PSU/SEGHENT NO. HOUSING UNIT NO. ]J]]]]]]]p]:] :11ii]]]]]]i~Ji TOTAL VISITS [] iiiiiiiiiiiliiiililiiiiiiiiiiiiii

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1 EGYPT DEMOGRAPHC AND HEALTH SURVEy HOUSEHOLD SCHEDULE GOVERMORATE K SN/NARQAZ DENTFCATOR PSU/SEGHENT. BULDNG. GOVERRATE SHAKHA/VLLAGE HOUSEHOLD. URBAN... 1 RURAL... 2 LARGE CTY...1 HOUSNG UNT. URBAN... RURAL... 2 SHALL CTY...2 TO~N,,..3 VLLAGE...4 PSU/SEGNENT. lllllll HOUSEHOLD, URBAN/RURAL 1~4EN'S STATUS SUBSAHPLE 1 2 NAHE OF HOUSEHOLD HEAD ADDRESS N DETAL LOCAL TY SUBSAMP LE NTERVEWER VSTS FNAL VST DATE TEAN NTERVEWER SUPERVSOR ASSSTANT SUPERVSOR RESULT DAY MONTH YEAR -7 FX TEAM NTERVEWER SUPERVSOR ASSMT SUPERVSOR RESULT NEXT VST: DATE ]J]]]]]]]p]:] :11ii]]]]]]i~Ji TOTAL VSTS [] TME iiiiiiiiiiiliiiililiiiiiiiiiiiiii RESULT CODES:? C(~fPLEFED 2 HOUSEHOLD HEHBER AT HO4E OR COMPETENT PERSON AT HOHE AT THE TME OF VST 3 ENTRE HOUSEHOLD ABSENT FOR AN EXTENDED PEROD 4 POSTPONED 5 REFUSED 6 DUELLNG VACANT OR ADDRESS T A DWELLNG 7 DWELLNG DESTROYED 8 DWELLNG T FOUND 9 OTHER TOTAL N HO(JSEHOLD WOMEN TOTAL ELGBLE LNE. OF RESPONDENT FOR HOUSEHOLD SCHEDULE JlJ FELD EDTOR OFFCE EDTOR CODER [EYER NAHE DATE SGNATURE 267 -i-1

2 Ue would Like soma information about HOUSEHOLD SCHEDULE,le ~ho usustty tve tn your household or who are staying with you now. J LNE USUAL RESDENTS AND VSTORS RELATONSHP RESDENCE SEX AGE NARTAL STATUS F AGE 15 YEARS OR OLDER PLease give me the names of the persons ~ho usustty Live in your household and guests of the household who stayed here Last night, starting with the head of the household. AFTER LSTNG NAMES, ASK QUESTONS 003"005 TO BE SURE THAT THE LBTHG S C~PLETE. THEN GO ON TO QUESTON 006. What s the relationship of (HAHE) to the head of the household? (BEE COOES BELOW). Does Did s Now old Uhat is (NAHE'S) (NN4E) (NAHE) (NN4E) was current marital usually sleep male (NAHE)! status? Live here or st his/! here? Last female? her Last 1 )tarred night? b rthday? 2 UDOt/ED 3 DVORCED RECORD N 6 NEVER NARBED/ COHPLETED SGNED CONTRACT YEARS. 01 HEAD 02, 03 F~ 0~ ~-~ o, 06 ~-~ N F N YEARS 2,2 2 M D - - N - - m,2 21[- ~ D ~ 2 M D - - i - - m 22 21~ B 2 2 ~.n-~ D 2 2 ~ D D~ ~-~ 2 ~,2 M D ', -~ Just to make sure that have s complete listing: 003 Are there any other persons such as small children or [~ = ADD TO 002 infants who are not listed? n a~itions are there any other people who.my not members of your family, such ms domestic servants, Lodgers or friends who usually Live here? Do you have any guests or t~rary visitors staying here, or anyone else who slept here Lest night? [--~ r ADD TO 002 r] ~ ADD TO 002 No [].o [] HO [] COOES FOR god6 RELATONSHP TO HOUSEHOLD HEAD: 01 = HEAD OZ = UFE OA HUSBAND O] = SON OR DAUGHTER 04 = SON-N-LAW OR DAUGHTER-N-LAW 05 = GRANDCHLD 06 = PARENT 07 = PARENT-N'LAW 08 = BADTHEB OR SSTER 10 = OTHER RELATVE 11 = ADOPTED~FOSTER CHLD J2 = STEP CHLD 13 = T RELAYED 98 = DON'T KNDU 268

