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DEMOGRAPHIC AND HEALTH SURVEY - II
COTE D'IVOIRE 1998-99
HOUSEHOLD QUESTIONNAIRE

NATIONAL STATISTICAL INSTITUTE
REPUBLIC OF IVORY COAST

IDENTIFICATION

DEPARTMENT___
SUB PREFECTURE___
CENSUS DISTRICT___
CLUSTER NUMBER___
STRUCTURE NUMBER___
HOUSEHOLD NUMBER___

ABIDJAN/OTHER CITIES/RURAL?

ABIDJAN 1
OTHER CITIES 2
RURAL 3

INTERVENTION ZONE:

YES 1
NO 2

NAME OF HEAD OF HOUSEHOLD: ___

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME____

RESULTS___

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY): ___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY): ___

TOTAL NUMBER OF VISITS:____

TOTAL PERSONS IN HOUSEHOLD: ___
TOTAL ELIGIBLE WOMEN: ___
TOTAL ELIGIBLE MEN: ___
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE: ___

SUPERVISOR:
NAME___
DATE___

FIELD EDITOR:
NAME___
DATE___

OFFICE EDITOR: ___

KEYED BY: ___

Now we would like 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 household?

HEAD OF HOUSEHOLD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
FATHER OR MOTHER 06
FATHER-IN-LAW OR MOTHER-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?

M 1
F 2

7) AGE:
How old is (NAME)?

IF 95 YEARS OR MORE, RECORD '95'.

IN YEARS: ___

8) EDUCATION:
IF AGE 6 YEARS OR OLDER:
Has (NAME) ever been to school?

YES 1
NO 2 (GO TO 15)

9) IF ATTENDED SCHOOL:
What is the highest level of school (NAME) has attended?

PRIMARY 1
SECONDARY, 1ST CYCLE 2
SECONDARY, 2ND CYCLE 3
HIGHER 4
DK 8

What is the highest grade (NAME) completed at that level?

PRIMARY
CP1 1
CP2 2
CE1 3
CE2 4
CM1 5
CM2 6
DK 8
SECONDARY, 1ST CYCLE
6TH 1
5TH 2
4TH 3
3RD 4
DK 8
SECONDARY, 2ND CYCLE
2ND 1
1ST 2
FINAL 3
DK 8
HIGHER
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR OR MORE 5
DK 8

10) IF LESS THAN 25 YEARS:
Is (NAME) still in school?

YES 1
NO 2

15) WOMEN'S ELIGIBILITY:
CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15 - 49.

15A) MEN'S ELIGIBILITY:
CIRCLE THE LINE NUMBER OF ALL MEN 15 - 59.
(IF MEN'S SURVEY IS PLANNED IN THIS HOUSEHOLD)

TICK HERE IF CONTINUATION SHEET 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: ___ (ENTER EACH IN TABLE)
NO: ___

2. In addition, are there any other people who many 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 IN EACH TABLE)
NO: ___

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

PIPED WATER
PIPED INTO DWELLING/YARD/PLOT 12 (GO TO 18)
PUBLIC TAP 13
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 18)
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 18)
TANKER TRUCK 51 (GO TO 18)
OTHER (SPECIFY): ___ 96

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

MINUTES: ___
ON PREMISES 996

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

FLUSH TOILET 11
LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31
OTHER (SPECIFY): ___ 96

19) Does your household have:

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

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 STOVE/ELECTRIC STOVE
YES 1
NO 2

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

ROOMS: ___

21) MAIN MATERIAL OF THE FLOOR

RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD/PALM/BAMBOO 21
FINISHED FLOOR
CEMENT 31
TILES 32
OTHER FINISHED 33
OTHER (SPECIFY): ___ 96

22) Does any member of your household own:

A bicycle?
A motorcycle or moped?
A car?

BICYCLE
YES 1
NO 2
MOTORCYCLE/MOPED
YES 1
NO 2
CAR
YES 1
NO 2