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DEMOGRAPHIC AND HEALTH SURVEY-REPUBLIC OF RWANDA 2000-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME____

NAME OF HOUSEHOLD HEAD____

PREFECTURE (ADMINISTRATIVE CENTER)____

TOWN OR MUNICIPALITY____

SECTOR____

SUB-SECTOR___

HOUSEHOLD NUMBER

URBAN/RURAL

URBAN 1
RURAL 2

LARGE CITY, OTHER CITY, RURAL?

KIGALI 1
OTHER CITY 2
RURAL 3

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME____
RESULT____

RESULT

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)_____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME____

FINAL VISIT
DAY___
MONTH____
YEAR: 2000
NAME____
RESULT____

TOTAL NUMBER OF VISITS_____

TOTAL NUMBER OF PEOPLE IN HOUSEHOLD____

TOTAL NUMBER OF ELIGIBLE WOMEN____

TOTAL NUMBER OF ELIGIBLE MEN____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

LANGUAGE OF INTERVIEW

KINYARWANDA 1
OTHER LANGUAGE (SPECIFY)_____ 2

INTERPRETER USED?

YES 1
NO 2

FIELD EDITOR
NAME___
DATE____

SUPERVISOR
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 who stayed here last night, starting with the head of the household.

NAME____

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

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

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

MALE 1
FEMALE 2


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

YES 1
NO 2

6) RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is (NAME)?

AGE IN YEARS____

ELIGIBILITY:
8) CIRCLE THE LINE NUMBER OF ALL WOMEN 15-49

ELIGIBILITY:
8A) CIRCLE THE LINE NUMBER OF ALL MEN 15-59 IF MEN'S SURVEY IS PLANNED

ELIGIBILITY:
9) CIRCLE THE LINE NUMBER OF ALL CHILDREN UNDER 6 YEARS OLD

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS UNDER 15 YEARS OLD:

10) Is (NAME)'s natural mother alive?

YES 1
NO 2
DON'T KNOW 8

11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD '00' IF MOTHER IS NOT A MEMBER OF THE HOUSEHOLD.

LINE NUMBER___

12) Is (NAME)'s natural father alive?

YES 1
NO 2
DON'T KNOW 8

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. RECORD '00' IF FATHER IS NOT A MEMBER OF THE HOUSEHOLD.

LINE NUMBER_____

EDUCATION IF 5 YEARS OR OLDER:

14) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

15) What is the highest level of school (NAME) has attended? What is the last class that (NAME) successfully completed at that level?

LEVEL
KINDERGARTEN/ELEMENTARY 0
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
CLASS___
KINDERGARTEN/ELEMENTARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
REFORMED PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
POST-PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
SECONDARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
HIGHER
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98

EDUCATION IF AGE 5-24 YEARS:

16) Is (NAME) currently attending school?

YES 1 (GO TO 18)
NO 2

17) Has (NAME) attended school at any time during the current school year?

YES 1
NO 2 (GO TO 19)

18) During this current school year, what level and class was (NAME) attending?

LEVEL___
KINDERGARTEN/ELEMENTARY 0
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
CLASS____
KINDERGARTEN/ELEMENTARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
REFORMED PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
POST-PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
SECONDARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
HIGHER
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98

19) During the last school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO NEXT LINE)

20) During the last school year, what level and class was (NAME) attending?

LEVEL___
KINDERGARTEN/ELEMENTARY 0
PRIMARY 1
REFORMED PRIMARY 2
POST-PRIMARY 3
SECONDARY 4
HIGHER 5
DON'T KNOW 8
CLASS_____
KINDERGARTEN/ELEMENTARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
DON'T KNOW 98
PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
DON'T KNOW 98
REFORMED PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
EIGHTH YEAR 08
DON'T KNOW 98
POST-PRIMARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
SEVENTH FAMILIAL 01
EIGHTH FAMILIAL 02
NINTH FAMILIAL 03
DON'T KNOW 98
SECONDARY
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR 06
SEVENTH YEAR 07
DON'T KNOW 98
HIGHER
LESS THAN 1 YEAR 00
FIRST YEAR 01
SECOND YEAR 02
THIRD YEAR 03
FOURTH YEAR 04
FIFTH YEAR 05
SIXTH YEAR AND HIGHER 06
DON'T KNOW 98

CHECK HERE IF A CONTINUATION SHEET IS USED__

Just to make sure that I have a complete listing:

1) Are there any other people such as small children or infants who have not been listed?

