Final Version

Identification

Department
Commune

Urban/rural (urban=1, rural=2)

Name of head of household
Cluster number
Household number

Household selected for men's survey? (1=Yes, 2=No)

Interviewer visits
1 2 3
Date

Interviewer's name
Result*

Final visit
Day
Month
Year 201
Int. number
Result

Next visit
Date
Time

Total no. of visits

*Result codes:

Total persons in household
Total eligible women
Total eligible men
Line no. of respondent to household questionnaire

Language of questionnaire 01
Language of interview
Native language of respondent

Translator used (Yes=1, No=2)

Language codes:

Supervisor
Name
Date

Editor
Name
Number

Introduction and consent
Hello. My name is ___. I am working with the National Institute of Statistics and Economic Analysis (INSAE). We are conducting a survey about health and other topics all over Benin. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 30 to 45 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you 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.
In case you need more information about the survey, you may contact the person listed on this card.

Give card with contact information
Do you have any questions?
May I begin the interview now?

Signature of interviewer Date

100) Record the time

Household schedule
1) 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.

After listing the names and recording the relationship and sex for each person, ask questions 2a-2c to be sure that the listing is complete.

Then ask appropriate questions in columns 5-20 for each person.

3) Relationship to head of household
What is the relationship of (name) to the head of the household?
See codes below.

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)?
If 95 or more, record 95.

If age 10 or older:
8) Marital status
What is (name)'s current marital status?

Eligibility
9) Circle line number of all women age 15-49

10) If household selected for man's survey
Circle line number of all men age 15-59

11) Circle line number of all children age 0-5
If household selected for men's survey

11a) Circle line number of all women age 30-49

11B) Circle line number of all men age 30-64

Just to make sure that I have a complete listing:

Codes for q. 3: Relationship to head of household

Life migration for residents

11c) Birth place:
In what commune was (name) born?
Record dept/comm or country for abroad

11d) Former residence
In what commune did (name) live before moving here?
Record dept/comm or country for abroad

11e) How long was (name)'s stay in this commune?
Note: 1 and the number of months for less than 1 year
OR
2 and number of years for more than 1 year
AND 998 if since birth--skip to 11g

Return migration
11f) Has (name) returned from this commune after having lived there for at least 6 months?
Yes 1
No 2

Migratory status
11g) Guess the migratory status
Record
1=non-migrant If Q 11e= 9 and 98
2=return migrant if Q11e=9 and 98 and Q11f-1
3=Other return migrant if q11e=9 and 98 and [##translator note: text is cut off here]

If 0-17 years

Survivorship and residence of biological parents
12) Is (NAME)'s natural mother alive?

13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?

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

15) Does (NAME)'s natural father live in this household or was he a guest last night?

Codes for q 17 and 19: Education

Level

Class

If age 5 years or older

Ever attended school
16) Has (NAME) ever attended school?

17) What is the highest level of school (NAME) has attended?
See codes below.
What is the highest grade (NAME) completed at that level?

If age 5-24 years
Current/recent school attendance
18) Did (name) attend school at any time during the (2016-2017) school year?

19) During this/that school year, what level and grade (is/was) (name) attending?
See codes below.

If age 0-4 years
Birth registration
20) Does (name) have a birth certificate?

If no, probe: Has (name)'s birth ever been registered with the civil authority?

If age 6 or older
Literacy
20a) If level in column 17=2, 3, or 4: Ask: Can (name) read, write, and understand at least one national language?
Other: Ask: Can (name) read, write, and understand at least one language?

If yes, which ones?

Codes for Qs 17 and 19: Education
Level attainted
Class successfully achieved

Codes for Q20a: Literacy

[##translator note: questions 1-20 repeated for line numbers 11-20 to accommodate larger households]

Tick here if continuation sheet used

Codes for Q3: for relationship with head of household

Household characteristics

No.
Questions and filters
Coding categories
Skip

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

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

103) Where is the water source located?

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

105) Check 101 and 102: Code 14 or 21 circled

106) In the past two weeks, was the water from this source not available for at least one full day?

107) Do you do anything to the water to make it safer to drink?

108) What do you usually do to make the water safer to drink?
Anything else?
Record all mentioned

109) What kind of toilet facility do members of your household usually use?
If not possible to determine, ask permission to observe the facility.

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

111) Including your own household, how many households use this toilet facility?

112) Where is this toilet facility located?

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

114) Is the cooking usually done in the house, in a separate building, or outdoors?

115) Do you have a separate room which is used as a kitchen?

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

117) Does this household own any livestock, herds, other farm animals, or poultry?

118) How many of the following animals does this household own?
If none, enter 00
If 95 or more, enter 95
If unknown, enter 98

119) Does any member of this household own any agricultural land?

