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CONTINUED DEMOGRAPHIC AND HEALTH SURVEY (EDS-CONTINUED 2014)

HOUSEHOLD QUESTIONNAIRE

REPUBLIC OF SENEGAL
MINISTRY OF PLANNING
MINISTRY OF HEALTH AND SOCIAL ACTION

ICF

IDENTIFICATION

PLACE NAME________

NAME OF HEAD OF HOUSEHOLD___________

HOUSEHOLD NUMBER___________

PLOT NUMBER_______

CLUSTER NUMBER_________

REGION________

URBAN/RURAL

URBAN 1
RURAL 2

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__________
INTERVIEWER'S NAME____________
RESULT*_______

RESULT

1COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
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 201__
INT. NUMBER__________
CODE RESULT__________

TOTAL NO. OF VISITS________

TOTAL PERSONS IN HOUSEHOLD__________
TOTAL ELIGIBLE WOMEN___________
TOTAL ELIGIBLE MEN_____________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE________

SUPERVISOR
NAME_______
DATE_______

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Agency of Statistics and Demography, in collaboration with the Ministry of Health and of Social Action. We are conducting a survey about health all over Senegal. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER_______ DATE_______

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2-END

HOUSEHOLD SCHEDULE

1) LINE NO.

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.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A, 2B, 2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

NAME__________

2A) Just to make sure that I have a complete listing:
Are there any other persons such as small children or infants that we have not listed?

YES (ADD EACH IN TABLE(
NO

2B) 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 (ADD EACH IN TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD EACH IN TABLE)
NO

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 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
98 DON'T KNOW

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is (NAME)?
IF 95 OR MORE, RECORD 95.

IN YEARS_____

8) MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME)'s current marital status?

1 MARRIED OR LIVING TOGETHER
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED TOGETHER

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-59

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS:

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

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD 00.

LINE NUMBER__________

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

YES 1
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)

15) Does (NAME)'s natural father live in this household or was he a guest last night?
IF YES: what is his name?
RECORD FATHER'S LINE NUMBER.
IF NO, RECORD 00.

LINE NUMBER_______

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER:

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20G)

17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

LEVEL
1 PRIMARY
2 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS:

18) Did (NAME) attend school at any time during the (2013-2014) school year? (2)

YES 1
NO 2 (GO TO 19A)

19) During this/that school year, what level and grade (is/was) (NAME) attending?

LEVEL
1 PRIMARY
2 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE
98 DON'T KNOW

PREVIOUS SCHOOL ATTENDANCE

19A) Did (NAME) attend school at any time during the previous school year?

YES 1
NO 2 (GO TO 20G)

19B) During the previous school year, what level and grade was (NAME) attending?

LEVEL
1 PRIMARY
2 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE
98 DON'T KNOW

20) BIRTH REGISTRATION IF AGE UNDER 5 YEARS (0-59 MONTHS): Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DON'T KNOW

[##translator note: questions 1-20 repeated for line numbers 11-20 to accommodate larger households]

CHILDCARE OF CHILDREN AGE 3-5:

20D) During this school year, did (NAME) go to a care facility outside of the home, such as nursery school, Case des Tout Petits (national childcare facility), a community center, or other?

YES 1
NO 2 (GO TO 20G)
DON'T KNOW 8 (GO TO 20G)

20E) What establishment did (NAME) go to?
RECORD APPROPRIATE CODE

01 NURSERY SCHOOL (EDUCATIONAL)
02 NURSERY SCHOOL (NON-EDUCATIONAL)
03 CASE DES TOUT PETITS (NATIONAL CHILDCARE FACILITY)
04 PRIMARY SCHOOL
05 DAARA, KORAN, ARAB (RELIGIOUS SCHOOL, ISLAM)
06 COMMUNITY CENTER
96 OTHER

