PLACE NAME (COMMUNE/VILLAGE) ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
REGION ______
RURAL 2
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL?
REGIONAL CAPITAL (THIES, KAOLACK, ZIGUINCHOR, ST. LOUIS, DIOURBEL) 2
OTHER CITY 3
RURAL 4
NAME/LINE NUMBER OF RESPONDENT ON THE HOUSEHOLD SHEET _____
NO 2
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE_____
INTERVIEWER NAME_____
RESULT___
NO MEMBER OF HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9
NO MEMBER OF HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 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 _____
INTERVIEWER CODE_____
RESULT_____
NO MEMBER OF HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9
TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____
SUPERVISOR
NAME_____
DATE_____
FIELD EDITOR
NAME_____
DATE_____
KEYED BY_____
CODE _____
1. LINE NUMBER (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)
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 slept 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?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDSON OR GRANDDAUGHTER 05
FATHER OR MOTHER 06
FATHER-IN-LAW OR MOTHER --IN-LAW 07
BROTHER OR SISTER 08
CO-WIFE 09
OTHER RELATIVE 10
NOT RELATED 11
DOESN'T KNOW 98
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. RESIDENCE: Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
FEMALE 2
7. AGE: How old is (NAME)?
RECORD '97' FOR 97 YEARS OR MORE.
ELIGIBILITY OF WOMEN:
15. CIRCLE THE LINE NUMBER OF ALL FEMALE RESIDENTS OR VISITORS BETWEEN 15-49 YEARS. (SEE 5, 6 AND 7)
ELIGIBILITY OF MEN:
16. CIRCLE THE LINE NUMBER OF ALL MALE RESIDENTS OR VISITORS AGED 20 YEARS OR MORE. (SEE 5, 6 AND 7)
MARK HERE IF ANOTHER SHEET WAS USED_____
TOTAL NUMBER OF ELIGIBLE PEOPLE_____
Just to be sure that I have a complete list:
1) Are there other persons such as small children or infants that we have not recorded on the list?
NO
2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?
NO
3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?
NO
17. What is the main source of water that the members of your household use to wash their hands and to wash the dishes?
PUBLIC TAP/STANDPIPE 12
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 19)
OTHER (SPECIFY) _____ 71
18. How long does it take to go there, get water, and come back?
ON SITE 996
19. Do the members of your household obtain water from the same origin to drink?
NO 2
20. From where does the drinking water for your household come?
PUBLIC TAP/STANDPIPE 12
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 71
21. What kind of toilet facility do the members of your household use?
COMMUNAL FLUSH 12
LATRINES 22
OTHER (SPECIFY) _____41
Electricity?
Radio?
Television?
Refrigerator or freezer?
Video?
Telephone?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
23. How many rooms in your household do you use to sleep in?
24. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION
DUNG 12
VINYLE OR LINO/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
25. Is there anyone in your household who owns:
A bicycle?
A scooter or motorcycle?
A car?
A carriage or cart?
Another mode of transportation?
NO 2
NO 2
NO 2
NO 2
NO 2
26. How do you dispose of your waste water?
CLOSED CANAL 2
OPEN CANAL 3
IN THE SEA/RIVER/POND 4
HOLE DUG IN THE HOUSE 5
IN THE ROAD/NATURE 6
OTHERS (SPECIFY) _____ 7
27. In what do you keep your household garbage?
GARBAGE CAN WITHOUT LID 2
PLASTIC BAGS 3
USED KITCHEN UTENSILS 4
OTHER (SPECIFY) _____5
28. Where do you put your household garbage before disposing of it?
OUTSIDE THE CONCESSION (YARD/PLOT) 2
29. How is your household garbage disposed of?
BURIED 2
AUTHORIZED DEPOSITORY 3
WILD (NOT AUTHORIZED) DEPOSITORY 4
INCINERATION 5
OTHER (SPECIFY) _____6