YES (RECORD 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 (RECORD 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 (RECORD EACH IN TABLE)
NO

21) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO RESIDENCE 11 (GO TO 23)
PIPED INTO COURTYARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
UNCOVERED WELL

UNCOVERED WELL IN HOUSEHOLD 21 (GO TO 23)
UNCOVERED WELL IN COURTYARD/PLOT 22 (GO TO 23)
UNCOVERED PUBLIC WELL 23
COVERED WELL OR BOREHOLE
COVERED WELL IN HOUSEHOLD 31 (GO TO 23)
COVERED WELL IN COURTYARD/PLOT 32 (GO TO 23)
COVERED PUBLIC WELL 33
SURFACE WATER

SPRING 41
RIVER/STREAM 42
POND/LAKE 43
DAM 44
RAINWATER 51 (GO TO 23)
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY)_____ 96

22) How long does it take to go there, get water, and come back?

MINUTES___
ON PREMISES 996

23) What kind of toilet do members of your household use?

FLUSH TOILET 11
PIT/LATRINE
TRADITIONAL PIT LATRINE 21
VIP IMPROVED PIT LATRINE 22
NO TOILETS/NATURE 31 (GO TO 25)
OTHER (SPECIFY)____ 96

24) Do you share this installation with other households?

YES 1
NO 2

25) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

26) In your household, what kind of fuel do you mainly use for cooking?

ELECTRICITY 01
BOTTLED GAS/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, BROWN COAL (LIGNITE), PEAT 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY)____ 96

27) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM LEAVES/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR LINOLEUM/ASPHALT 32
TILE OR STONE SLABS 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)____ 96

28) Does any member of your household own:

A bicycle?
YES 1
NO 2
A moped or motorcycle?
YES 1
NO 2
A car/van or pickup truck?
YES 1
NO 2

29) In your household, do you have mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 33)

30) CHECK COLUMNS 6 AND 7:
NUMBER OF CHILDREN UNDER 5 YEARS OLD WHO SLEPT IN THE HOUSEHOLD LAST NIGHT

NONE (GO TO 33)
ONE (GO TO 31)
TWO OR MORE (GO TO 32)

31) Did (NAME) sleep under a mosquito net last night?

YES 1 (GO TO 33)
NO 2 (GO TO 33)

32) Among the children under 5 years old who slept in the household last night, did all of them, some of them, or none of them sleep under a mosquito net?

ALL 1
SOME 2
NONE 3

33) In your household, is there a place to wash hands?

YES 1
NO 2 (GO TO 35)

34) ASK TO SEE THE PLACE MOST FREQUENTLY USED TO WASH HANDS AND VERIFY IF THE FOLLOWING OBJECTS ARE THERE

TAP WATER
YES 1
NO 2
SOAP, ASHES, OR OTHER WASHING PRODUCT
YES 1
NO 2
BASIN
YES 1
NO 2

35) ASK RESPONDENT FOR A SPOONFUL OF SALT. TEST THE SALT TO CHECK FOR THE PRESENCE OF IODINE.
RECORD THE PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
30 PPM 4

HEIGHT AND WEIGHT MEASUREMENTS

CHECK COLUMNS 8 AND 9: RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN 15-49 YEARS OLD AND CHILDREN UNDER 6 YEARS OLD:

36) LINE NUMBER FROM COLUMN 8

LINE NUMBER___

37) NAME FROM COLUMN 2

NAME___

38) AGE FROM COLUMN 7

AGE___

39) What is (NAME)'s birthday?
[FOR CHILDREN UNDER AGE 6 ONLY]

BIRTHDAY___

WEIGHT AND HEIGHT OF WOMEN 15-49 AND CHILDREN BORN IN OR AFTER 1995:

40) WEIGHT (KILOGRAMS)

WEIGHT___

41) HEIGHT (CENTIMETERS)

HEIGHT___

42) MEASURED LYING DOWN OR STANDING UP?
[FOR CHILDREN BORN IN OR AFTER 1995 ONLY]

LYING 1
STANDING 2

43) RESULT

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

CHECK HERE IF A CONTINUATION SHEET IS USED__