20F) For how many years?
RECORD APPROPRIATE CODE

1 CURRENT YEAR ONLY
2 SINCE LAST YEAR
3 SINCE YEAR BEFORE LAST
7 OTHER

SELECTION TABLE FOR CHILDREN'S WORK

20G) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 17 YEARS OLD LIVING IN THIS HOUSEHOLD:

TWO OR MORE
ONLY ONE (GO TO 20O)
NONE (GO TO 21)

TABLE 1: ELIGIBLE CHILDREN AGE 5-17 FOR QUESTIONS ON CHILDREN'S "WORK"

RECORD EACH CHILD AGE 5-17 FROM THE HOUSEHOLD TABLE IN THE TABLE BELOW, IN THE SAME ORDER AS ON THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS WHO ARE NOT AGE 5-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD, THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 5-17 IN THE RESERVED SPACE. (Q.20M)

20H)RANK NUMBER

RANK________

20I) LINE NUMBER FROM Q. 1

LINE NO.______

20J) NAME FROM Q. 2

NAME___________

20K) SEX FROM Q. 4

MALE 1
FEMALE 2

20L) AGE FROM Q. 7

AGE__________

20M) TOTAL NUMBER OF CHILDREN AGE 5-17

NUMBER__________

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON "WORK"

USE THIS TABLE TO SELECT ONE CHILDREN AGE 5-17.
a) TAKE THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE OF THE QUESTIONNAIRE.
B) THIS IS THE NUMBER OF THE LINE TO SELECT.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q.20M.
D) THIS IS THE NUMBER OF THE COLUMN TO SELECT
E) FIND THE SPACE WHERE THE SELECTED LINE AND COLUMN MEET AND CIRCLE THAT NUMBER.
F) THIS IS THE RANK NUMBER OF THE CHILD WHO WILL BE SELECTED FOR "WORK"

EXAMPLE:
THE HOUSEHOLD NUMBER IS 36, SO PICK LINE 6.
THERE ARE 3 ELIGIBLE CHILDREN IN THIS HOUSEHOLD, SELECT COLUMN 3.
THE SPACE AT THE INTERSECTION OF LINE 6 AND COLUMN 3 CONTAINS THE NUMBER 2: THE 2ND ELIGIBLE CHILD LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED. IF THE LINE NUMBER OF 3 ELIGIBLE CHILDREN IS 07, 11, AND 16, THE CHILD SELECTED IS THE 2ND CHILD LISTED, MEANING THE ONE WITH LINE NUMBER 11.

20n) LAST DIGIT IN HOUSEHOLD NUMBER 0-9

TOTAL NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD 1-8+

20o) RECORD THE RANK (Q20H), THE LINE NUMBER (Q 20I), THE NAME (Q20J), AND AGE (Q20L) OF THE CHILD SELECTED

RANK OF CHILD__________
LINE NUMBER OF CHILD_________
NAME OF CHILD__________
AGE OF CHILD_________

WORK OF CHILDREN

20p) Now I would like to talk about all the work that the children of this household can do.

Since last (DAY OF THE WEEK), did (NAME) do any of the following activities, even if only for one hour?

a) Did (NAME) work on his/her own land/farm/garden or help with the household land/farm/garden or take care of animals. For example: grow farm products, harvest them, feed animals, take them to pasture or milk them?

WORKED ON LAND/FARM/GARDEN OR TAKE CARE OF ANIMALS
YES 1
NO 2

b) Did (name) help with a family business, the business of other relatives with or without payment or work in his/her own business?

HELPED IN FAMILY BUSINESS/HELP ANOTHER RELATIVE/IN OWN BUSINESS
YES 1
NO 2

c) Did (name) produce, sell goods, artisanal products, cloths, food, or agricultural products?

PRODUCED/SOLD GOODS/ARTISANAL PRODUCTS/CLOTHS/FOOD, OR AGRICULTURAL PRODUCTS
YES 1
NO2

d) Since last (day of week), did (NAME) engage in any other type of activity in exchange for payment either in case or in kind, even if for only one hour?

