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Household Listing Template 1 -Form Fill

IDENTIFICATION AND INTERVIEW ELIGIBILITY

Q01

NAME OF DISTRICT

Q02

CODE OF DISTRICT

Q03

NAME OF BLOCK

Q04

CODE OF BLOCK

Q05

CLUSTER NAME

Q06

CLUSTER CODE

Q07

STRUCTURE NUMBER

Q08

HOUSEHOLD ID NUMBER

Q09

INTERVIEWER VISITS-1

Q09_1

DATE

Q09_2

TIME STARTED

Q09_3

TIME FINISHED

Q09_4

INTERVIEWER’S NAME

Q09_5

INTERVIEWER’S CODE

Q09_6

RESULT

COMPLETED

NO HOUSEHOLD MEMBER AT HOME OR NO ABLE PERSON AT HOME AT TIME OF VISIT

ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME

POSTPONED

REFUSED

DWELLING VACANT OR ADDRESS NOT A DWELLING

DWELLING DESTROYED

DWELLING NOT FOUND

OTHER

Q10

INTERVIEWER VISITS-2

Q10_1

DATE

Q10_2

TIME STARTED

Q10_3

TIME FINISHED

Q10_4

INTERVIEWER’S NAME

Q10_5

INTERVIEWER’S CODE

Q10_6

RESULT

COMPLETED

NO HOUSEHOLD MEMBER AT HOME OR NO ABLE PERSON AT HOME AT TIME OF VISIT

ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME

POSTPONED

REFUSED

DWELLING VACANT OR ADDRESS NOT A DWELLING

DWELLING DESTROYED

DWELLING NOT FOUND

OTHER

Q11

INTERVIEWER VISITS-3

Q11_1

DATE

Q11_2

TIME STARTED

Q11_3

TIME FINISHED

Q11_4

INTERVIEWER’S NAME

Q11_5

INTERVIEWER’S CODE

Q11_6

RESULT

COMPLETED

NO HOUSEHOLD MEMBER AT HOME OR NO ABLE PERSON AT HOME AT TIME OF VISIT

ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME

POSTPONED

REFUSED

DWELLING VACANT OR ADDRESS NOT A DWELLING

DWELLING DESTROYED

DWELLING NOT FOUND

OTHER

Q12

ID of household member

Q13

Name of person?

Q14

Relationship to household head?

HEAD OF HOUSEHOLD

WIFE/HUSBAND

OWN SON/DAUGHTER

STEP SON/DAUGHTER

GRANDCHILD

BROTHER/SISTER

PARENT

PARENT-IN-LAW

NIECE/NEPHEW

DAUGHTER IN LAW

BROTHER/SISTER IN LAW

Q15

Age?

Q16

Sex?

MALE

FEMALE

OTHER

Q17

Is the woman married and between 15-49 years of age?

YES

Q18

Since [December 2012] has the woman given birth to a baby that was born alive, born dead or lost before birth?

BORN ALIVE

BORN DEAD

LOST BEFORE FULL TERM

NOT GIVEN BIRTH IN LAST TWO YEARS

Q19

Did that most recent baby cry, move, or breathe when it was born?

YES

Q20

In what month and year was the most recent baby born?

Q21

Is the baby still alive?

YES

Q22

How old was the child when he/she died

Q23

Household Listing Template 1 -Form Fill

NAME OF DISTRICT

CODE OF DISTRICT

NAME OF BLOCK

CODE OF BLOCK

CLUSTER NAME

CLUSTER CODE

STRUCTURE NUMBER

HOUSEHOLD ID NUMBER

INTERVIEWER VISITS-1

DATE

TIME STARTED

TIME FINISHED

INTERVIEWER’S NAME

INTERVIEWER’S CODE

RESULT

INTERVIEWER VISITS-2

DATE

TIME STARTED

TIME FINISHED

INTERVIEWER’S NAME

INTERVIEWER’S CODE

RESULT

INTERVIEWER VISITS-3

DATE

TIME STARTED

TIME FINISHED

INTERVIEWER’S NAME

INTERVIEWER’S CODE

RESULT

ID of household member

Name of person?

Relationship to household head?

Age?

Sex?

Is the woman married and between 15-49 years of age?

Since [December 2012] has the woman given birth to a baby that was born alive, born dead or lost before birth?

Did that most recent baby cry, move, or breathe when it was born?

In what month and year was the most recent baby born?

Is the baby still alive?

How old was the child when he/she died

In what month and year did this pregnancy end?