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1999 ZIMBABWE DEMOGRAPHIC AND HEALTH SURVEY

HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

NAME OF HOUSEHOLD HEAD __________

WARD NAME __________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE ___

URBAN/RURAL

URBAN 1
RURAL 2

LARGE CITY/SMALL CITY/TOWN/RURAL

LARGE CITY 1
SMALL CITY 2
TOWN 3
RURAL 4

MALE SURVEY

YES 1
NO 2

INTERVIEWER VISITS

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 ___

TOTAL NUMBER OF VISITS ___

*RESULT CODES

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 OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) __________

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE ___

LANGUAGE OF QUESTIONNAIRE:

ENGLISH 3

LANGUAGE OF INTERVIEW:

SHONA 1
NDEBELE 2
ENGLISH 3
OTHER 4

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 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? *

* CODES FOR QUESTION 3
RELATIONSHIP TO THE HEAD OF 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
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DON'T KNOW

RESIDENCE

4) Does (NAME) usually live here?

YES 1
NO 2

5) Did (NAME) stay here last night?

YES 1
NO 2

SEX

6) Is (NAME) male or female?

MALE 1
FEMALE 2

AGE

7) How old is (NAME)?
AGE IN COMPLETED YEARS

IN YEARS ___

ELIGIBILITY

8)
"CIRCLE" LINE NUMBER OF ALL WOMEN AGE 15-49

"ROOF" LINE NUMBER OF ALL MEN AGE 15-54

"BOX" LINE NUMBER OF ALL CHILDREN UNDER AGE 6

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS 0-14 YEARS OLD **

** QUESTION 9 THROUGH QUESTION 12
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD. IN QUESTION 10 AND QUESTION 12, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE

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

YES 1
NO 2
DK 8

10) IF ALIVE: Does (NAME)'s natural mother live in this household?

IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

LINE NUMBER ___

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

YES 1
NO 2
DK 8

12) IF ALIVE: Does (NAME)'s natural father live in this household?

IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

LINE NUMBER ___

EDUCATION

IF AGE 3 YEARS OR OLDER

13) Has (NAME) ever been to school?

YES 1
NO 2 (SKIP TO NEXT LINE)

14) What is the highest level of school (NAME) attended or attending? ***

What is the highest grade (NAME) completed at that level? ***

LEVEL ___
GRADE ___

*** CODES FOR QUESTIONS 14, 15C AND 15F
EDUCATION LEVEL:

0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW

EDUCATION GRADE:

00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

IF AGE 3-24 YEARS

15A) Is (NAME) currently attending school?

YES 1 (SKIP TO 15C)
NO 2

15B) Was (NAME) ever in attendance in school at any point during this school year?

YES 1
NO 2 (SKIP TO 15D)

15C) During this school year, what level and grade [is (NAME) attending / was (NAME) enrolled in]? ***

LEVEL ___
GRADE ___

15D) Did (NAME) attend school during the previous school year?

YES 1 (SKIP TO 15F)
NO 2

15E) Was (NAME) ever in attendance in school at any point during the previous school year?

YES 1
NO 2 (SKIP TO NEXT LINE)

15F) During the previous school year, what level and grade [did (NAME) attend / was (NAME) enrolled in]? ***

LEVEL ___
GRADE ___

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?

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, who have not been listed?

YES ___ (ENTER EACH IN TABLE)
NO ___

16) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO OWN DWELLING 11 (SKIP TO 18)
PIPED INTO YARD/PLOT 12 (SKIP TO 18)
PUBLIC TAP 13
WELL WATER
PROTECTED WELL 21
UNPROTECTED WELL 22
BOREHOLE 23
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE/DAM 33
RAINWATER 41 (SKIP TO 18)
OTHER (SPECIFY) __________ 96 (SKIP TO 18)

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

MINUTES ___
ON PREMISES 996

18) What kind of toilet or sanitation facility do most members of your household use?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE/BLAIR TOILET 22
NO FACILITY/BUSH/FIELD 31 (SKIP TO 19)
OTHER (SPECIFY) __________ 96