IF NO, PROBE:
Please include any type of activity that (NAME) might have done as regular or temporary employment, for his/her own business or as an employer, or as an unpaid family worker to help with household or farm tasks.

ALL OTHER ACTIVITIES
YES 1
NO 2

20Q) CHECK 20 [A] TO [D]:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 20V)

20R) Since last (DAY OF WEEK), approximately how many hours in total did (NAME) work doing (this activity/these activities)?
IF LESS THAN ONE HOUR, RECORD 00

NUMBER OF HOURS_________

20S) Does/Do (this activity/these activities) require carrying heaving loads?

YES 1 (GO TO 20V)
NO 2

20T) Does/Do (this activity/these activities) require working with dangerous tools (knives, etc) or operating heavy machinery?

YES 1 (GO TO 20V)
NO 2

20U) How would you describe (NAME)'s work environment?

a) Is (NAME) exposed to dust/smoke or gas?
YES 1 (GO TO 20V)
NO 2
b) Is (NAME) exposed to cold, heat, or excessive humidity?
YES 1 (GO TO 20V)
NO 2
c) Is (NAME) exposed to loud noises or vibrations?
YES 1 (GO TO 20V)
NO 2
d) Is (NAME) exposed to working at high heights?
YES 1 (GO TO 20V)
NO 2
e) Is (NAME) exposed to chemical products (pesticides, glues, etc) or to explosives?
YES 1 (GO TO 20V)
NO 2
f) Is (NAME) exposed to other things, behaviors, or conditions that are bad for his/her health or security?
Yes 1
No 2

20V) Since last (DAY OF WEEK), did (NAME) fetch water or firewood for the household?

YES 1
NO 2 (GO TO 20X)

20W) In total, since last (DAY OF WEEK), how many hours did (NAME) spend fetching water or firewood for the household?
IF LESS THAN ONE HOUR, RECORD 00

NUMBER OF HOURS_________

20X) Since last (DAY OF WEEK), did (NAME) do any of the following tasks for the household?

a) make purchases for the household?
YES 1
NO 2
b) fix any type of equipment for the household?
YES 1
NO 2
c) cook or clean utensils for the household?
YES 1
NO 2
d) wash clothing?
YES 1
NO 2
e) take care of children?
YES 1
NO 2
f) take care of elderly or sick people?
YES 1
NO 2
g) other tasks for the household?
YES 1
NO 2

20Y) CHECK 20W [A] TO [G]:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 21)

20Z) Since last (DAY OF WEEK), about how many hours in total did (NAME) spend doing these activities?
IF LESS THAN ONE HOUR, RECORD 00

NUMBER OF HOURS____

PREVALENCE OF CHRONIC ILLNESS AND DANGEROUS PRACTICES

21) I would like to ask you some questions about the health of the members of your household. Does (NAME) suffer from any type of chronic illness?

1 YES
2 NO (GO TO 28)

22) What illness does (NAME) have?
RECORD THE NAME OF THE ILLNESS AND THE CODE.

01 HYPERTENSION
02 DIABETES
03 CHRONIC ULCER
04 ANEMIA
05 SICKLE-CELL ANEMIA
06 HEMOPHILIA
07 HEART DISEASE
08 RENAL FAILURE
09 LIVER DISEASE
10 OSTEOARTHRITIS
11 TUBERCULOSIS
12 CHRONIC HEADACHES
13 HEART ATTACK
14 EPILEPSY
15 ASTHMA
16 LUNG DISEASE
17 HYPERTHYROIDISM
18 HYPOTHYROIDISM
19 PROSTATE PROBLEMS
20 CATARACTS
21 OPACITY OF THE CORNEA (CONTACT LENS)
22 CHRONIC BACK PAIN OR SPINAL PROBLEMS
23 MENTAL ILLNESS
24 SKIN DISEASE
25 CANCEROUS TUMORS
26 GUM OR MOUTH DISEASE
96 OTHER (SPECIFY)

23) Did a doctor inform (NAME) that he/she has this illness?

