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BURKINA FASO DEMOGRAPHIC AND HEALTH SURVEY (EDSBF-II) - HOUSEHOLD QUESTIONNAIRE 1998

IDENTIFICATION

PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER _____
VILLAGE/SECTOR _____
CLUSTER NUMBER _____
NAME OF HEAD OF CONCESSION _____
CONCESSION NUMBER _____
HOUSEHOLD UNIT NUMBER _____

URBAN/RURAL:

URBAN 1
RURAL 2

OUAGA/BOBO/OTHER CITIES/RURAL:

OUAGA 1
BOBO 2
OTHER CITIES 3
RURAL 4

INTERVENTION ZONE:

YES 1
NO 2

NAME OF HOUSEHOLD HEAD _____

HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____

RESULT _____

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____

TOTAL NUMBER OF VISITS _____

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 _____

HOUSEHOLD SCHEDULE

We would like some information about people who usually live in your household or are staying with you now.

1. LINE NUMBER:

LINE NO. _____

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.

NAME _____

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

01 HEAD
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?

YES 1
NO 2

5. RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

6. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

7. AGE: How old is (NAME)?
IF 95 OR OLDER, RECORD '95'.

IN YEARS _______

7A. What is (NAME)'s ethnicity?

BOBO 01
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?

YES 1
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?

LEVEL _____
PRIMARY 1
SECONDARY (1ST CYCLE) 2
SECONDARY (2ND CYCLE) 3
POST-SECONDARY 4
DOESN'T KNOW 8
GRADE ______
PRIMARY
0 LESS THAN ONE YEAR COMPLETED
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
0 LESS THAN ONE YEAR COMPLETED
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
HIGH SCHOOL
0 LESS THAN ONE YEAR COMPLETED
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
POST-SECONDARY
0 LESS THAN ONE YEAR COMPLETED
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?

YES 1
NO 2

MARITAL STATUS, FOR PERSONS 15 YEARS AND OLDER:

10A. Is (NAME) currently married/in a union, widowed, divorced/separated, or single?

MARRIED/IN UNION 1
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?

YES (ADD TO TABLE)
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?

YES (ADD TO TABLE)
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?

YES (ADD TO TABLE)
NO

16. What is the main source of drinking water for members of your household during the dry season?

PIPED WATER
PIPED INTO DWELLING/YARD/PLOT 12 (GO TO 18)
PUBLIC TAP/STANDPIPE 13
OPEN TUBE WELL OR BOREHOLE
TRADITIONAL WELL IN DWELLING/YARD/PLOT 21 (GO TO 18)
TRADITIONAL PUBLIC WELL 22
BORE HOLE 23
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
BOTTLED WATER 51 (GO TO 18)
WATER VENDOR 61
OTHER (SPECIFY) _____ 96

16A. What is the main source of drinking water for members of your household during the rainy season?

PIPED WATER
PIPED INTO DWELLING/YARD/PLOT 12 (GO TO 18)
PUBLIC TAP/STANDPIPE 13
OPEN TUBE WELL OR BOREHOLE
TRADITIONAL WELL IN DWELLING/YARD/PLOT 21 (GO TO 18)
TRADITIONAL PUBLIC WELL 22
BORE HOLE 23
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAIN WATER 41 (GO TO 18)
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?

YES 1
NO 2

17. How long does it take to get water and come back?

MINUTES_____
ON SITE 996

18. What kind of toilet facility does your household use?

FLUSH TOILET
PRIVATE FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT LATRINE
RUDIMENTARY 21
VENTILATED IMPROVED PIT LATRINE 22
NO TOILET/OUTSIDE 31
OTHER (SPECIFY) _____ 96

19. Does your household have:

Electricity?
A radio?
A television?
A telephone?
A refrigerator?
A portable stove/gas or electric cooktop?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
PORTABLE STOVE/GAS OR ELECTRIC COOKTOP
YES 1
NO 2

20. In your household, how many rooms do you use for sleeping?

NUMBER OF ROOMS_____

21. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
SAND 11
EARTH 12
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) __________ 96

22. Does any member of this household own:

A bicycle?
A motorcycle or motor scooter?
A car?

BICYCLE
YES 1
NO 2
MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
CAR
YES 1
NO 2

22A. What kind of salt do you generally use to do the cooking in your household?

PACKAGED SALT (IODIZED) 1
PACKAGED SALT (NON-IODIZED) 2
SALT FOR ANIMALS 3
SALT FOR ANIMALS 4 (NOTE: REPEATED IN ORIGINAL DOCUMENT)
BULK SALT 5
OTHER (SPECIFY) _____ 6