18A) With how many other households do you share this facility?
RECORD "00" IF TOILET NOT SHARED

NUMBER OF HOUSEHOLDS ___

19) Does your household have:

ELECTRICITY?
YES 1
NO 2
A RADIO?
YES 1
NO 2
A TELEVISION?
YES 1
NO 2
A TELEPHONE?
YES 1
NO 2
A REFRIGERATOR?
YES 1
NO 2

19A) What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE/PARAFFIN 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) __________ 96

21) MAIN MATERIAL ON THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) __________ 96

22) Does any member of your household own:

A MODERN OXCART/SCOTCHCART?
YES 1
NO 2
A BICYCLE?
YES 1
NO 2
A MOTORCYCLE?
YES 1
NO 2
A CAR OR TRUCK?
YES 1
NO 2

22A) Does your household have any bednets that are used while sleeping?

YES 1
NO 2 (SKIP TO 22E)

22B) CHECK 5 AND 7:
NUMBER OF CHILDREN UNDER AGE 5 WHO SLEPT IN THE HOUSEHOLD LAST NIGHT

NONE ___ (SKIP TO 22E)
ONE ___
TWO OR MORE ___ (SKIP TO 22D)

22C) Did (NAME) sleep under a bednet last night?

YES 1 (SKIP TO 22E)
NO 2 (SKIP TO 22E)

22D) Did all, some or none of the children under age 5 who slept in the household last night sleep under a bednet?

ALL CHILDREN 1
SOME CHILDREN 2
NONE 3

22E) Does your household have any place which is used for hand washing?

YES 1
NO 2 (SKIP TO 23)

22F) ASK TO SEE THE PLACE USED MOST OFTEN AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT

WATER/TAP
YES 1
NO 2
SOAP, ASH OR OTHER CLEANSING AGENT
YES 1
NO 2
BASIN
YES 1
NO 2

23) TYPE OF SALT
TEST OF IODINE.

00 PPM (NO IODINE/UNDETECTABLE) 1
01-14 PPM 2
15+ PPM 3

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS (8): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

WOMEN 15-49

24) LINE NUMBER FROM COLUMN 8

LINE NUMBER ___

25) NAME FROM COLUMN 2

NAME __________

26) AGE FROM COLUMN 7

YEARS ___

HEIGHT AND WEIGHT MEASUREMENT OF WOMEN 15-49

28) WEIGHT (KILOGRAMS)

KILOGRAMS ___

29) HEIGHT (CENTIMETERS)

CENTIMETERS ___

31) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

CHILDREN UNDER 6

24) LINE NUMBER FROM COLUMN 8

LINE NUMBER ___

25) NAME FROM COLUMN 2

NAME __________

26) AGE FROM COLUMN 7

AGE ___

27) What is (NAME)'s date of birth?

DATE OF BIRTH __________

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1994 OR LATER

28) WEIGHT (KILOGRAMS)

KILOGRAMS ___

29) HEIGHT (CENTIMETERS)

CENTIMETERS ___

30) MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

31) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

TICK HERE IF CONTINUATION SHEET USED ___

HEMOBGLOBIN MEASUREMENT OF WOMEN 15-49

32) CHECK COLUMN 26:

AGE 15-17 1
AGE 18-49 2 (SKIP TO 34)

33) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

LINE NUMBER ___

34) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT *
CIRCLE CODE (AND SIGN)

GRANTED 1
SIGN __________
REFUSED 2 (SKIP TO NEXT LINE)

35) HEMOGLOBIN LEVEL (G/DL)

LEVEL ___

36) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN JANUARY 1994 OR LATER

33) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

LINE NUMBER ___

34) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT *
CIRCLE CODE (AND SIGN)

SIGN __________ 1
REFUSED 2 (SKIP TO NEXT LINE)

35) HEMOGLOBIN LEVEL (G/DL)

LEVEL ___

36) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

* CONSENT STATEMENT

As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem which results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in January 1994 or later) participate in the anemia testing part of this survey and give a sample of blood from a finger or heel. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you [and NAME OF CHILD(REN)] participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.