PREFECTURE (ADMINISTRATIVE CENTER)___
TOWN OR MUNICIPALITY___
SECTOR___
SUB-SECTOR___
HOUSEHOLD NUMBER___
RURAL 2
OTHER CITY 2
RURAL 3
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER NAME __________
RESULT___
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME
3 ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING EMPTY OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)____
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME___
FINAL VISIT
DAY __________
MONTH __________
YEAR _____
NAME __________
RESULT __________
TOTAL NUMBER OF PEOPLE IN HOUSEHOLD___
TOTAL NUMBER OF ELIGIBLE WOMEN___
FIELD EDITOR:
NAME__________
DATE_____
OFFICE EDITOR:
NAME__________
DATE_____
KEYED BY:
NAME__________
DATE_____
Now we would like information about the people who usually live in your household or who are staying with you now.
1) LINE NUMBER
2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household or are staying with you now, 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?
02 WIFE OR 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 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 NOT RELATED
98 DON'T KNOW
4) RESIDENCE: Does (NAME) usually live here?
NO 2
5) RESIDENCE: Did (NAME) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGE 6 YEARS OR OLDER:
8) Has (NAME) ever attended school?
NO 2
DON'T KNOW 8
9) What is the highest level of education and the last class that he/she successfully completed?
1 PRIMARY SCHOOL NOT YET COMPLETED
2 PRIMARY SCHOOL COMPLETED
3 POST-PRIMARY SCHOOL NOT COMPLETED
4 POST-PRIMARY SCHOOL COMPLETED
5 SECONDARY NOT COMPLETED
6 SECONDARY COMPLETED
7 HIGHER
8 DON'T KNOW
10) Does (NAME) still go to school?
NO 2
DON'T KNOW 8
11) Is (NAME)'s mother still living?
NO 2
DON'T KNOW 8
12) Is (NAME)'s father still living?
NO 2
DON'T KNOW 8
13) ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN ELIGIBLE FOR THE INDIVIDUAL QUESTIONNAIRE
CHECK HERE IF A CONTINUATION SHEET IS USED__
TOTAL NUMBER OF ELIGIBLE WOMEN___
Just to make sure that I have a complete listing:
1) Are there any other people such as small children or infants that have not been listed?
NO
2) In addition, are there any other people who may not be members of your family, such as servants, lodgers, or friends, who usually live here?
NO
3) Are there any guests or temporary visitors staying at your house, or anyone else who stayed here last night?
NO
14) What is the main source of water used to wash hands and dishes?
PIPED INTO COURTYARD OR PLOT 02 (GO TO 16)
PUBLIC TAP 03
MANUAL PUMPED WELL 04
WELL WITHOUT MANUAL PUMP 05
SPRING 06
RIVER, SURFACE WATER 07
OTHER VENDOR 08
RAINWATER 09
OTHER (SPECIFY)____ 10
15) How long does it take to go there, get water, and come back?
ON PREMISES 996
16) Does your household use this same source for drinking water?
NO 2
17) What is the main source of drinking water for members of your household?
PIPED INTO COURTYARD OR PLOT 02
PUBLIC TAP 03
MANUAL PUMPED WELL 04
WELL WITHOUT MANUAL PUMP 05
SPRING 06
RIVER, SURFACE WATER 07
OTHER VENDOR 08
RAINWATER 09
OTHER (SPECIFY)____ 10
18) What kind of toilet facility does your household have?
PIT TOILET OR LATRINE 2
OTHER (SPECIFY)_____ 3
NO TOILETS 4
NO 2
NO 2
NO 2
20) In your household, how many rooms are used for sleeping?
21) MAIN MATERIAL OF THE FLOOR
(RECORD OBSERVATION)
VINYL STRIPS 02
TILE OR STONE SLABS 03
WOOD PLANKS 04
CEMENT 05
EARTH/SAND 06
OTHER (SPECIFY)_____ 07
22) Does any member of your household own:
NO 2
NO 2
NO 2