HOUSEHOLD SCHEDULE
IDENTIFICATION
PROVINCE
DISTRICT
EA NUMBER
EA TYPE
SADHS CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME OF HOUSEHOLD HEAD
IS HOUSEHOLD SELECTED FOR ADULT HEALTH
NO 2
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME RESULT
TOTAL NO. OF VISITS
TOTAL IN HOUSEHOLD
TOTAL ADULTS 15 YEARS AND OVER
TOTAL WOMEN 15-49 YEARS
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE
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) ____________________________
* CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:
02 = WIFE/HUSBAND/PARTNER
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 =NIECE/NEPHEW
10 =OTHER RELATIVE
11 = ADOPTED/FOSTER/STEP CHILD
12 = NOT RELATED
98 = DON'T KNOW
** CODES FOR Q.10 (EDUCATION GRADE)
71 = SUB A/CLASS 1
72 = SUB B/CLASS 2
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 = STANDARD 9
10 = STANDARD 10
11 = FURTHER STUDIES INCOMPLETE
12 = DIPLOMA/OTHER POSTSCHOOL COMPLETE
13 = FURTHER DEGREE COMPLETE
98 = DON'T KNOW
12 = POLITICAL VIOLENCE child.
13 = OTHER ASSAULT OUTSIDE OF HOME
14 = SELF INFLICTED VIOLENCE
21 = TRAFFIC COLLISION
22 = ACCIDENT AT WORK
23 = SPORT
96 = OTHER UNINTENTIONAL
**** Q.15 THROUGH Q.18:
These questions refer to the biological parents of the child. Record 00 if parent not member of household.
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.
(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?
RESIDENCE
(4) Does (NAME) usually live here?
NO 2
(5) Did (NAME) stay here last night?
NO 2
(6) SEX
Is (NAME) male or female?
F 2
(7) AGE
How old is (NAME)?
(WRITE 00 IF UNDER 1 YEAR).
IF 95 OR OVER, WRITE '95'
(8) GRANTS/PENSION
Does (NAME) receive a child maintenance grant, a disability grant or a pension from the government?
NO 2
DK 8
(9) Has (NAME) ever been to school?
NO 2
IF ATTENDED SCHOOL
(10) What is the highest level of school (NAME) completed? **
IF AGE LESS THAN 25 YEARS
(11) Is (NAME) still in school?
NO 2
(12) WORK
(AGE 10+) Did (NAME) work for pay during the last 7 days?
NO 2
INJURIES IN THE LAST MONTH
(13) Did (NAME) have any injury that was treated by a doctor or nurse during the last 30 days?
NO 2 (GO TO15)
DK 8 (GO TO 15)
(14) (IF INJURED IN LAST 1 MONTH)
What type of injury*** did (NAME) have?
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD****
(15) Is (NAME)'s natural mother alive?
NO 2
DK 8
(16) (IF ALIVE) Does (NAME)'s natural mother live in this household? IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
(17) Is (NAME)'s natural father alive?
NO 2
DK 8
(18) (IF ALIVE) Does (NAME)'s natural father live in this household? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
(19) CIRCLE LINE NUMBER OF ALL PERSONS 15 YEARS OR OLDER
(20) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
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 workers, 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 that have not been listed?
NO
21 Has anyone in the household died in the last 12 months?
NO 2 (GO TO 25)
22 In the last 12 months, how many people in your household died?
23 In the last 12 months, how many people in your household died from an injury sustained as a result of violence either between them and other people or from violence inflicted upon themselves?
24 In the last 12 months, how many persons in your household died from an unintentional injury they sustained such as from a traffic collision, or an injury (such as falls, burns or cuts) that happened at home/work/school/etc?
25 What is the main source of drinking water for members of your household?
PIPED WATER (TAP) IN SITE/YARD 12 (GO TO 28)
PUBLIC TAP 13
WATER CARRIER/TANKER 21
BOREHOLE/W ELL 31
DAM/RIVER/STREAM/SPRING 32
RAIN-WATER TANK 41 (GO TO 28)
BOTTLED WATER 51 (GO TO 28)
OTHER 96
26 How long does it take you to get there, get water, and come back?
ON PREMISES 996
27 Who fetched the water yesterday?
RECORD ALL MENTIONED.
MALE ADULT B
FEMALE CHILD C
MALE CHILD D
DON'T KNOW Z
28 What kind of toilet facility does your household have?
FLUSH TOILET (SHARED) 12
BUCKET LATRINE 21
PIT LATRINE 22
NO FACILITY/BUSH/FIELD 31
OTHER 96
29 Does your household have:
Electricity?
A radio?
A television?
A telephone?
A refrigerator?
A personal computer (PC)?
A washing machine?
NO2
NO2
NO2
NO2
NO2
NO2
NO2
30 What does your household use for cooking and heating?
RECORD ALL MENTIONED.
GAS B
PARAFFIN C
W OOD D
COAL E
ANIMAL DUNG F
OTHER __________ X
31 How many rooms in your household are used for sleeping?
32 MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION
BARE WOOD PLANKS 21
CEMENT 31
VINYL 32
CARPET 33
CERAMIC TILES 34
PARQUET OR POLISHED WOOD 35
OTHER ________ 96
33 MAIN MATERIAL IN THE WALLS.
RECORD OBSERVATION
MUD 12
MUD AND CEMENT 13
CORRUGATED IRON/ZINC 21
PREFAB 22
BARE BRICK/CEMENT BLOC 23
PLASTER/FINISHED 31
OTHER __________ 96
34 Let us speak about the household and what it can afford. Would you say that the people here often, sometimes, seldom or never go hungry?
SOMETIMES 2
SELDOM 3
NEVER 4
35 Does any member of your household own:
A bicycle?
A motorcycle?
A car?
A donkey or a horse?
Sheep or cattle?
NO2
NO2
NO2
NO2
NO2