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REPUBLIC OF SENEGAL DEMOGRAPHIC AND HEALTH SURVEY (EDSIII) - 1997 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME (COMMUNE/VILLAGE) ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
REGION ______

URBAN/RURAL

URBAN 1
RURAL 2

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL?

DAKAR (DAKAR REGION NOT RURAL) 1
REGIONAL CAPITAL (THIES, KAOLACK, ZIGUINCHOR, ST. LOUIS, DIOURBEL) 2
OTHER CITY 3
RURAL 4

NAME/LINE NUMBER OF RESPONDENT ON THE HOUSEHOLD SHEET _____

MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE_____
INTERVIEWER NAME_____
RESULT___

RESULTS_____

1 COMPLETED
2 NO MEMBER OF HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT TIME OF THE VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME
4 POSTPONED
5 REFUSED
6 EMPTY DWELLING OR NO DWELLING AT THE ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR _____
INTERVIEWER CODE_____
RESULT_____

TOTAL NUMBER OF VISITS_____

TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

KEYED BY_____
CODE _____

HOUSEHOLD TABLE

1. LINE NUMBER (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

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 slept 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?

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDSON OR GRANDDAUGHTER
06 FATHER OR MOTHER
07 FATHER-IN-LAW OR MOTHER --IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 NOT RELATED
98 DOESN'T KNOW

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)?
RECORD '97' FOR 97 YEARS OR MORE.

YEARS ___

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?

YES (WRITE EACH ONE IN THE TABLE)
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?

YES (WRITE EACH ONE IN THE TABLE)
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?

YES (WRITE EACH ONE IN THE TABLE)
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?

PIPED WATER
PIPED INTO DWELLING/INDOOR 11 (GO TO 19)
PUBLIC TAP/STANDPIPE 12
OPEN WELL
OPEN WELL IN DWELLING/YARD/PLOT 21 (GO TO 19)
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SURFACE WATER
RIVER/STREAM/BROOK 31
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
RAINWATER 41 (GO TO 19)
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?

MINUTES_____
ON SITE 996

19. Do the members of your household obtain water from the same origin to drink?

YES 1 (GO TO 21)
NO 2

20. From where does the drinking water for your household come?

PIPED WATER
PIPED INTO THE DWELLING/YARD/LOT 11
PUBLIC TAP/STANDPIPE 12
OPEN WELL
OPEN WELL IN DWELLING/ YARD/PLOT 21
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SURFACE WATER
RIVER/STREAM/BROOK 31
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
RAINWATER 41
TANKER TRUCK 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 71

21. What kind of toilet facility do the members of your household use?

FLUSH
PERSONAL FLUSH 11
COMMUNAL FLUSH 12
PIT/LATRINE
PIT 21
LATRINES 22
NO FACILITY IN THE HOUSEHOLD 31
OTHER (SPECIFY) _____41

22. Does your household have:

Electricity?
Radio?
Television?
Refrigerator or freezer?
Video?
Telephone?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
REFRIGERATOR/FREEZER
YES 1
NO 2
VIDEO
YES 1
NO 2
TELEPHONE
YES 1
NO 2

23. How many rooms in your household do you use to sleep in?

NUMBER OF ROOMS _____

24. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION

NATURAL MATERIAL
EARTH/SAND 11
DUNG 12
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYLE OR LINO/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ______ 41

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?

BICYCLE?
YES 1
NO 2
SCOOTER OR MOTORCYCLE?
YES 1
NO 2
CAR ?
YES 1
NO 2
CARRIAGE OR CART?
YES 1
NO 2
ANOTHER MODE OF TRANSPORTATION?
YES 1
NO 2

26. How do you dispose of your waste water?

SEWER SYSTEM 1
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 WITH LID 1
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?

INSIDE THE CONCESSION (YARD/PLOT) 1
OUTSIDE THE CONCESSION (YARD/PLOT) 2

29. How is your household garbage disposed of?

COLLECTED 1
BURIED 2
AUTHORIZED DEPOSITORY 3
WILD (NOT AUTHORIZED) DEPOSITORY 4
INCINERATION 5
OTHER (SPECIFY) _____6

30. END OF THE INTERVIEW.

HOUR_____
MINUTES_____