YES 1
NO 2

24) Does (NAME) receive regular treatment?

YES 1
NO 2

25) Does (NAME) have any other chronic illness?

YES 1
NO 2 (GO TO 28)

26)What is the second illness that (NAME) has?
RECORD THE NAME OF THE SECOND ILLNESS AND ITS CODE.

01 HYPERTENSION
02 DIABETES
03 CHRONIC ULCER
04 ANEMIA
05 SICKLE-CELL ANEMIA
06 HEMOPHILIA
07 HEART DISEASE
08 RENAL FAILURE
09 LIVER DISEASE
10 OSTEOARTHRITIS
11 TUBERCULOSIS
12 CHRONIC HEADACHES
13 HEART ATTACK
14 EPILEPSY
15 ASTHMA
16 LUNG DISEASE
17 HYPERTHYROIDISM
18 HYPOTHYROIDISM
19 PROSTATE PROBLEMS
20 CATARACTS
21 OPACITY OF THE CORNEA (CONTACT LENS)
22 CHRONIC BACK PAIN OR SPINAL PROBLEMS
23 MENTAL ILLNESS
24 SKIN DISEASE
25 CANCEROUS TUMORS
26 GUM OR MOUTH DISEASE
96 OTHER (SPECIFY)

27) Did a doctor inform (NAME) that he/she has this second illness?

YES 1
NO 2

RISKY BEHAVIOR DURING THE LAST 10 YEARS OR MORE IF 15 YEARS OR OLDER:

28) Does (NAME) smoke cigarettes or any other type of tobacco, or did he/she smoke in the past?

1 YES, CURRENTLY
2 YES, BEFORE
3 YES, RARELY
4 NO
8 DON'T KNOW

29) Does (NAME) drink alcohol?

1 YES, DAILY
2 YES, WEEKLY
3 YES, RARELY
4 YES, BEFORE
5 NO/NEVER
8 DON'T KNOW

DISABILITY MODULE

30) Does (NAME) have any type of physical, mental or other state dating 6 months or more that limit his/her normal daily activities, activities that could be completed by a person of the same age.

IF YES, ASK THE QUESTION: Does this state severely limit the daily activities of his/her life, or does it cause only minor limitations?

YES, SEVERELY 1
YES, MINOR 2
NO 3 (GO TO NEXT LINE)
DON'T KNOW 8 (GO TO NEXT LINE)

31) Does (NAME) have low or weak functioning in any of the following areas:
CIRCLE ALL FUNCTIONS MENTIONED

A SIGHT
B HEARING
C COMPREHENSION OR COMMUNICATION
D MOBILITY
E SELF-CARE
F RELATIONSHIPS WITH PEOPLE

32) What is the main cause of the incapacity?

01 CONGENITAL
02 RELATED TO BIRTHING CONDITIONS
03 CONTAGIOUS
04 OTHER CONGENITAL ILLNESS
05 PHYSICAL OR PSYCHOLOGICAL AGGRESSION
06 OLD AGE
07 INJURY/ACCIDENTS
08 BEWITCHMENT/MAGIC
09 WAR
96 OTHER (SPECIFY)
98 DON'T KNOW

33) How old was (NAME) when this current state began?

AGE____

34) In the last 12 months, did (NAME) receive any treatment or support?
WITH THE EXCEPTION OF Y, CIRCLE ALL CODES MENTIONED

A MEDICAL TREATMENT
B SOCIAL SUPPORT
C FINANCIAL SUPPORT
D NUTRITIONAL SUPPORT
Y NO SUPPORT

HOUSEHOLD CHARACTERISTICS

101a) What is the occupational status your household's dwelling?