3 ELOBLTY EDUCATON ~K STATUB CRCLE LNE Has (NAME) NUMBER OF ever been ~3MEN to school? ELGBLE FOR NDVDUAL F, NTERVEW ASK (L.e., EVER- QUESTONS MARRED Mt~tEH AGE F, YEARS SKP TO WHO ARE OUEST~ON USUAL 017. RESDENTS OR STAYED THERE ON THE NGHT BEFORE NTERVEW) F AGE 6 YEARS OR OLDER o14 ols O~d Olr o18 F ATTENDED SCHOOL Did s (NAME) (NAME) paid in cash What is the Whet FOR i work or kind for highest evel is the PERSONS during the work of school highest UNDER the he/she does? (NAME) grade AGE 25: Lest attended? he/she s (NAME) month? 1 CASH success- still in 2 KND 1 PRMARY fully schoot or F, 3 BOTH 2 PREPARATORY completed at the ASK T PAD 3 SECONDARY at that unfversfty? F, 4 UPPER NTER- level? GO TO MEDATE 006 FOR UNVERSTY NEXT 6 BORE THAN PERSON. UNVERSTY m LEVEL GRADE ~ B B O D El 12 B D O O B ~ 12 ~ ENTER THE TOTAL NUMBER OF ELGBLE WONEN: 020 TCK HERE F CONTNUATON SHEET USED: F~ D 269

4 . QUESTONS AND FLTERS 021 What type of dwelling does your household lfve n? SKP COONG CATEGORES TO APAR?.ENT... ' FREE STANDNG HOUSE... 2 OTHER s your dwelling owned by your household or not? F OgNEO: s it owned so~ety by y~r household or jointly ufth sor~eone else? O~HED... 1 O~/NED JONTLY... 2 REHTED... 3 OTHER ~N MATERAL OF THE FLOOR. RECORD your OBSERVATONS. NATURAL FLOOR EARTH/SAND FNSHED FLOOR PARQUET OR POLSHED JO00... ] CERAHC/HARBLE TLES... ]2 CEHENT TLES... ]3 CEMENT WALL-TO-WALL CARPET How many rooms are there in your dwelling (excluding the bathrooms, kitchen and stairway areas)? 025 How many of the rooms are used for sleeping? ~ RO(~S,,..,,,,,..o.o.o,... O27 or outside the dwelling? =... 2 What is the source of uater your household uses for drinking? PPED WATER PPED NTO RESDENCE/YARD/PLOT.11 ~29 PUBLC TAP WELL WATER WELL N RESDENCE/YARD/PLOT...21 ~29 PUBLC WELL m SURFACE WATER NLE/CANALS BOTTLED WATER =29 J 02sl O e hret"r Ook -- M''0TEs... J 029 What kind of toilet facility does your household have? OERN FLUSN TOLET TRADTONAL WTH TANK FLUSH TRADTONAL WTH BUCKET FLUSH PT TOLET/LATRNE FACLTY O3O Are there electrical con~ections in all or only part J, N ALL... 1 of the dwelling unit?, 1N PART... 2 HAS ELECTRCAL CONNECTONS

5 . QUESTONS AMO FLTERS COONG CATEGORES SKP TO 031 Ooes your household have: A radio with cassette recorder? A black end ehite television? A color television? A video? RADO WTH CASSETTE RECORDER. 2 BLACK AND WHTE TELEVSON COLOR TELEVSON... 2 VDEO Does your household have: An electric fan? A gas/electric cooking stove? A water heater? A refrigerator? A se~ingmaehine? An automatic washing machine? Any other washing machine? ELECTRC FAN... 2 GAS/ELECTR]C COOKNG STOVE,,.1 2 WATER HEATER REFRGERATOR SEWNG ~ACMNE AUTOMATC WASHNG HACHNE OTHER WASHNG MACHNE Do you or any member of your household on: A bicycle? A private car/motorcycle? Farm or other Lend? Livestock(donkeys, horses, cous, sheep, etc.)/pouttry? BCYCLE CAR/MOTORCYCLE FARM/OTHER LAND... 2 LVESTOCK/pOULTRY Whet type of salt is usually used for cooking in your household? (ASK TO SEE SALT PACKAGE), SALT N PLASTC BAGS PACKAGED SALT (loozed) PACKAGED SALT (MOT onzed) SALT FOR ARHALS LOOSE SALT SALT USE

6 OBSERVATONS THANK THE RESPONDENT FOR partcpatng N THE SURVEY. COMPLETE QUESTONS AS APPROPRATE. BE SURE TO REVEW THE QUESTONNARE FOR COMPLETENESS BEFORE LEAVNG THE HCUSEHOLD. 035 ] DEGREE OF C~ERATON. ~]l]llllllllll]ll.llll]lllllll.] VERY ~ NTERVE,'ERS COMMENTS: 037 FELD EDTORS CG~ENTS: 038 SUPERVSOR'S/ASSSTANT SUPERVSOS COMMENTS: 039 OFFCE EDTOR*S COMMENTS: 272