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UNITED REPUBLIC OF TANZANIA
BUREAU OF STATISTICS, PLANNING COMMISSION
TANZANIA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD SCHEDULE

IDENTIFICATION
NAME OF HOUSEHOLD HEAD ______________________
CLUSTER NUMBER ___
HOUSEHOLD NO. ___
REGION ___________________ ___
DISTRICT __________________ ___
WARD __________________ ___
ENUMERATION AREA _______________ ___

URBAN/RURAL ___

urban 1
rural 2

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE ___

large city 1
small city 2
town 3
countryside 4

HOUSEHOLD SELECTED FOR MALE SURVEY? ___

1 YES
2 NO

INTERVIEWER VISITS
INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________

INTERVIEWER VISIT 2
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________

INTERVIEWER VISIT 3
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________

NEXT VISIT:
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ____
ID NO. ____
RESULT ____

TOTAL NUMBER OF VISITS __
TOTAL IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE MEN __

*RESULT CODES:

1 COMPLETED
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________

FIELD EDITED BY
NAME ________
DATE ________

OFFICE EDITED BY
NAME ________
DATE ________

KEYED BY
NAME ________
DATE ________

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. (01-18)

(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.

____________ (LINE NO. 01-18)

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

___ (LINE NO. 01-18)

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

M 1
F 2

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

YES 1
NO 2

(6) Did (NAME) sleep here last night?

YES 1
NO 2

(7) AGE
How old is (NAME)?

IN YEARS __

EDUCATION
IF AGE 5 YEARS OR OLDER

(8) Has (NAME) ever been to school?

YES 1
NO 2

(9) What is the highest formal school (NAME) completed?**

____

(10) (IF AGED LESS THAN 25 YEARS) Is (NAME) still in school?

YES 1
NO 2

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD

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

YES 1
NO 2
DK 8

(12) (IF ALIVE) Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.***

___

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

YES 1
NO 2
DK 8

(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) (WOMEN) CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.

(16) (MEN) CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INDIVIDUAL INTERVIEW.

TICK HERE IF CONTINUATION SHEET USED __

TOTAL NUMBER OF ELIGIBLE WOMEN __
TOTAL NUMBER OF ELIGIBLE MEN__
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE: __

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) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?

YES ___ (ENTER EACH IN TABLE)
NO __

*CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD:

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER CHILD
11 NOT RELATED
98 DK

**CODES FOR Q.9 HIGHEST FORMAL SCHOOL:

00 LESS THAN 1 YEAR COMPLETED
01 STANDARD 1
02 STANDARD 2
03 STANDARD 3
04 STANDARD 4
05 STANDARD 5
06 STANDARD 6
07 STANDARD 7
08 STANDARD 8
09 FORM 1
10 FORM 2
11 FORM 3
12 FORM 4
13 FORM 5
14 FORM 6
15 UNIVERSITY
96 OTHER
98 DON'T KNOW

***QUESTIONS 12 AND14: RECORD '00' IF THE NATURAL (BIOLOGICAL) PARENT IS NOT A MEMBER OF THE HOUSEHOLD.

17. What is the source of water your household uses for handwashing and dishwashing?

PIPED INTO HOUSE/YARD/PLOT 11 (GO TO 18)
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 18)
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 18)
TANKER TRUCK 51
OTHER (SPECIFY) _______ 71

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

MINUTES ___
ON PREMISES 996

19. Does your household get drinking water from this same source?

YES 1 (GO TO 21)
NO 2

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

PIPED INTO HOUSE/YARD/PLOT 11 (GO TO 21)
PUBLIC TAP 12
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 21)
PUBLIC WELL 22
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 21)
TANKER TRUCK 51
OTHER (SPECIFY) _______ 71

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

MINUTES ___
ON PREMISES 996

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

OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
TRADITIONAL PIT TOILET 21
VENTILATED PIT LATRINE 22
NO FACILITY/BUSH/FIELD 31

23. Does your household have:

Electricity?
A radio?
A television?
A refrigerator?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

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

ROOMS ___

25. MAIN MATERIAL OF THE FLOOR.

EARTH/SAND 11
WOOD PLANKS 21
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
OTHER (SPECIFY) _____________ 41

26. Does any member of your household own:

A bicycle?
A motorcycle?
A car?

BICYCLE
YES 1
NO 2
MOTORCYCLE
YES 1
NO 2
CAR
YES 1
NO 2