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DEMOGRAPHIC AND HEALTH SURVEYS - TANZANIA 2004 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

REGION_____

DISTRICT_____

WARD____

ENUMERATION AREA_____

NAME OF HOUSEHOLD HEAD____

TDHS NUMBER____

HOUSEHOLD NUMBER_____

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE

LARGE CITY=1
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

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 IN HOUSEHOLD 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
DATE____
TIME____

FINAL VISIT
DAY____
MONTH____
YEAR___
INT. NUMBER___
RESULT____

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD____

TOTAL WOMEN 15-49____

TOTAL MEN 15-49____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR
DATE

KEYED BY
DATE

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.

LINE NUMBER____

(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.

NAME____

(3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the 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-WIFE
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER/STEPCHILD
12 = NOT RELATED
98 = DON’T KNOW

(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)?
IF 95 OR MORE, WRITE ‘95’

IN YEARS _______

(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?

YES 1
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

LINE NUMBER_____________

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

YES 1
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.

LINE NUMBER_____________

EDUCATION IF AGE 5 YEARS OR OLDER

(14) Has (NAME) ever attended school?

YES 1
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? ***

LEVEL ____
0=PREPRIMARY
1 = PRIMARY
2=POST PRIMARY TRAINING
3= SECONDARY O-LEVEL
4= SECONDARY A-LEVEL
5=POST-SECONDARY TRAINING ‘O’ LEVEL
6=POST-SECONDARY TRAINING’A’ LEVEL
7=UNIVERSITY
8= DON’T KNOW
GRADE _____
00=LESS THAN 1 YEAR COMPLETED
98 = DON’T KNOW

IF AGE 5-24 YEARS

(16) Is (NAME) currently attending school?

YES 1 (GO TO 18)
NO 2

(17) During the academic year that started in 2004, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 19)

(18) During the current school year, what level and grade [is/was] (NAME) attending?***

LEVEL ____
0=PREPRIMARY
1 = PRIMARY
2=POST PRIMARY TRAINING
3= SECONDARY O-LEVEL
4= SECONDARY A-LEVEL
5=POST-SECONDARY TRAINING ‘O’ LEVEL
6=POST-SECONDARY TRAINING’A’ LEVEL
7=UNIVERSITY
8= DON’T KNOW
GRADE _____
98 = DON’T KNOW

(19) During the academic year that started in 2003, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 20A)

(20) During that school year, what level and grade did (NAME) attend?***

LEVEL ____
0=PREPRIMARY
1 = PRIMARY
2=POST PRIMARY TRAINING
3= SECONDARY O-LEVEL
4= SECONDARY A-LEVEL
5=POST-SECONDARY TRAINING ‘O’ LEVEL
6=POST-SECONDARY TRAINING’A’ LEVEL
7=UNIVERSITY
8= DON’T KNOW
GRADE _____
98 = DON’T KNOW

EMPLOYMENT IF AGE 5 YEARS OR OLDER

(20A) During the last 12 months what was (NAME)’s main activity?

AGRICULTURE
01=FARMING/LIVESTOCK KEEPING
02=FISHING
PAID EMPLOYEE
03=GOVERNMENT AND PARASTATAL
04=PRIVATE
SELF-EMPLOYED (NOT IN AGRICULT./LIVESTOCK)
05=WITH EMPLOYEES
06=WITHOUT EMPLOYEES
07=UNPAID FAMILY HELPER IN A BUSINESS (NON-AG)
NOT WORKING
08=AND AVAILABLE FOR WORK
09=AND NOT AVAILABLE FOR WORK
10=HOUSEMAKER/HOUSEWIFE/HOUSE CHORES
11=STUDENT
12=UNABLE TO WORK (OLD, RETIRED, SICK, DISABLED)
13=OTHER (SPECIFY)

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?

