DEMOGRAPHIC AND HEALTH SURVEYS - TANZANIA 2004 - HOUSEHOLD QUESTIONNAIRE
REGION_____
DISTRICT_____
WARD____
ENUMERATION AREA_____
NAME OF HOUSEHOLD HEAD____
TDHS NUMBER____
HOUSEHOLD NUMBER_____
LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
LARGE CITIES ARE; DAR ES SALAAM AND MWANZA. SMALL CITIES ARE; ARUSHA, MOROGORO, DODOMA, MOSHI, TANGA, IRINGA MBEYA, SHINYANGA, TABORA, MJINI MAGHARIBI - ZANZIBAR. ALL OTHER URBAN AREAS ARE TOWN
HOUSEHOLD SELECTED FOR MEN'S SURVEY AND SALT TESTING
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
RESULT___
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _________ 9
FINAL VISIT
DAY____
MONTH____
YEAR___
INT. NUMBER___
RESULT____
TOTAL PERSONS IN HOUSEHOLD____
TOTAL WOMEN 15-49____
TOTAL MEN 15-49____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
FIELD EDITOR
NAME
DATE
OFFICE EDITOR
DATE
KEYED BY
DATE
Now we would like some information about the people who usually live in your household or who are staying with you now.
(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?
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
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEP CHILD 11
NOT RELATED 12
DON'T KNOW 98
(4) SEX: Is (NAME) male or female?
FEMALE 2
(5) RESIDENCE: Does (NAME) usually live here?
NO 2
(6) RESIDENCE: Did (NAME) stay here last night?
NO 2
(7) AGE: How old is (NAME)?
IF 95 OR MORE, WRITE '95'
(8) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
(8a) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-49
(9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD**
**THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
(10) Is (NAME)'s natural mother alive?
NO 2 (GO TO 12)
DON'T KNOW 8 (GO TO 12)
(11) (IF ALIVE) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
RECORD MOTHER'S LINE NUMBER
(12) Is (NAME)'s natural father alive?
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)
(13) (IF ALIVE) Does (NAME)'s natural father usually live in this household or was he a guest last night?
RECORD FATHER'S LINE NUMBER.
EDUCATION IF AGE 5 YEARS OR OLDER
(14) Has (NAME) ever attended school?
NO 2 (GO TO 20A)
(15) What is the highest level of school (NAME) has attended? ***
What is the highest grade (NAME) completed at that level? ***
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY O-LEVEL 3
SECONDARY A-LEVEL 4
POST-SECONDARY TRAINING 'O' LEVEL 5
POST-SECONDARY TRAINING'A' LEVEL 6
UNIVERSITY 7
DON'T KNOW 8
DON'T KNOW 98
(16) Is (NAME) currently attending school?
NO 2
(17) During the academic year that started in 2004, did (NAME) attend school at any time?
NO 2 (GO TO 19)
(18) During the current school year, what level and grade [is/was] (NAME) attending?***
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY O-LEVEL 3
SECONDARY A-LEVEL 4
POST-SECONDARY TRAINING 'O' LEVEL 5
POST-SECONDARY TRAINING'A' LEVEL 6
UNIVERSITY 7
DON'T KNOW 8
(19) During the academic year that started in 2003, did (NAME) attend school at any time?
NO 2 (GO TO 20A)
(20) During that school year, what level and grade did (NAME) attend?***
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY O-LEVEL 3
SECONDARY A-LEVEL 4
POST-SECONDARY TRAINING 'O' LEVEL 5
POST-SECONDARY TRAINING'A' LEVEL 6
UNIVERSITY 7
DON'T KNOW 8
EMPLOYMENT IF AGE 5 YEARS OR OLDER
(20A) During the last 12 months what was (NAME)'s main activity?
FISHING 02
PRIVATE 04
WITHOUT EMPLOYEES 06
UNPAID FAMILY HELPER IN A BUSINESS (NON-AG) 07
AND NOT AVAILABLE FOR WORK 09
STUDENT 11
UNABLE TO WORK (OLD, RETIRED, SICK, DISABLED) 12
OTHER (SPECIFY) 13
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?
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?
NO
3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?
