IDENTIFICATION

MEN'S SURVEY (YES=1,NO=2)

FIRST INTERVIEWER VISIT

SECOND INTERVIEWER VISIT

THIRD INTERVIEWER VISIT

FINAL VISIT

NEXT VISIT

Total no. of visits
*Result codes
1Completed
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)

Supervisor

Field editor

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.

Usual residents and visitors
2) 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 household.

Relationship to head of household
3) What is the relationship of (NAME) to the head of household?*

Sex
4) Is (NAME) male or female?

Residence

5) Does (NAME) usually live here?

6) Did (NAME) live here last night?

Age

7) How old is (NAME)?
If 95 years or more mark '95'

Education
If age 6 years or older

8) Has (NAME) ever attended school?

If attended school

9) What is the highest level of school (NAME) has attended?***
What is the highest grade (NAME) completed at that level?

10) If age 25 or under
Is (NAME) currently attending school?

Parental survivorship and residence for persons less than 18 years old**
11) If (NAME)'s natural mother alive?

12) If Alive: Does (NAME)'s natural mother live in this household? If yes, what is her name? Record mother's line number

13) If (NAME)'s natural father alive?

14) If Alive
Does (NAME)'s natural father live in this household? If yes, what is his name? Record father's line number

Eligibility
15) Circle the line number of all women age 15-49

15a) Check cover:
IF MEN'S SURVEY = YES
CIRCLE THE LINE NUMBER OF ALL MEN AGE 15-59

*Codes for column 3: Relationship to head of household:

01 HEAD
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 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER CHILD/STEPCHILD
12 NOT RELATED
98 DON'T KNOW

**Codes for Q. 11 through Q.14
These questions refer to the biological parents of the child.
In Q. 121 and Q. 14, record '00' if parent not listed in household schedule

***codes for q 9
(Including Madrasa)

Level/class

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?

2) In addition, are there any other people who many not be members of your family, such as domestic servants friends who usually live here?

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

CHILDREN'S WORK

16) CHECK COLUMN 5 AND 7: RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 17 LIVING IN THIS HOUSEHOLD.

17) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 IN THE HOUSEHOLD SCHEDULE

18) RECORD THE NAME OF EACH CHILD

ASK THE FOLLOWING QUESTIONS OF THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 5 CHILDREN, USE A SUPPLEMENTAL QUESTIONNAIRE)
Now I would like to ask you some questions on the types of work that children in your household do.

19) Since last (day of week of interview), did (name) do any work for anyone who is not a member of this household?
IF YES: WAS HE/SHE PAID IN CASH OR IN KIND?

20) Since last (day of week of interview), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

21) In the last 12 months, did (name) do any work for anyone who is not a member of this household?
IF YES: WAS HE/SHE PAID IN CASH OR IN KIND?

22) Since (day of week of interview), did (name) help with household chores? For example, doing the dishes, grocery shopping, cleaning, clothes washing, getting water, or watching children?

23) Since last (day of week of interview), approximately how many hours did he/she spend doing household chores?

24) Since last (day of week of interview), did (name) do any work on family land or in a family business?

25) Since last (day of week of interview), approximately how many hours did (name) spend doing this type of work in the fields or for a family business?

RECORD OF BIRTH CERTIFICATES

26) CHECK COLUMNS 5 AND 7:
Number of children aged 10 and under who usually live in the household

27) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 IN THE HOUSEHOLD SCHEDULE

28) RECORD THE NAME OF EACH CHILD

ASK THE FOLLOWING QUESTIONS OF THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 10 CHILDREN, USE A SUPPLEMENTAL QUESTIONNAIRE)

29) Was (name)'s birth declared to the state?

30) Was (name)'s birth declared to the state within three months of birth or when (name) was older?

Handicap
No.
Questions and filters
Coding categories
Skip

Now I would like to ask some questions about the health of each person usually living in your household, including small children.

31) Is there anyone in your household who is missing a limb, for example, a hand, an arm, a foot, or a leg?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING A LIMB. ASK Q. 33 ABOUT THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(If there are more than 3 people, use an additional questionnaire)

32) Name and line number form q. 1 and q.2

33) Has (name) had this problem since birth, or is it due to an accident, an illness, or another cause?
IF AN ACCIDENT, PROBE: What type of accident was it?

34) Is there anyone in your household with a deformity of an upper or lower extremity and who cannot walk or has difficulty walking and/or using his/her arms or hands?
If yes: Could you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH A DEFORMITY. ASK Q. 36 AND 37 FOR THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

35) Name and line number of q. 1 and q. 2

36) Has (name) had this deformity from birth or was it caused by an accident, and illness, or another cause?

37) Does (name) only have difficulty using his/her arms or legs, or can (name) not use his/her arms or legs at all?

38) Is anyone in your household blind or nearly blind?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH VISION PROBLEMS. ASK Q 40 AND 41 OF THE 1ST PERSON, THEN THE 2ND, ETC.

39) Name and line number from q. 1 and q. 2

40) Has (name) had vision problems since birth, or were the problems caused by an accident, an illness, or another cause?

41) Does (name) have trouble seeing or is (name) completely blind?

42) Is there anyone in your household who is almost or completely deaf?
IF YES: Can you tell me the name of these people?

Record the name and line number of each person with hearing problems. Ask q. 44 and 45 of the 1st person, then the 2nd person, etc.

43) Name and line number of q. 1 and q. 2

44) Did (name) have hearing problems since birth or were they caused by an accident, an illness, or another cause?

45) Does (name) have difficulty hearing or is (name) completely deaf?

46) Is there anyone in your household that has serious difficulty talking or is mute?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK. Q. 48 AND 49 FOR THE FIRST PERSON, THEN THE 2ND, ETC.

47) Name and line number from q. 1 and 1. 2

48) Has (name) had these problems with talking since birth or were they caused by an accident, an illness, or another cause?

49) Does name have difficulty talking or is (name) completely mute?

50) Is there anyone in your household who is missing certain bodily extremities, such as finger tips, toes, nose, or ears?
IF YES: Can you tell me the name of these people?

RECORD NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING CERTAIN BODY PARTS. ASK Q. 52 AND 53 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

51) Name and line number of q. 1 and q. 2

52) Has (name) had this problem since birth or was it caused by an accident, an illness, or another cause?

53) Does name have certain extremities that have no feeling?

54) Does anyone in your household have behavioral problems?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH BEHAVIORAL PROBLEMS. ASK Q 56 AND 57 FOR THE 1ST PERSON, THEN THE 2ND, ETC.

55) Name and line number from q. 1 and q. 2

56) Has (name) had this problem since birth or was it caused by an accident, and illness, or another cause?

57) Are (name)'s problems mild or serious?

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

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

60) What kind of toilet facilities does your household have?

61) Does your household have:

62) What type of lighting does your household mainly use?

63) Does any member of your household own:

64) In your household, how many rooms do you use to sleep?

65) Main material of the floor
RECORD OBSERVATION

66) Main material of the walls
RECORD OBSERVATION

67) Main material of roof
RECORD OBSERVATION

68) Does your household have any bednets that can be used while sleeping?

69) CHECK COLUMNS 6 AND 7:
Number of children under age 5 who slept in the household last night

70) Did (name) sleep under a bednet last night?

71) Did all, some, or none of the children under age 5 who slept in the household last night sleep under a bednet?

72) ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD RESULTS

Interviewer's observations
To be filled in after completing interview
(If the questionnaire is not filled out, explain)

Supervisor's observations
To be filled in after completing interview

Name of supervisor___________
Date______

Editor's observations
To be filled in after completing interview

Name of editor_____________
Date_____