OWNER 01
CO-OWNER 02
RENT-TO-OWN 03
RENTER 04
CO-RENTER 05
SUBTENANT 06
HOUSED BY EMPLOYER 07
HOUSED FREE OF CHARGE BY RELATIVE OR FRIEND 08

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER/INDUSTRIALIZED BAG 91
OTHER (SPECIFY) 96

103) Where is the water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES_____
DON'T KNOW 998

104A) Who usually goes to this water source to bring water to your household?

FEMALE ADULT (15 YEARS OR MORE) 1
MALE ADULT (15 YEARS OR MORE) 2
YOUNG GIRL (LESS THAN 15 YEARS) 3
YOUNG BOY (LESS THAN 15 YEARS) 4
DON'T KNOW 8

105) Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO 107)

106) What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED

A BOIL
B ADD BLEACH/CHLORINE
C STRAIN THROUGH A CLOTH
D USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.)
E SOLAR DISINFECTION
F LET IT STAND AND SETTLE
X OTHER (SPECIFY)
Z DON'T KNOW

107) What kind of toilet facility do members of your household usually use?

FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO PIT 12
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH MANUAL FLUSH 22
PIT LATRINE WITHOUT FLUSH 23
OTHER IMPROVED TRADITIONAL LATRINE SYSTEM 24
NO FACILITY/BUSH/FIELD 31 (GO TO 110)
OTHER (SPECIFY) 96

108) Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109) How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10_____

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does your household have:

ELECTRICITY?
YES 1
NO 2
A RADIO?
YES 1
NO 2
A TELEVISION?
YES 1
NO 2
A MMDS/TV5 ANTENNA
YES 1
NO 2
A SUBSCRIPTION TO CANAL?
YES 1
NO 2
A NON-MOBILE TELEPHONE?
YES 1
NO 2
A MOBILE TELEPHONE?
YES 1
NO 2
A WASHING MACHINE?
YES 1
NO 2
A REFRIGERATOR?
YES 1
NO 2
A PORTABLE STOVE/GAS OR ELECTRIC STOVE?
YES 1
NO 2
AN IMPROVED FIREPLACE?
YES 1
NO 2
A CD/DVD PLAYER?
YES 1
NO 2
AN AIR CONDITIONER?
YES 1
NO 2
A COMPUTER?
YES 1
NO 2
INTERNET AT HOME?
YES 1
NO 2

111) What type of fuel does your household mainly use for cooking?

ELECTRICITY 1
LPG 2
WOOD COAL 3
WOOD, STRAW 4
ANIMAL DUNG 5
OTHER (SPECIFY) 6

111a) What is the main source of lighting for your household?

ELECTRICITY (SENELEC [NATIONAL ELECTRIC COMPANY]) 01
GENERATOR 02
SOLAR 03
FLASHLIGHT 04
GAS LAMP 05
HURRICANE LAMP 06
ARTISANAL OIL LAMP 07
CANDLE 08
WOOD 09
OTHER (SPECIFY) 96

112) Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY) 6 (GO TO 114)

113) Do you have a separate room which is used as a kitchen?

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR WAXED WOOD 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY MATERIAL
MAT 21
WOOD 22
PALM/BAMBOO 23
CARDBOARD 24
FINISHED FLOOR
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
SHINGLES 36
OTHER (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) 96

117) How many rooms in this household are used for sleeping?

ROOMS_________

118) Does any member of your household own:

A BICYCLE?
YES 1
NO 2
A MOTORCYCLE OR MOTOR SCOOTER?
YES 1
NO 2
A PERSONAL CARE?
YES 1
NO 2
A COMMERCIAL CAR OR TRUCK?
YES 1
NO 2
A CART?
YES 1
NO 2
A PLOW?
YES 1
NO 2
A CANOE/OR FISHING NETS?
YES 1
NO 2

119) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950

HECTARES___________

95 OF MORE HECTARES 950
DON'T KNOW 998

121) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 123)

122) How many of the following animals does this household own?

