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Bangladesh 2014

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NIPORT, MOHFW<br />

Mitra and Associates<br />

BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY <strong>2014</strong><br />

HOUSEHOLD QUESTIONNAIRE<br />

IDENTIFICATION<br />

June 11, <strong>2014</strong><br />

DIVISION<br />

DISTRICT<br />

UPAZILA<br />

UNION/WARD<br />

VILLAGE/MOHALLA/BLOCK<br />

CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

RURAL=1, CITY CORPORATION=2, OTHER URBAN=3 . . . . . . . . . . .. . . . . . .. . . . . . . . . . .<br />

NAME OF THE HOUSEHOLD HEAD<br />

INTERVIEWER VISITS<br />

1 2 3<br />

FINAL VISIT<br />

DATE<br />

DAY<br />

MONTH<br />

YEAR<br />

2 0<br />

1 4<br />

INTERVIEWER'S NAME<br />

RESULT*<br />

INT. CODE<br />

RESULT*<br />

NEXT VISIT:<br />

DATE<br />

TIME<br />

TOTAL NUMBER<br />

OF VISITS<br />

*RESULT CODES:<br />

TOTAL PERSONS<br />

IN HOUSEHOLD<br />

1 COMPLETED<br />

2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT TOTAL ELIGIBLE<br />

AT HOME AT TIME OF VISIT<br />

WOMEN (EVER<br />

3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME MARRIED WOMEN<br />

4 POSTPONED 15-49 YR<br />

5 REFUSED<br />

6 DWELLING VACANT OR ADDRESS NOT A DWELLING TOTAL NUMBER OF<br />

7 DWELLING DESTROYED CHILDREN (0-5 YR)<br />

8 DWELLING NOT FOUND<br />

9 OTHER LINE NO.OF RESP.<br />

(SPECIFY)<br />

TO HOUSEHOLD<br />

QUESTIONNAIRE<br />

SUPERVISOR<br />

FIELD EDITOR<br />

OFFICE<br />

EDITOR<br />

KEYED BY<br />

NAME<br />

NAME<br />

Appendix E •<br />

245

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