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DEMOGRAPHIC AND HEALTH SURVEY-BENIN 2006-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

DEPARTMENT

MUNICIPALITY

DISTRICT

TOWN/NEIGHBORHOOD

CLUSTER NUMBER

STRUCTURE NUMBER

URBAN/RURAL

URBAN 1
RURAL 2

NAME AND HOUSEHOLD NUMBER OF HEAD OF HOUSHOLD _____

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_____
INTERVIEWER NAME_____
RESULT _____

RESULT_____

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 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: 2006
INTERVIEWER NUMBER_____
RESULT CODE_____

TOTAL NUMBER OF VISITS______

TOTAL PERSONS IN HOUSEHOLD ________

TOTAL ELIGIBLE WOMEN ________

TOTAL ELIGIBLE MEN _________

TOTAL PERSONS AGE 6 OR OLDER ________

TOTAL PERSONS AGE 18 OR OLDER ________

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ________

NAME AND NUMBER OF RESPONDENT________

LANGUAGE OF QUESTIONNAIRE:

FRENCH 1

LANGUAGE OF INTERVIEW:

FRENCH 1
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHER 8

INTERPRETER USED:

YES 1
NO 2

SUPERVISOR
NAME____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____

KEYED BY_____

INTRODUCTION AND CONSENT

Hello. My name is _________ and I work with the INSAE. We are conducting a national survey about various health and development issues. We would very much appreciate your participation in this survey. The survey usually takes between 20 and 25 minutes. As part of this survey we would first like to ask some questions about your household. Whatever information you provide will be kept strictly confidential. Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.

At this time do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer:_______
Date:_______

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

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

1) LINE NUMBER

LINE NUMBER___

2) USUAL RESIDENTS AND VISITORS: Please give me the name 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?

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is name?

IN YEARS ________

7A) EMICOV ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL PERSONS AGE 6 OR OLDER.

7B) CIRCLE THE LINE NUMBER OF ALL PERSONS AGE 18 OR OLDER.

8) EDSB- II ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

9) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-6

9A) CHECK IF HOUSEHOLD WAS SELECTED FOR THE MAN'S SURVEY. CIRCLE LINE NUMBER OF ALL MEN 15-64.

SOCIO-CULTURAL CHARACTERISTICS:

9B) ETHNICITY: What ethnicity/nationality is (NAME)?

ADJA AND SIMILAR 11
BARIBA AND SIMILAR 12
DENDI AND SIMILAR 13
FON AND SIMILAR 14
YOA AND LOKPA AND SIMILAR 15
OTAMARI AND SIMILAR 16
PEULH AND SIMILAR 17
YORUBA AND SIMILAR 18
ADJACENT COUNTRIES 21
OTHER COUNTRIES 22
OTHER ETHNICITIES 98

9C) RELIGION: What religion does (NAME) practice?

VODOUN 11
OTHER TRADITIONAL 12
ISLAM 21
CATHOLIC 31
PROTESTANT/METHODIST 41
OTHER PROTESTANT 42
CELESTE 51
OTHER CHRISTIAN RELIGION 52
OTHER RELIGION 61
NO RELIGION 71

TIME OF MIGRATION FOR RESIDENTS

9D) BIRTHPLACE: In what municipality was (NAME) born?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS.


MUNICIPALITY___

9E) FORMER RESIDENCE: In what residential municipality did (NAME) live before moving here?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS.


MUNICIPALITY___

9F) LENGTH OF CURRENT RESIDENCE: How long did (NAME) stay in that municipality?
IF SHORTER THAN ONE YEAR, RECORD IN MONTHS IN DURATION COLUMN.
IF LONGER THAN ONE YEAR, RECORD IN YEARS IN DURATION COLUMN.

PERIOD _____
SHORTER THAN ONE YEAR 1
LONGER THAN ONE YEAR 2
SINCE BIRTH 998
DURATION:
NUMBER OF MONTHS _____
NUMBER OF YEARS ____

9G) RETURNED MIGRATION: Is (NAME) back in this municipality after having stayed there for less than 6 months?

YES 1
NO 2

9H) MIGRATION STATUS: CONCLUDE MIGRATION STATUS.

1 = NON MIGRANT IF Q.9F=9 98
2 = RETURNED MIGRANT IF Q.9F DOES NOT EQUAL 998 AND Q.9G=1
3= OTHER MIGRANT IF Q.9F DOES NOT EQUAL 998 AND Q.9G=2

9I) REASON FOR SETTLING: What is the main reason why (NAME) settled in this municipality?

11 = ADVENTURE
12 = MARRIAGE
13 = DIVORCE/WIDOWHOOD/SEPARATION
14 = CEREMONIES
15 = FAMILY AUTHORITY
16 = FAMILY CONFLICTS
17 = STUDIES/LEARNING
18 = WORK
19 = RETIREMENT/PERMANENT RETURN
20 = OTHER REASONS
98 = SINCE BIRTH
96 = DON'T KNOW

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS FOR PERSONS YOUNGER THAN 18**
QUESTIONS 10 -13: THESE QUESTIONS ARE ABOUT THE CHILD'S BIOLOGICAL PARENTS.
FOR QUESTIONS 11 AND 13 RECORD:
'91' IF THE PARENTS LIVE IN THE MUNICIPALITY;
'92' IF THE PARENTS LIVE IN ANOTHER MUNICIPALITY;
'93' IF THE PARENTS LIVE ABROAD;
'98' IF DON'T KNOW.

10) Is (NAME)'s natural mother alive?

YES 1
NO 2
DON'T KNOW 8

11) IF ALIVE: Does (NAME)'s natural mother usually live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.

LINE NUMBER____

12) Is (NAME)'s natural father alive?

YES 1
NO 2
DON'T KNOW 8

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

LINE NUMBER ____

ORPHAN ASSISTANCE FOR PERSONS YOUNGER THAN 18**

13A) IF AT LEAST ONE PARENT IS DEAD: Did (NAME) receive any outside assistance in the last 12 months?
IF YES, Which ones?
IF NO, CIRCLE F (NONE).

MEDICAL SUPPORT A
EDUCATIONAL SUPPORT B
ECONOMIC SUPPORT C
PSYCHO-SOCIAL SUPPORT D
OTHER E
NONE F

BIRTH REGISTRATION IF 0-4 YEARS

13B) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

YES 1
NO 2
DON'T KNOW 8

EDUCATION IF 5 YEARS OR OLDER

14) ATTENDANCE: Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20L)

15) LEVEL OF INSTRUCTION: What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?

LEVEL____
1=PRIMARY
2=SECONDARY 1
3=SECONDARY 2
4=HIGHER
6=OTHER
GRADE____
00=LESS THAN ONE YEAR FINISHED
98=DON'T KNOW

15A) DIPLOMA: What is the highest diploma (NAME) has received?

1 = NONE
2 = CEP
3 = BEPC
4 = CAP
5 = BEP
6 = BAC/DTI
7 = DEUG/DUT/BTS/DUEL
8 = SUPPLEMENTARY DIPLOMA HIGHSCHOOL + 2
9 = OTHER DIPLOMA

15B) TYPE OF SCHOOL: Did (NAME) go to a public school, a private religious school, or a private secular school?

PUBLIC 1
PRIVATE RELIGIOUS 2
PRIVATE SECULAR 3

15C) TYPE OF TRAINING: Was the last type of training that (NAME) received general education, professional training, or informal training?

GENERAL 1
PROFESSIONAL 2
INFORMAL 3

CHILDREN'S EDUCATION AND WORK IF AGE 5-24 YEARS

16) Does (NAME) currently attend school?

YES 1 (GO TO 18)
NO 2

17) Did (NAME) attend school at any time during the 2005-2006 school year, which ended in June 2006?

YES 1
NO 2 (GO TO 19)

18) During the 2005-2006 school year, what level and grade (is/was) (NAME) attending? ***

LEVEL__
1=PRIMARY
2=SECONDARY 1
3=SECONDARY 2
4=HIGHER
6=OTHER
GRADE___
DON'T KNOW 98

19) Did (NAME) attend school at any time during the previous 2004-2005 school year?

YES 1
NO 2 (GO TO 20L)

20) During the previous school year, what level and grade was (NAME) attending? ***

LEVEL__
1=PRIMARY
2=SECONDARY 1
3=SECONDARY 2
4=HIGHER
6=OTHER
GRADE___
DON'T KNOW 98

20L) WORK STATUS: (Outside of school), did (NAME) do one or any activities for less than 4 hours, between 4 and 8 hours, or for 8 or more hours a day in the last 7 days?

LESS THAN 4 HOURS 1
4 TO 8 HOURS 2
MORE THAN 8 HOURS 3
NO 4 (GO TO 20N)

20M) TYPE OF WORK PERFORMED: What type of work did (NAME) perform for most of this time?

MASONRY 1
MECHANICAL AUTO WELDING 2
MANIPULATION OF CHEMICAL OR OTHER TOXIC PRODUCTS 3
UNDERGROUND WORK (PIPES) 4
TRANSPORTATION OF HEAVY LOADS 5
HOUSEWORK 6
FIELDWORK 7
OTHER 8

20N) MARITAL STATUS IF AGE 10 OR OLDER: What is (NAME)'s marital status?

SINGLE 1
MARRIED TO 1 WOMAN 2
MARRIED TO 2 WOMEN 3
MARRIED TO 3 OR MORE WOMEN 4
DIVORCED/SEPARATED 5
WIDOW/WIDOWER 6
COHABITATION 7

CHECK HERE IF CONTINUATION SHEET USED

Just to make sure I have a complete listing:

Are there any other persons such as small children or infants that we have not listed?

YES (ADD EACH TO TABLE)
NO

In addition, are there any other people who may not be members of your family, such as domestic servants or friends who usually live here?

YES (ADD EACH TO TABLE)
NO

Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD EACH ALL TO TABLE)
NO

HOUSEHOLD CHARACTERISTICS

21) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 22C)
PIPED ELSEWHERE 12
PUBLIC TAP/STANDPIPE 13
DUG WELL
WELL WITH MANUAL PUMP 21
CASED WELL 22
UNPROTECTED WELL 23
SURFACE WATER
EQUIPPED SPRING 31
RIVER/BACKWATER/POND 32
RAINWATER IN TANK 41
OTHER RAINWATER 42
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 23)
OTHER (SPECIFY) 96 ________

22) How long does it take you to go there, get water, and come back?

MINUTES ________
ON PREMISES 996

22A) How far is the source from your house?

ON PREMISES 1
LESS THAN 1 KILOMETER 2
1 KILOMETER OR MORE 3
DON'T KNOW 8

22B) How often do you stock up on drinking water? Per day? Per week? Per month?
RECORD NUMBER OF TIMES PER DAY, PER WEEK, OR PER MONTH.

PER DAY ________ 1
PER WEEK ________ 2
PER MONTH ________ 3

22C) Do you do anything to make the water safer to drink? For example, do you boil it or strain it or add any type of product before drinking it?

NO/NOTHING 1
BOIL 2
STRAIN THROUGH A CLOTH 3
USE WATER FILTER 4
ADD BLEACH/CHLORINE 5
OTHER (SPECIFY) ________ 6

23) What kind of toilet facility do members of your household usually use?

PIT LATRINE
NON-VENTILATED PIT LATRINE 21
VENTILATED PIT LATRINE 22
FLUSH TOILET 23
SEWAGE SYSTEM 24
HANGING LATRINE 25 (GO TO 24C)
NO FACILITY/BUSH 31 (GO TO 24C)
OTHER (SPECIFY) ________ 96

24) Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 24C)

24A) How many households use this toilet facility?
IF 5 HOUSEHOLDS OR MORE, RECORD '5'.

NUMBER OF OTHER HOUSEHOLDS ________

24B) Does this toilet facility belong exclusively to the households that use it, or is it a public or communal toilet?

PRIVATE TOILETS 1
PUBLIC/COMMUNAL TOILETS 2

24C) What is the main method of evacuation for the household waste?

PUBLIC REFUSE COLLECTION 11
PRIVATE REFUSE COLLECTION/NGO 12
BURIED 13
BURNED 14
IN THE YARD 15
OUTDOORS 16
OTHER (SPECIFY) ________ 96

24D) What is the main method of evacuation for the used water in your household?

CLOSED CANAL 11
OPEN CANAL 12
SEPTIC TANK 13
CESSPOOL 14
SEWER 15
IN THE YARD 16
OUTDOORS 17
OTHER (SPECIFY) 96

25) How many of each of these goods do you own in your household?
RECORD THE SPECIFIC NUMBER OF EACH ITEM IN EACH APPROPRIATE SPACE.

CAR _____
CANOE _____
HI-FI SYSTEM____
REFRIGERATOR_____
IMPROVED FIREPLACE____
ELECTRIC IRON_____
BEDS____
NON-MOBILE TELEPHONE____
METHOD OF INTERNET ACCESS
NONE 0
TELEPHONE 1
SATELLITE 2
IN CYBER 3
OTHER 4
MOTORCYCLE/MOPED____
RADIO____
CD/DVD PLAYER____
STOVE____
WASHING MACHINE_____
MODERN COUCH____
SEWING MACHINE____
MOBILE TELEPHONE_____
PLOTS
NUMBER OF PLOTS _________
BICYCLE____
TELEVISION___
VCR___
FAN____
GENERATOR_____
FOAM MATTRESS_____
COMPUTER_____
INTERNET CONNECTION
YES 1
NO 2
RENTAL HOUSE
MONTHLY TOTAL ________ (X1000 FCFA)

26) What type of fuel does your household mainly use for cooking?

WOOD/STRAW 1
CHARCOAL 2
ELECTRICITY 3
GAS 4
PETROLEUM 5
OTHER (SPECIFY) ________ 8

26A) What type of lighting does your household mainly use?

ELECTRICITY 11
PETROLEUM 21
GAS 22
OIL 31
SOLAR ENERGY 41
COMMUNITY GENERATOR 51
PRIVATE GENERATOR 52
OTHER (SPECIFY) ________ 96

27) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
TILE 32
CEMENT 33
CARPET 34
OTHER (SPECIFY) ________ 96

27B) MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.

NATURAL WALLS
EARTH 11
STONE 12
RUDIMENTARY WALLS
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED WALLS
BRICKS 31
PARTLY HARD MATERIAL 32
OTHER (SPECIFY) ________ 96

27C) MAIN MATERIAL OF ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
EARTH 11
STRAW 12
RUDIMENTARY ROOFING
WOOD/PLANKS 21
PALM/BAMBOO 22
FINISHED ROOFING
SHEET METAL 31
TILE 32
SLAB 33
OTHER (SPECIFY) _________ 96

28) How many rooms in this household are used for sleeping?

NUMBER OF ROOMS FOR SLEEPING ________

29) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 33)

29A) How many mosquito nets does your household have?
IF 6 OR MORE NETS, RECORD '6'.

NUMBER OF NETS ________

30) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD. ASK THE FOLLOWING QUESTIONS FOR EACH NET.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

31) How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS AGO ________
3 OR MORE YEARS AGO 96

31A) Where did you buy the mosquito net?

HEALTH CENTER 1
NGO 2
MARKET 3
OTHER 6

32A) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
UNSURE/DON'T KNOW 8

32B) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 32D)
UNSURE/DON'T KNOW 8 (GO TO 32D)

32C) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO ________

3 OR MORE YEARS AGO 95
UNSURE/DON'T KNOW 98

32D) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 32F)
DON'T KNOW 8 (GO TO 32F)

32E) Who slept under the mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

NAME ________
LINE NUMBER ________

32F) GO BACK TO 30 IN FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS IN THE HOUSEHOLD, GO TO 33.

33) Is there a place in your household to wash one's hands?

IN DWELLING/IN THE YARD/IN THE PLOT 1
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)

34) ASK TO SEE THE MOST USED PLACE TO WASH HANDS AND CHECK TO SEE IF THE FOLLOWING OBJECTS ARE FOUND THERE:

WATER/FAUCET
YES 1
NO 2
SOAP/ASHES/OTHER CLEANING PRODUCT
YES 1
NO 2
BASIN
YES 1
NO 2

35) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT AND TEST SALT FOR IODINE.
RECORD IN PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
15 PPM AND ABOVE 3
NO SALT IN HOUSEHOLD 4 (GO TO 36)
SALT NOT TESTED (SPECIFY REASON) ________ 6

35A) CHECK TO SEE IF THE CONTAINER THAT HOLDS THE SALT IS CLOSED, AND CLOSE OR FAR FROM A SOURCE OF LIGHT, HEAT OR HUMIDITY, OR IF IT IS OPEN.
RECORD OBSERVATION

CONTAINER CLOSED, FAR FROM LIGHT/HEAT 1
CONTAINER CLOSED, CLOSE TO HEAT/LIGHT 2
CLOSED BLACK PLASTIC BAG, FAR FROM HEAT/LIGHT 3
CLOSED BLACK PLASTIC BAG, CLOSE TO LIGHT/HEAT 4
OPEN CONTAINER 5
OTHER (SPECIFY) ________ 6

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS (8) AND (9):
RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49, ALL MEN AGE 15-64, AND ALL CHILDREN AGE 0-6.

36) LINE NUMBER FROM COLUMN 8

LINE NUMBER___

37) NAME FROM COLUMN 2

NAME___

38) AGE FROM COLUMN 7

YEARS ________

39) What is (NAME)'s date of birth?
[ASK FOR CHILDREN AGE 0-6 ONLY]

* FOR CHILDREN NOT INCLUDED IN ANY SECTION 2 ON REPRODUCTION ON A WOMAN'S QUESTIONNAIRE (ORPHANS, ADOPTED CHILDREN, ETC.), ASK THE DAY, MONTH, AND YEAR OF BIRTH.

FOR ALL OTHER CHILDREN, COPY THE MONTH AND YEAR FROM QUESTION 215 IN SECTION 2 OF THEIR MOTHER'S SURVEY AND ASK THE DAY OF BIRTH.

DAY___
MONTH____
YEAR___

40) WEIGHT (KILOGRAMS)
[ASK FOR WOMEN AGE 15-49 AND CHILDREN AGE 0-6 ONLY]

KILOGRAMS___

41) HEIGHT (CENTIMETERS)
[ASK FOR WOMEN AGE 15-49 AND CHILDREN AGE 0-6 ONLY]

CENTIMETERS____

42) MEASURED LYING DOWN OR STANDING UP
[ASK FOR CHILDREN AGE 0-6 ONLY]

LYING DOWN 1
STANDING 2

43) RESULT:
[ASK FOR WOMEN AGE 15-49 AND CHILDREN AGE 0-6 ONLY]

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 6

CHECK HERE IF CONTINUATION SHEET USED _____

MEASURE OF HEMOGLOBIN IN WOMEN AGE 15-49, MEN AGE 15-64, AND CHILDREN BORN IN 2001 OR LATER

44) CHECK COLUMN (38):
[ASK FOR WOMEN AGE 15-49 AND MEN AGE 15-64 ONLY]

AGE 15-17 1 (GO TO 45)
AGE 18-49 2 (GO TO 46)

45) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED ON HOUSEHOLD QUESTIONNAIRE.

LINE NUMBER____

46) READ CONSENT TO WOMAN/PARENT/RESPONSIBLE ADULT.*
CIRCLE CODE (AND SIGN.)

AGREED 1
SIGN ________
REFUSED 2 (GO TO NEXT LINE)

47) HEMOGLOBIN LEVEL (G/DL)

G/DL____

48) CURRENTLY PREGNANT
[ASK ONLY FOR WOMEN AGE 15-49]

YES 1
NO/ DON'T KNOW 2

49) RESULT

MEASURED 1
ABSENT 2
REFUSED 3
OTHER 4

DO NOT FORGET TO RECORD THE HEMOGLOBIN LEVEL OF EACH RESPONDENT ON THE FORM.

*CONSENT STATEMENT

As part of this survey, we would like to know the level of anemia in women and children. Anemia is a serious health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that (you and you children born in 2001 or later) participate in this anemia test by giving a few drops of blood from your finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidential.

Will you (and NAME OF CHILDREN) participate in this anemia test? You can say yes to the test, or you can say no. It is up to you to decide and we will respect your decision. Will you tell me if you accept to participate in the test?

50) CHECK 47 AND 48:
NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN LEVEL IS LOWER THAN THE BASE CRITERIA. *

ONE OR MORE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT THE RESULT OF THE HEMOGLOBIN TEST AND CONTINUE WITH QUESTION 51. **)
NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT THE RESULT OF THE HEMOGLOBIN TEST AND END THE HOUSEHOLD SURVEY.)

*THE BASE CRITERIA IS 9 G/DL FOR PREGNANT WOMEN AND 7 G/DL FOR CHILDREN, MEN AND WOMEN WHO ARE NOT PREGNANT (OR WHO DO NOT KNOW IF THEY ARE PREGNANT).

** IF THERE IS MORE THAN ONE WOMAN OR CHILD WHO IS BELOW THE BASE CRITERIA, READ THE STATEMENT IN QUESTION 51 TO EACH WOMAN WHO IS BELOW THE BASE CRITERIA AND TO EACH WOMAN/PARENT/RESPONSIBLE ADULT OF THE CHILD WHO IS BELOW THE BASE CRITERIA.

51) We have detected a lower hemoglobin level in (your blood/CHILD'S NAME'S blood/CHILDREN'S NAME'S blood). This means that (you/_____) are severely anemic, which is a serious health problem. We advise you to go to a Health Center for a medical follow-up. This will help you get the proper treatment.

INFORMED CONSENT (HIV TEST)

INFORMED CONSENT FOR ADULTS 18 YEARS OR OLDER

In this survey, we are doing a study of HIV/AIDS among women age 15-49 and men age 15-64. You are aware, perhaps, that AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Benin.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. The injection does not hurt. It looks like an ant bite. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood sample is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, if you want to do a screening test, we will give you a reference sheet for you to go to the Voluntary Screening Center for a free test.

Do you have any questions?

Now, will you participate in the HIV study?

GO TO COLUMN 67 AND CIRCLE APPROPRIATE CODE.

INFORMED CONSENT FOR YOUNG PEOPLE AGE 15-17.

1st stage: Ask for informed consent of parent/responsible adult.

The HIV/AIDS study includes young women and men starting at 15 years. For the HIV test of these young people age 15-17, we ask their parents or a responsible adult to give their consent, and we also get the consent of the young person.

We ask that the young person, (NAME), participates in the HIV test by giving us a few drops of blood from a finger. To obtain these drops of blood we use sterile, non-reusable instruments made of new materials. They have never been used before you, and they will not be used after.

The blood sample is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, if (NAME OF YOUNG PERSON) wants a screening test, we will give you a reference sheet for you to go to the Voluntary Screening Center for a free test.

Now, can (NAME) participate in the study?

GO TO COLUMN 66 AND CIRCLE THE APPROPRIATE CODE.

2nd stage: Informed consent of young person

IF THE PARENT/RESPONSIBLE ADULT OF THE YOUNG PERSON ALLOWS HE/SHE TO PARTICIPATE IN THE TEST, READ THE INFORMED CONSENT TO THE YOUNG PERSON.

In this survey, we are doing a study of HIV/AIDS among women age 15-49 and men age 15-64. You are aware, perhaps, that AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Benin.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. The injection does not hurt. It looks like an ant bite. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood sample is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, if you want to do a screening test, we will give you a reference sheet for you to go to the Voluntary Screening Center for a free test.

Do you have any questions?

Now, will you participate in the HIV study?

GO TO COLUMN 67 AND CIRCLE APPROPRIATE CODE.

DO NOT FORGET TO GIVE EACH ELIGIBLE PERSON A REFERENCE SHEET FOR A FREE TEST.

HIV TEST - MEN AND WOMEN

CHECK COLUMNS (8) AND (9A) OF THE HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER, NAME, AND SEX OF ALL WOMEN AGE 15-49 AND MEN AGE 15-64. THIS PAGE WILL BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO THE DATA BASE FOR DHS-IV

TOTAL NUMBER OF SAMPLES ________

60) LINE NUMBER FROM COLUMN 8 OR 9A

LINE NUMBER___

61) NAME FROM COLUMN 2

NAME________

62) SEX FROM COLUMN 4

MALE 1
FEMALE 2

63) AGE FROM COLUMN 7

YEARS ________

64) CHECK AGE IN COLUMN 63

15-17 1
18 AND OVER (GO TO 67)

65) LINE NUMBER OF PARENT/RESPONSIBLE ADULT

LINE NUMBER___

66) READ THE CONSENT TO THE PARENT OR THE RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN.)

ACCEPTED 1
SIGN________
REFUSED 2
NOT READ 3

67) READ THE CONSENT TO THE WOMAN/MAN OR YOUNG PERSON. CIRCLE THE CODE (AND SIGN).

ACCEPTED 1
SIGN ________
REFUSED 2
NOT READ 3

68) RESULT

SAMPLE TAKEN 1
REFUSED 2
ABSENT 3
TECHNICAL PROBLEM 4
OTHER (SPECIFY) ________ 6

69) BAR CODE LABEL.

PLACE FIRST STICKER HERE
PLACE SECOND STICKER ON FILTER PAPER
PLACE THIRD STICKER ON TRANSMITTAL FORM

CHECK HERE IF CONTINUATION FORM IS USED.