IF NONE, ENTER 00
IF 95 OR MORE, ENTER 95
IF UNKNOWN, ENTER 98

MILK COWS OR BULLS?
NUMBER______
CAMELS?
NUMBER______
HORSES, DONKEYS, OR MULES?
NUMBER______
GOATS?
NUMBER_______
SHEEP?
NUMBER______
PIGS?
NUMBER______
POULTRY?
NUMBER______

123) Does any member of this household have a bank account or an account in another financial institution (mutual savings, savings and loan, savings bank…)?

YES 1
NO 2
DON'T KNOW 8

123A) Does any member of this household have a tontine?

YES 1
NO 2
DON'T KNOW 8

123B) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES 1
NO 2
DON'T KNOW 8

125) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY)_____ X
DON'T KNOW Z

125A) Were the windows in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

YES 1
NO 2
DON'T KNOW 8

125B) Were the doors in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

YES 1
NO 2
DON'T KNOW 8

126) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 127D)

127) How many mosquito nets does your household have?
IF 25 OR MORE NETS, RECORD 25.

NUMBER OF NETS _____

127A) Do you use mosquito nets outside of the bedrooms: for example, in the yard, under trees?

YES 1
NO 2

127B) Do members of your household sleep under the mosquito nets continuously throughout the year?

YES 1
NO 2
DON'T KNOW/DON'T RECALL 8 (GO TO 128)

127C) Why do members of your household not sleep under the mosquito nets continuously throughout the year?

NOT MANY MOSQUITOES 1 (GO TO 128)
BECAUSE OF THE HEAT 2 (GO TO 128)
DON'T LIKE 3 (GO TO 128)
FORGOT/NEGLIGENCE 4 (GO TO 128)
OTHER (SPECIFY) 6 ______ (GO TO 128)
DON'T KNOW/DON'T RECALL 8 (GO TO 128)

127D) Why are there no usable mosquito nets in your household?

A LACK OF MEANS A (GO TO 136A)
B NOT NECESSARY B (GO TO 136A)
C USE SOMETHING ELSE C (GO TO 136A)
D NO MOSQUITOES D (GO TO 136A)
E DON'T LIKE E (GO TO 136A)
X OTHER (SPECIFY) X _____ (GO TO 136A)
Y DON'T KNOW Y (GO TO 136A)

128) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD. ASK THE FOLLOWING QUESTIONS FOR EACH NET.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00
ENTER NUMBERS OF MONTHS

MONTHS AGO _____

MORE THAN 37 MONTHS AGO 95
NOT SURE 98

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
OLYSET-NET 12 (GO TO 134)
DAWA PLUS 13 (GO TO 134)
ICONLIFE 14 (GO TO 134)
INTERCEPTOR 15 (GO TO 134)
OTHER TREATED MOSQUITO NET
K-ONET 21
NETTO 22
SENTINELLE 23
OTHER (SPECIFY) 26
(ALL SKIP TO 132)
MADE BY A TAILOR 30
OTHER (SPECIFY) _____ 31
DON'T KNOW BRAND 98

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
NOT SURE 8

132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD 00.
RECORD THE NUMBER OF MONTHS

MONTHS AGO _____

MORE THAN 24 MONTHS AGO 95
NO SURE 98

134) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 135A)
DON'T KNOW 8 (GO TO 135A)

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

RECORD ALL THE PERSONS WHO SLEPT UNDER THE MOSQUITO NET LAST NIGHT.

NAME_________
LINE NUMBER________

135A) Was the net modified after have been obtained?

YES 1
NO 2
DON'T KNOW 8

135B) CHECK 134:

YES 1 (GO TO 135D)
NO/DON'T KNOW 2

135C) Why did no one sleep under this mosquito net last night?
IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN ONE.

NO MOSQUITOES 1
HEAT 2
TORN 3
NOT EFFECTIVE 4
OTHER (SPECIFY) _____ 6
DON'T KNOW 8

135D) Where did you get this mosquito net?