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

YES (ENTER EACH IN TABLE)
NO

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 23)
PIPED INTO YARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
NEIGHBOUR’S TAP 14
WATER FROM OPEN WELL
OPEN WELL IN DWELLING 21 (GO TO 23)
OPEN WELL IN YARD/PLOT 22 (GO TO 23)
OPEN PUBLIC WELL 23
NEIGHBOUR’S OPEN WELL 24
WATER FROM COVERED WELL OR BOREHOLE
PROTECTED WELL IN DWELLING 31 (GO TO 23)
PROTECTED WELL IN YARD/PLOT 32 (GO TO 23)
PROTECTED PUBLIC WELL 33
NEIGHBOUR’S BOREHOLE 34
SURFACE WATER
SPRING 41
RIVER/STREAM 42
POND/LAKE 43
DAM 44
RAINWATER 51 (GO TO 23)
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?

MINUTES____
ON PREMISES 996

23. What kind of toilet facilities does your household have?

FLUSH TOILET 11
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?

YES 1
NO 2

25. Does your household have:

a) Electricity?
b) A paraffin lamp?
c) A radio?
d) A television?
e) A telephone/mobile?
f) An iron (either charcoal or electric)?
g) A refrigerator?

ELECTRICITY
YES 1
NO 2
PARAFFIN LAMP
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE/MOBILE
YES 1
NO 2
IRON
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

26. What type of fuel does your household mainly use for cooking?

MAIN ELECTRICITY 01
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?

MAIN ELECTRICITY 01
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.

NATURAL FLOOR
EARTH/SAND 01
DUNG 02
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
OTHER (SPECIFY) ___________

27A. WALL MATERIALS
RECORD OBSERVATION.

GRASS 01
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.

GRASS/LEAVES/MUD 01
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)

ROOMS ______

28. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?
A bank account?

BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BANK ACCOUNT
YES 1
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)

ARABLE LAND _______
LAND FOR GRAZING _______

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, RENTED 1
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)

ARABLE LAND _______
LAND FOR GRAZING _______

28D. How far is it to the nearest market place?
(WRITE ‘00’ IF LESS THAN ONE KILOMETRES)

KILOMETRE _______

28E. How many meals does your household usually have per day?

MEALS _______

28F. In the past week, on how many days did the household consume meat?

DAYS ______

28G. How often in the last year did you have problems in satisfying the food needs of the household?

NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5

29. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 35)

29A. How many mosquito nets does your household have?

NUMBER OF NETS ______

IF MORE THAN 10 NETS, USE EXTRA QUESTIONNAIRE(S).

31. How long ago did your household obtain the mosquito net?

MOS AGO _______
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?

YES 1
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?

YES 1
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’.

MONTHS AGO _______

MORE THAN 3 YEARS AGO 95
NOT SURE 98

32D. Did anyone sleep under this mosquito net last night?

YES 1
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.

NAME _______
LINE NO. _______

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)

0 PPM (NO IODINE) 1
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)

LINE NUMBER__________

(37) NAME FROM COL. (7)

NAME__________

(38) AGE FROM COL. (7)

YEARS _______

(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.

DAY ________
MONTH _______
YEAR _______

(40) WEIGHT (KILOGRAMS)

WEIGHT__________ . ___

(41) HEIGHT (CENTIMETERS)

HEIGHT__________ . ___

(42) MEASURED LYING DOWN OR STANDING UP

LYING 1
STAND. 2

(43) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

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.

(44) CHECK COLUMN (38)

AGE 15-17 1
AGE 18-49 2 (GO TO 46)

(45) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD ‘00’ IF NOT LISTED IN HOUSEHOLD SCHEDULE.

LINE NUMBER____________

(46) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1 (SIGN) _______
REFUSED 2 (GO TO NEXT LINE)

(47) HEMOGLOBIN LEVEL (G/DL)

LEVEL_______ . ___

(48) CURENTLY PREGNANT

YES 1
NO/DON'T KNOW 2

(49) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

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*

ONE OR MORE
GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN CONTINUE WITH 51.**
NONE
GIVE EACH
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?

YES 1
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.