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DEMOGRAPHIC AND HEALTH SURVEY-COTE D'IVOIRE 1994-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

DEPARTMENT NAME__

SUB-PREFECTURE NAME__

CENSUS DISTRICT__

CLUSTER NUMBER___

STRUCTURE NUMBER__

HOUSEHOLD NUMBER__

URBAN/RURAL__

URBAN 1
RURAL 2

HOUSEHOLD SELECTED FOR MEN'S SURVEY? ____

LARGE CITY, SMALL CITY, OR COUNTRYSIDE?

LARGE CITY 1
SMALL CITY 2
COUNTRYSIDE 3


INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____

RESULT____

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
HOUSEHOLD ABSENT 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 (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____

FINAL VISIT
DAY____
MONTH____
YEAR 94
NAME____
RESULT____

TOTAL NUMBER OF VISITS_____

TOTAL PERSONS IN HOUSEHOLD_____

TOTAL ELIGIBLE WOMEN____

TOTAL ELIGIBLE MEN____

LANGUAGE OF INTERVIEW____

INTERPRETER USED?

YES
NO

SUPERVISOR
NAME__
DATE___

FIELD EDITOR
NAME___
DATE___

KEYED BY
NAME___
DATE___

HOUSEHOLD SCHEDULE

Now we would like 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 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?

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
ADOPTED/FOSTER CHILD 09
STEPCHILD 10
NEPHEW OR NIECE 11
COUSIN 12
OTHER RELATIVE 13
NOT RELATED 14
DON'T KNOW 98

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)?

AGE IN YEARS___

EDUCATION IF AGE 6 YEARS OR OLDER:

8) Has (NAME) ever been to school?

YES 1
NO 2

9) 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
HIGHER 4
DON'T KNOW 8

GRADE___

PRIMARY
CP1 01
CP2 02
CE1 03
CE2 04
CM1 05
CM2 06
SECONDARY 1ST CYCLE
6TH 01
5TH 02
4TH 03
3RD 04
SECONDARY 2ND CYCLE
2ND 01
1ST 02
FINAL 03
HIGHER
01
02
03
04
ETC
DON'T KNOW
DON'T KNOW 98

IF LESS THAN 25 YEARS OLD:

10) Is (NAME) still in school?

YES 1
NO 2

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS IF LESS THAN 15 YEARS OLD:

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

YES 1
NO 2
DON'T KNOW 8

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

LINE NUMBER___

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

YES 1
NO 2
DON'T KNOW 8

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

LINE NUMBER___

ELIGIBILITY:
15) CIRCLE THE LINE NUMBER OF ALL ELIGIBLE WOMEN FOR THE INDIVIDUAL QUESTIONNAIRE

ELIGIBILITY:
16) CIRCLE THE LINE NUMBER OF ALL ELIGIBLE MEN FOR THE INDIVIDUAL QUESTIONNAIRE

RECORD HERE THE NAME OF THE PERSON INTERVIEWED_____

TICK HERE IF CONTINUATION SHEET USED____

TOTAL NUMBER OF ELIGIBLE PERSONS:

NUMBER OF WOMEN__
NUMBER OF MEN___

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 (ENTER EACH IN TABLE)
NO

2) In addition, 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 (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

17) What is the main source of water used to wash hands and dishes?

PIPED WATER
PIPED INTO DWELLING/YARD/PLOT 11 (GO TO 19)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 19)
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 19)
TANKER TRUCK 51
OTHER (SPECIFY)____ 61

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

MINUTES_____
ON PREMISES 996

18A) How far away is your house from (SOURCE OF WATER) in meters?

METERS____
ON PREMISES 9996

19) Does your household use this same source for drinking water?

YES 1 (GO TO 21)
NO 2

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

PIPED WATER
PIPED INTO DWELLING/YARD/PLOT 11
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY)_____ 71

21) What kind of toilet facility does your household have?

FLUSH TOILET
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE
WC 21
TRADITIONAL PIT TOILET 22
VENTILATED IMPROVED PIT (VIP) LATRINE 23
NO FACILITY/BUSH/FIELD 31
OTHER (SPECIFY)____ 41

22) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

23) How many rooms in your household are used for sleeping?

NUMBER OF ROOMS____

24) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANK 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES/CARPET 33
CEMENT 34
OTHER (SPECIFY) 41

25) Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car?
YES 1
NO 2