Fn PSU/SEGMENT NO. IILlllll MONTH YEAR DATE TOTAL VISITS TOTAL IN HOUSEHOLD TOTAL ELIGIBLE [ ~ WOMEN TOTAL ELIGIBLE MEN

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1 EGYPT DEMOGRAPHC AND HEALTH SURVEY HOUSEHOLD SCHEDULE DENTFCATON GOVERNORATE KSN/MARQAZ SHAXHA/VLLAGE HOUSEHOLD NO. URBAN... 1 LARGE CTY...1 RURAL... 2 SMALL CTY...2 SUBSAMPLE: YES... 1 NO... 2 PSU/SEGNENT NO. BULDNG NO. HOUSE NO. TOWN...,3 VLLAGE...4 GOVERNORATE Fn PSU/SEGMENT NO. Llllll HOUSEHOLD NO. URBAN/RURAL NAME OF HOUSEHOLD HEAD ADDRESS N DETAL LOCAL TY SUBSAMPLE NTERVEWER VSTS FNAL VST DATE DAY MONTH YEAR TEAM TEAM NTERVEWER,S NAME SUPERVSOR,S NAME RESULT NTERVEWER SUPERVSOR RESULT NEXT VST: DATE TME TOTAL VSTS RESULT CODES: COMPLETED 2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT THE TME OF VST 3 ENTRE HOUSEHOLD ABSENT FOR AN EXTENDED PEROD 4 POSTPONED 5 REFUSED 6 DWELLNG VACANT OR ADDRESS NOT A DWELLNG 7 DWELLNG DESTROYED 8 DWELLNG NOT FOUND 9 OTHER ADDRESS CHECKED (by NAME: TOTAL N HOUSEHOLD TOTAL ELGBLE [ ~ WOMEN TOTAL ELGBLE MEN LNE NO. OF RESPONDENT FOR ~-~ HOUSEHOLD SCHEDULE 2 RERTERVEW E FELD EDTOR OFFCE EDTOR CODER KEYER NAME DATE SGNATURE

2 We would like some information about the LNE USUAL RESDENTS AND VSTORS HOUSEHOLD SCHEDULE usually live in your household or who are staying with you now. RELATONSHP TO THE HOUSEHOLD HEAD RESDENCE >tease give me the names of What is the :he persons who usually live relationship of our household and guests (NAME) to the )f the household who stayed head of the mre last night, starting with household? ;he head of the household. XFTER LSTNG NAMES, ASK ~UESTONE 003"005 TO BE SURE rhat THE LSTNG S CONPLETE. then GO ON TO QUESTON 006. ' 81 oo9 GENERATON C(TJPLE RELATONSHP NUMBER NUMBER TO HEAD OF HOUSEHOLD Does (NAME) usually live here? Did (NAME) sleep ~ here last night ~ FOR CODER FOR COOER FOR CODER o, D El o, Fl o~ ~ ~ ~7-7 og, F F-F7 ; ; ;,, Just to make sure that 1 have a coa~olete listing: 003 Are there any other persons such as small children or infants that we have not listed? 004 n addition, are there any other people who may not be n~=n~)ers of your family, such as domestic servants, lodgers or friends who usually live here? 005 DO you have any guests or temporary visitors staying here, or anyone else who slept here last night? YES F~ ~ ENTER EACH N TABLE NO [] YES F~ " ENTER EACH N TABLE NO [] YES [~ ENTER EACH N TABLE NO [] O-2A 242

3 SEX AGE MARTAL STATUS s F AGE 15 YEARS OR OLDER How otd (NAME) was me[e (NAME) or female? at his/ her test birthday? What is (NAME'S) current marital status? 1 MARRED 2 WDOWED 3 DVORCED 4 NEVER MARRED/ SGNED CONTRACT M F, 21 ~ N YEARS D!il ~ D O-2B 243

4 ELGBLTY EDUCATON HUSBAND F AGE 3 YEARS OR OLDER SUBSANPLE o16 olr o18 0~9 020 CRCLE LNE FOR HOUSEHOLDS Has (NARE)' NUMBER OF N HUSBAND ever been WOMEN SURVEY to school? ELGBLE FOR SUBSANPLE: NDVDUAL F YES, = NTERVEW CRCLE LNE ASK (i.e. w EVER- NUMBER OF QUESTONS MARRED MEN ELGBLE WOMEN AGE FOR NDVDUAL F NO, YEARS NTERVEW SKP TO WHO ARE (.E. w MEN OUESTON USUAL WHOSE WVES 021. RESDENTS OR STAYED THERE ON THE NGHT BEFORE NTERVEW) ARE ELGBLE) What is the highest Level of school (NAME) attended? 0 NURSERY 1 PRMARY 2 PREPARATORY 3 SECONDARY 4 UPPER NTER" MEDATE 5 UNVERSTY 6 MORE THAN UNVERSTY F ATTENDED SCHOOL What FOR is the PERSONS highest UNDER grade AGE 25: he/she s success- (NAME) fully stilt cofnpteted in at that school? level? llmmmm LEVEL GRADE D D ENTER THE TOTAL NUHDER OF ELGBLE; ~EN S D MEN 026 TCK HERE F CONTNUATON SHEET USED: S O-3A 244