120) How many hectares of agricultural land do members of this household own?
If 95 or more, circle 950

121) Does your household have:

122) Does any member of your household own:

123) Does any member of this household have a bank account?

123a) Does any member of this household have an account in another micro-finance organization?

124) Does anyone in your household smoke? Would you say daily, weekly, monthly, less than monthly, or never?

125) At any time in the past 12 months, has anyone come into your dwelling to spay the interior walls against mosquitos?

126) Who sprayed the dwelling?

127) Does your household have any mosquito nets?

128) How many mosquito nets does your household have?
If 7 or more nets, record 7.

Mosquito nets

129) Ask the respondent to show you the nets in the household.
If more than 3 nets, use additional questionnaire(s).

130) How many months ago did your household get the mosquito net?
If less than one month ago, record 00.

131) Observe or ask the brand/type of mosquito net.
If brand is unknown and you cannot observe the net, show pictures of typical net types/brands to respondent.

Long-lasting insecticide-treated net (LLIN)

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

133) How many months ago was the net last soaked or dipped
If less than one month ago, record 00.

134) Did you get the net through a mass distribution campaign, during an antenatal care visit, during an immunization visit, or at a primary school?

135) Where did you get the net?

135a) How did you acquire the mosquito net?

136) Did anyone sleep under this mosquito net last night?

137) Who slept under the mosquito net last night?
Record the person's name and line number from household schedule

138) Go back to 129 for next net; or, if no more nets, go to 139.

Additional household characteristics
139) We would like to learn about the places that households use to watch their hands. Can you please show me where members of your household most often wash their hands?

140) Observe presence of water at the place for handwashing.
Record observation

141) Observe presence of soap, detergent, or other cleansing agent at the place for handwashing.

142) Observe main materials of the floor in the dwelling.
Record observation.

143) Observe main material of the roof of the dwelling.
Record observation.

144) Observe main materials of the exterior walls of the dwelling.
Record observation.

144a) Where do you usually through away your household garbage?

144b) Where do you usually through away dirty water?

145) I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?

Test salt for iodine

Selection of a child for children's work and discipline

No.
Questions and filters
Coding categories

151) Check column 7 in the list of household members and record the total number of children age 1-17.

152) Check the number of children age 1-17 from Q. 151:

152) List each child age 1-17 below in the order in which they appear on the list of household members. Do not include other household members outside of the group aged 1-17. Record the line number, name, sex and age of each child.

153) Rank number

154) Line number from column 1

155) Name from column 2

156) Sex from column 4

157) Age from column 7

158) Check the digit of the household number of the cover page. Go to this line number of the table below. Verify the total number of children Q 151 on the previous page. Go to this column number in the table below.

Find the space where the line and the column cross and circle the number that is in the space. This is the rank number of the child selected for the children's work/discipline among the eligible children in Q 153.

Record the rank number, line number, age, and name of the child selected in the space below.
Example: The household number is 716 and Q 151 shows that there are three eligible children age 1-17 in the household. Since the last digit of the household number is 6, go to line six, and since there are three eligible children, go to column 3. Find the space where the line and column intersect (2) and circle the number. Now, go to Q 153 and find the second child. Write the name, age, line number, and rank of the child in the space below.

Last digit the household number

159)

Children's work

No.
Questions and filters
Coding categories
Skip

161) Check age of child selected from Q 159

162) Now I would like to ask you some questions on the type of work that children in your household can do.

Since last (day of week), did (name) do any of the following activities, even if only for one hour?

163) Check 162, a to d

164) Since last (day of week), approximately how many hours total did (name) work on this activity/these activities?

165) Does this activity/do these activities require carrying heavy loads?

166) Does this activity/do these activities require working with dangerous tools (knives, etc.) or big machines?

167) Now I would like to ask some questions about how you would describe (name)'s work environment.

168) Since last (day of week), did name fetch water for the household?

169) In total, since last (day of week), how many hours did (name) spend fetching water for the household?
If less than one hour, record 00

170) Since last (day of week), did (name) fetch firewood for the household?

171) In total, since last (day of week), how many hours did (name) spend fetching firewood for the household?
If less than one hour, record 00

172) Since last (day of week), did (name) do any of the following tasks for the household?

173) Check 172 a to g:

174) Since last (day of week of interview), about how many hours in total did (name) spend doing these activities?

Discipline of children

No.
Questions and filters
Coding categories
Skip

181) Check age of selected child in Q 159:

182) Record the child's line number and name from 159

183) Now I would like to talk about something else.
Adults use certain methods to teach child how to behave well or to correct behavioral problems. I will read you a list of methods that are used. Please tell me if you or someone else in your household has

184) Do you think that to properly raise and educate (name), you must punish him/her physically?

185) Record the time

Interviewer's observations
To be filled in after completing interview

Comments about the interview:

Comments on specific questions:

Any other comments:

Supervisor's observations

Editor's observations