PERSONS IN HOUSEHOLD __

TOTAL WOMEN ELIGIBLE __

TOTAL ELIGIBLE MEN __

LINE NO. OF RESP. TO HOUSEHOLD QUEST.

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 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?*

_________
*CODES FOR Q. 3

01 HEAD
02 WIFE OF HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 BROTHER-IN-LAW
10 NEPHEW/NIECE
11 CO-WIFE
12 OTHER RELATIVE
13 ADOPTED/FOSTER/STEPCHILD
14 NOT RELATED
98 DON'T KNOW

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

M 1
F 2

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

YES 1
NO 2

6. Did (NAME) stay here last night?

YES 1
NO 2

7. AGE: How old is (NAME)?

IN YEARS_____

8. MARITAL STATUS: AGE 10 AND OVER: Has (NAME) ever been married?

YES 1
NO 2

9. IF YES, Has (NAME) started living with his/her spouse?

YES 1
NO 2

10. ELIGIBILITY: CIRCLE LINE NO. OF ALL WOMEN AGE 15-49 WITH YES IN COL.8 AND COL.9

____

11. CIRCLE LINE NO. OF MEN AGE 15-59 WITH YES IN COL.8 AND COL.9

____

12. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

____

13. IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

YES 1
NO 2 (NEXT LINE)

14. What is the highest grade of school (NAME) has completed?**

GRADE ____
**CODES FOR Qs. 14, 17 AND 19'

00 LESS THAN GRADE 1
01 GRADE 1
02 GRADE 2
03 GRADE 3
04 GRADE 4
05 GRADE 5
06 GRADE 6
07 GRADE 7
08 GRADE 8
09 GRADE 9
10 COMPLETED SLC
11 INTERMEDIATE 1ST YEAR/ 10+1
12 INTERMEDIATE COMPLETE/ 10+2
13 BACHELOR'S NOT COMPLETE
14 BACHELOR'S COMPLETE/HIGHER
95 NON-FORMAL EDUCATION
98 DON'T KNOW

15. IF AGE 5-24 YEARS: Is (NAME) currently attending school?

YES 1 (GO TO 17)
NO 2

16. During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 18)

17. During the current school year, what grade is/was (NAME) attending?**

GRADE _____
**CODES FOR Qs. 14, 17 AND 19'

00 LESS THAN GRADE 1
01 GRADE 1
02 GRADE 2
03 GRADE 3
04 GRADE 4
05 GRADE 5
06 GRADE 6
07 GRADE 7
08 GRADE 8
09 GRADE 9
10 COMPLETED SLC
11 INTERMEDIATE 1ST YEAR/ 10+1
12 INTERMEDIATE COMPLETE/ 10+2
13 BACHELOR'S NOT COMPLETE
14 BACHELOR'S COMPLETE/HIGHER
95 NON-FORMAL EDUCATION
98 DON'T KNOW

18. During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (NEXT LINE)

19. During that school year, what grade did (NAME) attend?**

GRADE____
**CODES FOR Qs. 14, 17 AND 19

00 LESS THAN GRADE 1
01 GRADE 1
02 GRADE 2
03 GRADE 3
04 GRADE 4
05 GRADE 5
06 GRADE 6
07 GRADE 7
08 GRADE 8
09 GRADE 9
10 COMPLETED SLC
11 INTERMEDIATE 1ST YEAR/ 10+1
12 INTERMEDIATE COMPLETE/ 10+2
13 BACHELOR'S NOT COMPLETE
14 BACHELOR'S COMPLETE/HIGHER
95 NON-FORMAL EDUCATION
98 DON'T KNOW

TICK HERE IF CONTINUATION SHEET USED __

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

YES (ENTER EACH IN TABLE)
NO

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

PIPED WATER
PIPED INTO HOUSE/YARD/PLOT 11 (GO TO 22)
PUBLIC/NEIGHBORS TAP 12
DUG WELL
WELL IN HOUSE/YARD/PLOT 21 (GO TO 22)
PUBLIC/NEIGHBORS WELL 22
TUBEWELL/BOREHOLE
TUBEWELL IN YARD/PLOT 31 (GO TO 22)
PUBLIC/NEIGHBORS TUBEWELL 32
SURFACE WATER
SPRING/KUWA 41
RIVER/STREAM/POND/LAKE 42
STONE TAP/DHARA 43
OTHER (SPECIFY) 96

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

MINUTES __________
ON PREMISES 996

22. What kind of toilet facilities does your household have?

FLUSH TOILET 11
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT LATRINE 22
NO FACILITY/BUSH/FIELD 31 (GO TO 24)
OTHER (SPECIFY) 96

23. Do you share this facility with other households?

YES 1
NO 2

24. Does your household have

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

25. What type of fuel does your household mainly use for cooking?

IF RESPONDENT MENTIONS FIREWOOD/CHARCOAL/DUNG, PROBE FOR THE TYPE OF CHULO (FIREPLACE).
IF RESPONDENT MENTIONS IMPROVED SMOKELESS CHULO, CIRCLE 02, IF NOT CIRCLE 01

TRAD'L FIREWOOD/CHARCOAL/DUNG 01
IMPROVED SMOKELESS CHULO 02
BIOGAS 03
LPG GAS 04
ELECTRCITY 05
KEROSENE 06
OTHER (SPECIFY) _________ 96

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

HINDU 1
BUDDHIST 2
MUSLIM 3
CHRISTIAN 4
OTHER (SPECIFY) ____________ 6

27. What is the caste of the head of the household?

WRITE CASTE ON LINE PROVIDED, LEAVE BOX BLANK. CODE WILL BE FILLED BY FIELD EDITOR.

_______________

28. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

EARTH/MUD/DUNG 11
WOOD PLANKS 21
LINOLEUM/CARPET 31
CERAMIC TILES, MARBLE CHIPS 32
CEMENT 33
OTHER (SPECIFY) _________ 96

WEIGHT AND HEIGHT MEASUREMENT

CHECK COLUMNS (10) AND (12): RECORD LINE NUMBER, NAME AND AGE OF EVER-MARRIED WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

29. WOMEN 15-49: LINE NO. FROM COL. 10

__

30. NAME FROM COL. 2

__

31. AGE FROM COL. 7

YEARS_____

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49:
33. WEIGHT (KILOGRAMS)

___._

34. HEIGHT (CENTIMETERS)

___._

35. CURRENTLY PREGNANT

YES 1
NO/DK 2

36. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

___

29. CHILDREN UNDER AGE 6: LINE NO. FROM COL. 12

__

30. NAME FROM COL. 2

NAME __

32. What is (NAME)'s date of birth?

DAY __
MONTH __
YEAR ____

WEIGHT AND HEIGHT OF CHILDREN BORN SINCE BAISAKH 1, 2052:
33. WEIGHT (KILOGRAMS)

__.__

34. HEIGHT (CENTIMETERS)

____._

35. MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

36. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

___

TICK HERE IF CONTINUATION SHEET USED __