PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER _____
VILLAGE/SECTOR _____
CLUSTER NUMBER _____
NAME OF HEAD OF CONCESSION _____
CONCESSION NUMBER _____
HOUSEHOLD UNIT NUMBER _____
RURAL 2
OUAGA/BOBO/OTHER CITIES/RURAL:
BOBO 2
OTHER CITIES 3
RURAL 4
NO 2
HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____
SUPERVISOR
NAME _____
DATE _____
FIELD EDITOR
NAME _____
DATE _____
OFFICE EDITOR _____
KEYED BY _____
We would like some information about people who usually live in your household or are staying with you now.
1. LINE NUMBER:
2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 HUSBAND OR WIFE
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CHILDREN ADOPTED/BEING TAKEN CARE OF
10 CHILD OF PARTNER
11 NIECE OR NEPHEW
12 COUSIN
13 OTHER RELATIVE
14 NOT RELATED
98 DOESN'T KNOW
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. RESIDENCE: Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
FEMALE 2
7. AGE: How old is (NAME)?
IF 95 OR OLDER, RECORD '95'.
7A. What is (NAME)'s ethnicity?
DIOULA 02
FULFULDE/PEUL 03
GOURMATCHE 04
GOUROUNSI 05
LOBI 06
MOSSI 07
SENOUFO 08
TOUAREG/BELLA 09
OTHERS 10
EDUCATION, IF AGE 6 YEARS OR OLDER:
8. Has (NAME) ever attended school?
NO 2 (GO TO 10A)
9. IF ATTENDED: What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SECONDARY (1ST CYCLE) 2
SECONDARY (2ND CYCLE) 3
POST-SECONDARY 4
DOESN'T KNOW 8
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW
EDUCATION, IF LESS THAN 25 YEARS:
10. Is (NAME) still attending school?
NO 2
MARITAL STATUS, FOR PERSONS 15 YEARS AND OLDER:
10A. Is (NAME) currently married/in a union, widowed, divorced/separated, or single?
WIDOWED 2
DIVORCED/SEPARATED 3
SINGLE 4
ELIGIBILITY:
15. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
ELIGIBILITY:
15A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59. (IF THE MEN'S SURVEY IS PLANNED FOR THIS HOUSEHOLD.)
CHECK HERE IF ANOTHER SHEET IS USED _____
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO
2) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends, who usually live here?
NO
3) Are there any other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
16. What is the main source of drinking water for members of your household during the dry season?
PUBLIC TAP/STANDPIPE 13
TRADITIONAL PUBLIC WELL 22
BORE HOLE 23
RIVER/STREAM 32
POND/LAKE 33
DAM 34
WATER VENDOR 61
OTHER (SPECIFY) _____ 96
16A. What is the main source of drinking water for members of your household during the rainy season?
PUBLIC TAP/STANDPIPE 13
TRADITIONAL PUBLIC WELL 22
BORE HOLE 23
RIVER/STREAM 32
POND/LAKE 33
DAM 34
BOTTLED WATER 51 (GO TO 18)
WATER VENDOR 61
OTHER (SPECIFY) _____ 96
16B. Do you use the "tamis filter" to treat public tap or well water, surface water or vendor water before consumption?
NO 2
17. How long does it take to get water and come back?
ON SITE 996
18. What kind of toilet facility does your household use?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT LATRINE 22
OTHER (SPECIFY) _____ 96
Electricity?
A radio?
A television?
A telephone?
A refrigerator?
A portable stove/gas or electric cooktop?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
20. In your household, how many rooms do you use for sleeping?
21. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
EARTH 12
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
22. Does any member of this household own:
A bicycle?
A motorcycle or motor scooter?
A car?
NO 2
NO 2
NO 2
22A. What kind of salt do you generally use to do the cooking in your household?
PACKAGED SALT (NON-IODIZED) 2
SALT FOR ANIMALS 3
SALT FOR ANIMALS 4 (NOTE: REPEATED IN ORIGINAL DOCUMENT)
BULK SALT 5
OTHER (SPECIFY) _____ 6