5 OCCUPATON WORK STATUS 001 F ABE 6 YEARS OR OLDER What is the OCCUPAmain work that TONAL (NAME) does? GROUP F AGE 6 YEARS OR OLDER AND WORKNG 023 J 024 Did (NAME) work during the last month? ls (NAME) usually paid in cash or kind for the work he/she does? 1 CASH 2 KND 3 BOTH 4 NOT PAD FOR C~ER 01 ~--~ ~ ~ ~ ~ ~ ~ ~ ~ ~ O-3B 245

6 NO. QUESTONS AND FLTERS SKP COONG CATEGORES TO What type of dwelling does your household Live in? S yc~jr dwelling owned by your household or not? if OWNED: s it owned solely by your household or jointly with someone else? FREE STANDNG HOUSE 2 OTHER 3... OWNED... OWNED JONTLY... 2 RENTED... ] OTHER MAN MATERAL OF THE FLOOR. RECORD YOUR OBSERVATONS. NATURAL FLOOR EARTH/SAND FNSHED FLOOR PARQUET OR POLSHED WOOD CERAMC/MARBLE TLES CEMENT TLES CEMENT WALL'TO'WALL CARPET OTHER How many rooms are there in your dwelling (excluding the bathr(~s, kitchens and stairway areas)? ROOMS... ll 031 HOW many of the rooms are used for sleeping? ROOMS s there a special room used only for cooking inside YES... 1 or outside the dwelling? NO What is the source of water your household uses for drinking? o3, 8 ~o.,o,- ~ck~ ~ d es c ~''ake' ~ g 'here'. t water' PPED WATER PPED NTO RESDENDE/YARD/PLOT.11~35 PUBLC TAP l WELL WATER WELL N RESDENCE/YARD/PLOT "35 PUBLC WELL SURFACE WATER NLE/CANALS OTHER 71 MNUTEs... ~ 1 ; 035 Does your household get water for other uses (e.g., for YES... 1,37 handwashing and dishwashing) from the same source? NO

7 RO. QUESTONS AND FLTERS COONG CATEGORES SKP TO 036 What is the source of water your household uses For for handwashing or dishwashing or other uses? PPED WATER PPED NTO RESDENCE/YARD/PLOT.11 PUBLC TAP WELL WATER WELL N RESDENCE/YARD/PLOT PUBLC WELL SURFACE WATER RLE/CABALS OTHER What kind of toilet facility does your household have? MOOERN FLUSH TOLET TRADTONAL WTH TANK FLUSH TRADTONAL WTH BUCKET FLUSH...13 PT TOLET/LATRNE NO FACLTY OTHER Are there electrical connections of the dwelling unit? 039 Does your household have: A radio with cassette recorder? A black and white television? A color television? A video? n all or only part YES, N ALL... 1 YES, N PART... 2 HAS NO ELECTRCAL CONNECTOBS...3 J ] RADO BLACK AND WHTE TELEVSON,1 2 COLOR TELEVSON VDEO Does your household have: YES NO An electric fan? A gas/etectric cooking stove? A water heater? A refrigerator? A washing machine? A sewing machine? ELECTRC FAN... 2 GAS/ELECTRC EOOKBG STOVE. 2 WATER HEATER... 2 REFRGERATOR... 2 WASHNG MACHNE... 2 SEWNG MACHNE Do you or any member of your household own: YES NO A bicycle? A private car/motorcycle? Transport equipment (truck, taxi, van, bus, etc.)? Residential or coff=lercial buildings other than the dwelling unit? Farm or other land? Livestock(donkeys, horses, cows, sheep, etc.)/pouttry? Mechanical farm equipment (tractor, etc.)? BCYCLE CAR/MOTORCYCLE TRANSPORT EQUPMENT RESDENTAL/COMMERCAL BULDNGS FARM/OTHER LAND LVESTOCK/POULTRY FARM MPLEMENTS ?

8 OBSERVATONS THANK THE RESPONDENT FOR PARTCPATNG N THE SURVEY. COMPLETE QUESTONS AS APPROPRATE. TO REVEM THE QUESTONNARE FOR COMPLETENESS BEFORE LEAVNG THE HOUSEHOLD. BE SURE 042 DEGREE OF COOPERATON. POOR,,.,... o... 1 FAR... 2 GO(X),, , ,.3 VERY GOOD NTERVEWER'S COMMENTS: 044 FELD EDTOR'S CO~4MENTS: 045 SUPERVSORJS COMMENTS: 046 OFFCE EDTORJS COMMENTS: