IDENTIFICATION

DEPARTMENT

MUNICIPALITY

DISTRICT

TOWN/NEIGHBORHOOD

CLUSTER NUMBER

STRUCTURE NUMBER

URBAN/RURAL

NAME AND HOUSEHOLD NUMBER OF HEAD OF HOUSHOLD _____

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

INTERVIEWER VISITS

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

RESULT_____

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:

LANGUAGE OF INTERVIEW:

INTERPRETER USED:

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:_______

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

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.

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

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

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

6) Did (NAME) stay here last night?

7) AGE: How old is name?

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)?

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

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.

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

9H) MIGRATION STATUS: CONCLUDE MIGRATION STATUS.

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

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?

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

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

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

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?

EDUCATION IF 5 YEARS OR OLDER

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

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

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

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

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

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

16) Does (NAME) currently attend school?

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

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

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

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

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?

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

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

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?

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?

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

HOUSEHOLD CHARACTERISTICS

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

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

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

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.

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?

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

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

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

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

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

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

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.

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

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

27) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

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

27C) MAIN MATERIAL OF ROOF.
RECORD OBSERVATION.

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

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

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

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).

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

31A) Where did you buy the mosquito net?

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

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

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

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

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

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?

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

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

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

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

37) NAME FROM COLUMN 2

38) AGE FROM COLUMN 7

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.

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

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

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

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

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]

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

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

47) HEMOGLOBIN LEVEL (G/DL)

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

49) RESULT

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. *

*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

61) NAME FROM COLUMN 2

62) SEX FROM COLUMN 4

63) AGE FROM COLUMN 7

64) CHECK AGE IN COLUMN 63

65) LINE NUMBER OF PARENT/RESPONSIBLE ADULT

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

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

68) RESULT

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.

NAME OF RESPONDENT________
LINE NUMBER OF HOUSEHOLD HEAD OR OF RESPONDENT_________

LIFE CONDITIONS

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

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

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

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

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

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

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

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

NUTRITION

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

CLOTHING

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

HOUSING

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

HEALTH AND BODY CARE

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

TRANSPORTATION

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

EDUCATION AND HOBBIES

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

RELATIONS

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

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

6. What is your households' current financial situation?

7. Is your household income:

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

SOCIAL INSERTION/ SECURITY

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

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

11. Do you watch the news?

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

BATTLE AGAINST POVERTY

13. What does it mean to you to be "poor"?

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

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

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

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?