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DEMOGRAPHIC AND HEALTH SURVEYS - ZAMBIA 1992 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PROVINCE _________________ ___

DISTRICT _____________________ ___

CSA NUMBER ___

SEA NUMBER ___

HOUSEHOLD NUMBER ___

NAME OF HOUSEHOLD HEAD _______________ ___

URBAN/RURAL

URBAN = 1
RURAL = 2

LUSAKA/OTHER CITY/TOWN/VILLAGE

LUSAKA = 1
OTHER CITY = 2
TOWN = 3
VILLAGE = 4

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT____

RESULT* ______________

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) _________

NEXT VISIT:
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT ____

TOTAL NUMBER OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN __

LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE __

LANGUAGE OF QUESTIONNAIRE:

ENGLISH 01

FIELD EDITED BY
NAME ________
DATE ________

OFFICE EDITED BY
NAME ________
DATE ________

KEYED BY
NAME ________ ___
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 OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = OTHER RELATIVE
10 = ADOPTED, FOSTER, STEPCHILD
11 = NOT RELATED
98 = DON'T KNOW

(4) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

(5) RESIDENCE: Did (NAME) sleep here last night?

YES 1
NO 2

(6) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

(7) AGE: How old is (NAME)?

IN YEARS __

EDUCATION IF AGED 6 YEARS OR OLDER

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

YES 1
NO 2

(9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? How many years did (NAME) complete at that level?

LEVEL
1 = PRIMARY
2 = SECONDARY
3 = HIGHER
8 = DON'T KNOW
YEARS
00 = LESS THAN 1 YEAR COMPLETED
98 = DON'T KNOW

(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
DON'T KNOW 8

(12) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
RECORD 00 IF PARENT NOT MEMBER OF HOUSEHOLD.

LINE NUMBER___

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

YES 1
NO 2
DON'T KNOW 8

(14) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
RECORD 00 IF PARENT NOT MEMBER OF HOUSEHOLD.

LINE NUMBER__

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

TOTAL NUMBER OF ELIGIBLE WOMEN __

TICK HERE IF CONTINUATION SHEET USED __

1) Just to make sure that I have a complete listing: 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

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

PIPED WATER
PIPED INTO HOME OR PLOT 11 (GO TO 18)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 18)
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
RAINWATER 41 (GO TO 18)
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18)
OTHER (SPECIFY) _______ 71

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

MINUTES ___
ON PREMISES 996

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

YES 1 (GO TO 20)
NO 2

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

PIPED WATER
PIPED INTO HOME OR PLOT 11
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
RAINWATER 41
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _______ 71

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

FLUSH TOILET
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31
OTHER (SPECIFY) ________ 41

21. 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

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

ROOMS ___

23. What is the material of the floor?

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS/BOARDS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
TERRAZO TILE 32
PVC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _____________ 41

24. 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