NO
21. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
NEIGHBOUR'S TAP 14
OPEN WELL IN YARD/PLOT 22 (GO TO 23)
OPEN PUBLIC WELL 23
NEIGHBOUR'S OPEN WELL 24
PROTECTED WELL IN YARD/PLOT 32 (GO TO 23)
PROTECTED PUBLIC WELL 33
NEIGHBOUR'S BOREHOLE 34
RIVER/STREAM 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
WATER VENDOR 62
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) ________________________ 96
22. How long does it take you to go there, get water, and come back?
ON PREMISES 996
23. What kind of toilet facilities does your household have?
PIT TOILET/LATRINE TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31 (GO TO 25)
OTHER (SPECIFY) ______________________ 96
24. Do you share these facilities with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
BOTTLED GAS 02
BIOGAS 03
PARAFFIN/KEROSENE 04
CHARCOAL 05
FIREWOOD 06
DUNG 07
CROP RESIDUALS 08
SOLAR 09
OTHER (SPECIFY) ______________________ 96
26A. What is the main source of energy for lighting in the household?
SOLAR 02
GAS 03
PARAFFIN-HURRICANE LAMP 04
PARAFFIN-PRESSURE LAMP 05
PARAFFIN-WICK LAMP 06
FIREWOOD 07
CANDLE 08
OTHER (SPECIFY) ____________________ 96
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 02
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
27A. WALL MATERIALS
RECORD OBSERVATION.
POLES AND MUD 02
SUNDRIED BRICKS 03
BAKED BRICKS 04
TIMBER 05
CEMENT BRICKS 06
STONES 07
OTHER (SPECIFY) _____________________ 96
27B. ROOFING MATERIAL
RECORD OBSERVATION.
IRON SHEETS 02
TILES 03
CONCRETE 04
ASBESTOS 05
OTHER (SPECIFY) _____________________ 96
27C. How many rooms in your household are used for sleeping?
(INCLUDING ROOMS OUTSIDE THE MAIN DWELLING)
28. Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
28A. How many acres of land for farming/grazing are owned by the household?
(PUT '0' IF NONE AND 9999.8 IF DOESN'T KNOW)
28B. Does the household use land for farming/grazing that it doesn't own?
IF YES, is it rented, sharecropped, private land provided free, or open access/communal/other?
YES, SHARECROPPED 2
YES, PRIVATE LAND PROVIDED FREE 3
YES, OPEN ACCESS/COMMUNAL 4
NO 5 (GO TO 28D)
28C. How many acres of land are used?
(PUT '0' IF NONE AND 9999.8 IF DOESN'T KNOW)
28D. How far is it to the nearest market place?
(WRITE '00' IF LESS THAN ONE KILOMETRES)
28E. How many meals does your household usually have per day?
28F. In the past week, on how many days did the household consume meat?
28G. How often in the last year did you have problems in satisfying the food needs of the household?
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5
29. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 35)
29A. How many mosquito nets does your household have?
IF MORE THAN 10 NETS, USE EXTRA QUESTIONNAIRE(S).
31. How long ago did your household obtain the mosquito net?
MORE THAN 3 YEARS AGO 95
NOT SURE 98
32A. When you got the net, was it already treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
32B. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?
NO 2 (GO TO 32D)
NOT SURE 8 (GO TO 32D)
32C. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.
MORE THAN 3 YEARS AGO 95
NOT SURE 98
32D. Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 32F)
NOT SURE 8 (GO TO 32F)
32E. Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THEHOUSEHOLD SCHEDULE.
32F. GO BACK TO 31 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 35.
35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HH 5
SALT NOT TESTED (SPECIFY REASON)________________ 6
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT
CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
(36) LINE NO. FROM COL. (8)
(39) What is (NAME'S) date of birth?
* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.
MONTH _______
YEAR _______
(42) MEASURED LYING DOWN OR STANDING UP
STAND. 2
NOT PRESENT 2
REFUSED 3
OTHER 6
TICK HERE IF CONTINUATION SHEET USED
* CONSENT STATEMENT
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1999 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILD[REN]) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
AGE 18-49 2 (GO TO 46)
(45) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.
(46) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)
REFUSED 2 (GO TO NEXT LINE)
NO/DON'T KNOW 2
NOT PRESENT 2
REFUSED 3
OTHER 6
Note: In countries where some enumeration areas are higher than 1,000 meters, altitude information should be collected on a separate form for each enumeration area higher than 1,000 meters so that the anemia estimates can be adjusted appropriately.
50. CHECK 47 AND 48:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*
MEASUREMENT AND WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END HOUSEHOLD INTERVIEW.
51. We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at ________________________ about (your condition/the condition of NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?
NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT
NAME OF PARENT/RESPONSIBLE ADULT
AGREES TO REFERRAL?
NO 2
* The cutoff point is 9 g/dl for pregnant women and 7 g/dl for children and women who are not pregnant (or who don't know if they are pregnant).
** If more than one woman or child is below the cutoff point, read the statement in Q.51 to each woman who is below the cutoff point and to each woman/parent/responsible adult of a child who is below the cutoff point.