Data Cart

Your data extract

0 variables
0 samples
View Cart


DEMOGRAPHIC AND HEALTH SURVEYS - ZAMBIA 1996 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

CLUSTER NUMBER ___

PROVINCE _________________ ___

DISTRICT _____________________ ___

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

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES = 1
NO = 2

INTERVIEWER VISITS

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

RESULT* ______________

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ______
TIME _____

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

TOTAL NUMBER OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL ELIG. WOMEN __

TOTAL ELIG. MEN __

LINE NUMBER OF RESP. TO HOUSEHOLD SCHEDULE _

LANGUAGE OF QUESTIONNAIRE:

ENGLISH 01

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR

KEYED BY

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/STEP CHILD
12 = NOT RELATED
98 = DON'T KNOW

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

YES 1
NO 2

(5) RESIDENCE: Did (NAME) stay 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 __

(8) EDUCATION IF AGE 6 YEARS OR OLDER: Has (NAME) ever been to school?

YES 1
NO 2

(9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at that level?

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

(10) IF AGE LESS THAN 25 YEARS: Is (NAME) still in school?

YES 1
NO 2

(11) MARITAL STATUS IF AGE 12 YEARS OR OLDER: Is (NAME) married, living together, separated, divorced, or never married?

1 = MARRIED
2 = LIVING TOGETHER
3 = SEPARATED
4 = DIVORCED
5 = WIDOWED
6 = NEVER MARRIED

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD

(12) Is (NAME)'s natural mother alive?

YES 1
NO 2
DON'T KNOW 8

(13) 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___

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

YES 1
NO 2
DON'T KNOW 8

(15)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__

(16) ELIGIBILITY WOMEN: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

(16A) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 (IF HOUSEHOLD FALLS IN MEN'S SAMPLE).

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

YES (ENTER EACH IN TABLE)
NO

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

PIPED WATER
PIPED INTO HOME OR PLOT 11 (GO TO 19)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 19)
PUBLIC SHALLOW WELL 22
PUBLIC TRADITIONAL WELL 23
PUBLIC BOREHOLE 24
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
RAINWATER 41 (GO TO 19)
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 19)
OTHER (SPECIFY) _______ 96

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

MINUTES ___
ON PREMISES 996

19. 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) ________ 96

20. 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

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

ROOMS ___

22. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND/MUD 11
RUDIMENTARY FLOOR
WOOD PLANKS/BOARDS 21
FINISHED FLOOR
WOODEN TILE 31
CERAMIC/TERRAZO/MARBLE TILE 32
CEMENT/CONCRETE 33
OTHER (SPECIFY) _____________ 96

23. 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

24. We would like to check whether the salt used in your household is iodized. May we see a sample of the salt used to cook meal eaten by members of your household last night?

IODIZED 1
NOT IODIZED 2 (IND. QRE)
NOT TESTED 3 (IND. QRE)
NO SALT AT HOME 4 (IND. QRE)

25. RECORD IODATE SCORE

0 01
25 02
50 03
75 04
100 plus 05