MODULE: DIFFERENT POVERTY DIMENSIONS

NAME OF RESPONDENT________
LINE NUMBER OF HOUSEHOLD HEAD OR OF RESPONDENT_________

LIFE CONDITIONS

1) Given your household income, do you feel that:

YOU LIVE WELL 01
YOU LIVE MORE OR LESS OKAY 02
YOU LIVE OKAY, BUT IT NEEDS ATTENTION 03
YOU LIVE WITH DIFFICULTY 04

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, mostly necessary, or not necessary?

NUTRITION AND CLOTHING

01) THREE MEALS A DAY, DAILY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
02) CONSUME CEREALS OR ROOTS DAILY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
03) CONSUME VEGETABLES DAILY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
04) CONSUME MEAT OR FISH DAILY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
05) A GOOD MEAL ON HOLIDAYS (SUNDAY, CEREMONIES, ETC.)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
06) SEVERAL SETS OF CLOTHES (AT LEAST TWO)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
07) SEVERAL PAIRS OF SHOES (AT LEAST TWO)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, necessary, or not necessary?

HOUSING

08) HAVING HOUSING (OWN OR RENT)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
09) HAVING SPACIOUS HOUSING (RENTED OR NOT)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
10) ACCESS TO DRINKING WATER
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
11) ACCESS TO ELECTRICITY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
12) HAVING TABLES AND BEDS IN THE HOUSE
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
13) HAVING PERSONAL CARE PRODUCTS (SOAPS, HAIR PRODUCTS, ETC)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, necessary, or not necessary?

HEALTH, BODY CARE

14) ABILITY TO CARE OF ONESELF WHEN SICK
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
15) ABILITY TO TAKE CARE OF OWN BODY (SOAP, PERSONAL HYGIENE PRODUCTS, ETC)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, necessary, or not necessary?

WORK

16) HAVING STEADY WORK
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
17) WORK NIGHT AND DAY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, necessary, or not necessary?

TRANSPORTATION

18) ABILITY TO TAKE THE BUS (OR EQUIVALENT) TO GO TO WORK
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
19) ABILITY TO TAKE THE TAXI ON SPECIAL OCCASIONS (EMERGENCIES)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
20) PERSONAL MODE OF TRANSPORTATION (MOTORCYCLE, BICYCLE)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

2) In terms of necessary minimal needs required for an acceptable condition of life, do you feel that the following items are essential, necessary, or not necessary?

EDUCATION, HOBBIES, AND MISCELLANEOUS

21) ABILITY TO SEND CHILDREN TO SCHOOL
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
22) TAKE VACATION ONE TIME PER YEAR
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
23) OWN A RADIO
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
24) ABILITY TO BUY A TELEVISION
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
25) ABILITY TO BUY PRESENTS WHEN NECESSARY
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03
26) HAVE FEW CHILDREN (BIRTH CONTROL)
YES, ESSENTIAL 01
YES, MOSTLY NECESSARY 02
NOT NECESSARY 03

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

NUTRITION

01) NUMBER OF MEALS PER DAY (3 FOR EXAMPLE) FOR YOU AND YOUR HOUSEHOLD
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
02) DAILY CONSUMPTION OF CEREAL/ROOTS
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
03) DAILY CONSUMPTION OF VEGETABLES
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
04) DAILY CONSUMPTION OF MEAT OR FISH
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
05) HOLIDAY MEALS (SUNDAY, CEREMONIES, ETC.)
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

CLOTHING

06) CLOTHING FOR YOU AND YOUR HOUSEHOLD
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
07) SHOES FOR YOU AND YOUR HOUSEHOLD
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

HOUSING

08) YOUR HOUSING (RENTED OR NOT)
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
09) ACCESS TO PORTABLE WATER
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
10) ACCESS TO ELECTRICITY
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
11) FURNITURE IN THE HOUSE
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
12) PERSONAL CARE PRODUCTS (SOAP, HAIR PRODUCTS, ETC.)
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

HEALTH AND BODY CARE

13) TREATMENT, MEDICATION, IN CASE OF ILLNESS
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
14) CLEANLINESS, BODY CARE (SOAP, HAIR PRODUCTS, ETC.)
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

TRANSPORTATION

15) METHODS OF TRANSPORT USED
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

EDUCATION AND HOBBIES

16) EDUCATION OF CHILDREN
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
17) HOBBIES (OR VACATION) FOR YOU AND YOUR HOUSEHOLD
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

3) In terms of necessary minimal needs of your household, are you satisfied in the following areas:

