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REPUBLIC OF SENEGAL DEMOGRAPHIC AND HEALTH SURVEY (EDS)
HOUSEHOLD QUESTIONNAIRE - 1986

REGION____

VILLAGE____

DEPARTMENT____

NEIGHBORHOOD/REGION____

ARRONDISSEMENT/COMMUNE____

SUB-DISTRICT____

PARCELLE NUMBER____

CONCESSION NUMBER (a group of houses on a plot, usually centered around the huts of a man and his wives) ____

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____
INTERVIEWER NAME___
RESULT

RESULT ___

1 COMPLETED
2 NOT AT HOME OR NOT A COMPETENT RESPONDENT
3 POSTPONED
4 REFUSED
5 EMPTY DWELLING
6 NO DWELLING AT GIVEN ADDRESS
7 ADDRESS NOT RECEIVED OR INACCURATE ADDRESS
8 OTHER (SPECIFY) ____

NEXT VISIT
DATE____
TIME____

FINAL VISIT
MONTH _____
YEAR ____
INTERVIEWER CODE ____
RESPONDENT CODE ____

NUMBER OF VISITS____

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

Now I would like information on the people who usually live in your household or who are currently visiting your household.

001. HOUSEHOLD ORDER NUMBER:

ORDER NO. _____

002. ORDER NUMBER:

ORDER NO. _____

003. FIRST AND LAST NAMES OF USUAL RESIDENTS AND GUESTS:

NAME _____

004. RELATIONSHIPS IN HOUSEHOLD:

RELATION _____

005. SEX:

SEX ____

006. AGE IN COMPLETED YEARS:

AGE _____

007. MARITAL STATUS:

STATUS _____

008. RESIDENCE:

______

009. SELECTION OF ELIGIBLE WOMEN:

_____