Survey on Household Characteristics

Section 1. Record this information before approaching the household Please assign a unique household ID. What is today's date? What state are you in? Kaduna kad Kano kan Katsina kat Jigawa jig Yobe yob Zamfara zam Is this area rural, urban, peri-urban, or other? Urban urban Peri-urban peri Rural rural Other other_geolist Specify other Please enter the address or description of the home location. Please record the GPS coordinates of this home. If available, you may want to take a photo of the front of the house. Section 2. Household information Begin the interview with a short introduction about who you are, the program, and the purpose of the survey. Ask to interview the female in charge of the household or the oldest available female. If not available, male is ok. What is your name? What is your position in the household? Female head of household f_head Oldest female in household f_oldest Other female f_other Male head of household m_head Oldest male in household m_oldest Other male m_other How many people live in this household most of the time? How many of the people who live here are adults (age 18 or over)? How many boys under age 18 live here? Don't forget babies, visitors, and household help. How many girls under age 18 live here? Don't forget babies, visitors, and household help. Section 3. Contact information Thank you for participating in this survey. Here is my contact information if you want to reach me. If you're comfortable, is there any way we can get in touch with you? Yes yes No no Enter phone number or other contact. Section 4. Interviewer observations The roof of this house is made of: Metal sheets metal Brick brick Thatch / Palm leaf thatch Roofing tiles tiles Other other_roof Specify other The walls of the house are made of: Tin tin Brick brick Mud mud Concrete concrete Other other_wall Specify other The floor of the house is made of: Earth / Sand earth Ceramic tiles tiles Cement cement Wood wood Other other_floor Specify other Does the house appear to have access to improved toilet facilities? Yes yes No no What is the main source of light in the house? Electricity electricity Solar solar LPG gas gas Oil lamp oil Dark (only natural light) dark Other other_light Specify other Other identifying characteristics of house: Compared to other houses in the community, how would you say this one compares? Poorer than others poorer About the same as others same Wealthier than others wealthier Did you see anything that should be followed up or any other notes you wish to make?