RELATIONS

18) RELATIONSHIPS WITH FAMILY AND FRIENDS
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04
19) HELP TO DISTRESSED PARENTS
VERY SATISFIED 01
SATISFIED 02
NOT REALLY SATISFIED 03
NOT SATISFIED 04

4. Comparing your personal standard of living to the standard of living of households in your area, do you estimate you belong to:

20% OF THE POOREST 01
20% OF THOSE IN MODERATE POVERTY 02
20% OF THOSE IN THE AVERAGE 03
20% OF THOSE IN MODERATE WEALTH 04
20% OF THE WEALTHIEST 05

5. What would you say is the minimum amount necessary to satisfy your households’ fundamental needs?149

_____________ F. CFA

6. What is your households’ current financial situation?

CAN SAVE A REASONABLE AMOUNT OF MONEY 01
CAN SAVE A LITTLE AMOUNT OF MONEY 02
CAN NEITHER SAVE NOR USE UP SAVINGS 03
USE SOME SAVINGS 04
GOING INTO DEBT 05

7. Is your household income:

VERY INSTABLE 01
MORE OR LESS STABLE 02
STABLE 03

8. In the past year, has your standard of living improved, stayed the same, or deteriorated?

A) FOR YOUR HOUSEHOLD
IMPROVED 01
MAINTAINED 02
DETERIORATED 03
B) IN GENERAL (FOR HOUSEHOLDS IN YOUR AREA)
IMPROVED 01
MAINTAINED 02
DETERIORATED 03

SOCIAL INSERTION/ SECURITY

9. Does a member of your household belong to an association?

A. NEIGHBORHOOD ASSOCIATION
YES 01
NO 02
B. RELIGIOUS ASSOCIATION
YES 01
NO 02
C. PROFESSIONAL ASSOCIATION
YES 01
NO 02
D. POLITICAL ASSOCIATION
YES 01
NO 02
E. FAMILY ASSOCIATION
YES 01
NO 02
OTHER ASSOCIATION(S)_______ (SPECIFY)
YES 01
NO 02

10. If your household was to experience a difficult period, who would help in case of need?

A. FAMILY
YES 01
NO 02
B. NEIGHBOR
YES 01
NO 02
C. FRIENDS AND RELATIVES
YES 01
NO 02
D. RELIGIOUS ASSOCIATION
YES 01
NO 02
NON-GOVERNMENT ORGANIZATION (NGO)
YES 01
NO 02
OTHER: ________ (SPECIFY)
YES 01
NO 02

11. Do you watch the news?

YES, REGULARLY 01
YES, FROM TIME TO TIME 02
NO, NO INTEREST 03
NO, NO TIME 04
NO, NO MEANS/MONEY 05

12. In the past year, were you a victim of violence (aggression, etc.) to...

A. YOU, PERSONALLY
YES 01
NO 02
B. A MEMBER OF YOUR HOUSEHOLD
YES 01
NO 02
C. A MEMBER OF THE LOCAL COMMUNITY
YES 01
NO 02

BATTLE AGAINST POVERTY

13. What does it mean to you to be “poor”?

A. LEVEL OF CONSUMPTION IS BELOW MINIMUM THRESHOLD FOR MAINTENANCE (DECLARED IN QUESTION 5)
YES 01
NO 02
B. MATERIAL WELL-BEING BELOW MINIMUM
YES 01
NO 02
C. PERSONAL WELL-BEING BELOW MINIMUM (HEALTH, EDUCATION)
YES 01
NO 02
D. BEING MARGINALIZED/EXCLUSION OF SOCIETY
YES 01
NO 02
E. FEELING VULNERABLE WHEN FACED WITH DIFFERENT RISKS
YES 01
NO 02
F. INCAPABLE TO CHANGE ONES OWN CONDITION OF LIFE
YES 01
NO 02

14. In your opinion, should the fight against poverty be a priority for your country?

YES 01
NO 02

15. Were you informed on the process to elaborate the Document of Strategy to Reduce Poverty (DSRP: framework document on strategies and support)?

YES 01
NO 02 – (GO TO 17)

16. Did you participate in the development of the DSRP (consultation/survey, workshop, seminar)?

YES 01
NO 02

17. Do you feel the politics put in place the past two (2) years have been effective in the reduction of poverty with a clear, fairly clear, or unclear focus?

CLEAR 01
FAIRLY CLEAR 02
UNCLEAR 03