WARD/VILLAGE __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE ___
RURAL 2
OTHER URBAN 2
RURAL 3
FIRST VISIT:
DATE _____
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE _____
TIME _____
SECOND VISIT:
DATE _____
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE _____
TIME _____
THIRD VISIT:
DATE _____
INTERVIEWER'S NAME __________
RESULT * __________
FINAL VISIT:
DAY ___
MONTH __________
YEAR _____
NAME __________
RESULT __________
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) __________
LINE NUMBER OF HOUSEHOLD RESPONDENT ___
LANGUAGE OF QUESTIONNAIRE: ENGLISH 3
NDEBELE 2
ENGLISH 3
OTHER (SPECIFY) __________ 6
DATE _____
DATE _____
OFFICE EDITOR ___
KEYED BY ___
Now we would like some information about the people who usually live in your household or who are staying with you now.
1) LINE NUMBER ___
2) 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-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER CHILD 10
NOT RELATED 11
DON'T KNOW 98
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGE 5 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? What is the highest grade/years (NAME) completed at that level?
2 SECONDARY
3 HIGHER
8 DON'T KNOW
98 DON'T KNOW
10) IF AGE LESS THAN 25 YEARS Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
These questions refer to the biological parents of the child. Record 00 if parent is not a member of household.
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
NAME __________
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
NAME __________
15) CIRCLE LINE NUMBER ELIGIBLE WOMEN. "ROOF" LINE NUMBER ELIGIBLE MEN
LINE NUMBER ELIGIBLE MEN ___
TICK HERE IF CONTINUATION SHEET USED ___
TOTAL NUMBER OF ELIGIBLE MEN ___
TOTAL NUMBER OF ELIGIBLE WOMEN ___
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 servants, 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 ___
16) What is the main source of drinking water for members of your household?
COMMUNAL TAP 12
UNPROTECTED WELL 22
BOREHOLE 23
RIVER/STREAM 32
POND/DAM/LAKE 33
17) How long does it take to go there, get water, and come back?
ON PREMISES 996
18) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
BLAIR TOILET 22
NO 2
NO 2
NO 2
NO 2
20) How many rooms in your household are used for sleeping?
21) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
22) Does any member of your household own:
NO 2
NO 2
NO 2
NO 2