PROVINCE _________________ ___
DISTRICT _____________________ ___
CSA NUMBER ___
SEA NUMBER ___
HOUSEHOLD NUMBER ___
NAME OF HOUSEHOLD HEAD _______________ ___
RURAL 2
LUSAKA/OTHER CITY/TOWN/VILLAGE
OTHER CITY 2
TOWN 3
VILLAGE 4
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT____
HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME 2
HOUSEHOLD ABSENT 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _________ 9
NEXT VISIT:
DATE ______
TIME _____
FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT ____
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 ________
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?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED, FOSTER, STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98
(4) RESIDENCE: Does (NAME) usually live here?
NO 2
(5) RESIDENCE: Did (NAME) sleep here last night?
NO 2
(6) SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGED 6 YEARS OR OLDER
(8) Has (NAME) ever been to school?
NO 2
(9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? How many years did (NAME) complete at that level?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
(10) IF AGED LESS THAN 25 YEARS: Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
(11) Is (NAME)'s natural mother alive?
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.
(13) Is (NAME)'s natural father alive?
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.
(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?
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) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO
16. What is the source of water your household uses for handwashing and dishwashing?
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
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?
ON PREMISES 996
18. Does your household get drinking water from this same source?
NO 2
19. What is the source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _______ 71
20. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) ________ 41
Electricity?
A radio?
A television?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
22. How many rooms in your household are used for sleeping?
23. What is the material of the floor?
TERRAZO TILE 32
PVC TILES 33
CEMENT 34
CARPET 35
24. Does any member of your household own:
A bicycle?
A motorcycle?
A car?
NO 2
NO 2
NO 2