DISTRIBUTION CAMPAIGN 01
HEALTH STRUCTURE 02
SCHOOL 03
OCB [LOCAL HEALTH NETWORK]/ASSOCIATIONS 04
PRIVATE PHARMACY 05
SELECT STATION 06
OTHER BUSINESS 07
RELATIVE/NEIGHBOR/FRIEND 08
DON'T KNOW 98

135E) How much did you pay for the mosquito net?
RECORD IN CFA FRANCS

PRICE_________
DON'T KNOW 9998

135F) CHECK 130 AND 132:
MIILDA OR OTHER TYPE OF MOSQUITO NET

Q. 130: MIILDA: (GO TO 135G A)
Q. 132: CODE 1: (GO TO 135G B)
Q. 132: CODES 2 OR 8: (GO TO 135G A)

135G)

a--Has this mosquito net been washed since you obtained it?

b--Has this mosquito net been washed since it was last soaked?

YES 1
NO 2 (GO TO 135I)
DON'T KNOW/UNSURE 8 (GO TO 135I)

135H) How many times has this mosquito net been washed in the last 12 months?

NUMBER OF WASHES_______
DON'T KNOW/UNSURE 98

135I) Have you ever used this mosquito net for any purpose other than for sleeping?

YES 1
NO 2 (GO TO 135K)
UNSURE/DON'T KNOW 8 (GO TO 135K)

135J) What are these other purposes?

A TO PROTECT HARVEST/PLANTS
B FOR FISHING
C ON MATTRESSES TO PROTECT AGAINST BED BUGS
D CLOTHING
X OTHER (SPECIFY) ______

135K) Have you ever tried to fix a hole in this mosquito net?

YES 1
NO 2
DON'T KNOW/UNSURE 8

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 136A

136A) In the last 12 months, have there been any mosquito nets in the household that are not longer there?

YES 1
NO 2 (GO TO 137)
UNSURE/DON'T KNOW 8 (GO TO 137)

136B) How many?

NUMBER _____

137) Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

137A) When do members of your household most often wash their hands?

A AFTER USING THE TOILET
B BEFORE EATING
C BEFORE PREPARING MEALS
D BEFORE TAKING CARE OF CHILDREN
E AFTER TAKING CARE OF CHILDREN

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE WHERE HOUSEHOLD MEMBERS WASH THEIR HANDS.

WATER AVAILABLE 1
WATER NOT AVAILABLE 2

139) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

A SOAP OR DETERGENT( LIQUID, POWDER, PASTE)
B ASH, MUD, SAND
C NONE

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) 6

140A) In the last three years, has there been any event the in your household?

YES 1
NO 2 (GO TO 201)

140B) What was the main event for your household?

ILLNESS 01
DEATH 02
LOSS OF EMPLOYMENT/UNEMPLOYED 03
LOWERED REVENUE/REMITTANCE RECEIVED 04
FLOOD/DRAUGHT/LOSS OF HARVEST 05
CONFLICT/INSECURITY/THEFT OR LOSS OF LIVESTOCK 06
FIRE 07
LOSS OF MONEY 08
OTHER (SPECIFY) 96

WEIGHT, HEIGHT, ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0-5

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 IN ORDER ACCORDING TO LINE NUMBER. IF MORE THAN 3 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (name)'s date of birth?

DAY ____
MONTH ____
YEAR _____

204) CHECK 203:
CHILD BORN IN JANUARY 2009 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE BIRTHS, GO TO INTERVIEW)

205) WEIGHT IN KILOGRAMS

KG ____.____

NOT PRESENT 99.94
REFUSED 99.95
OTHER 99.96

206) HEIGHT IN CENTIMETERS
IF LESS THAN 2 YEARS, MEASURE CHILD LYING DOWN, IF NOT, STANDING UP.

CM ____.____

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203:
IS CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN END INTERVIEW)
OLDER 2

209) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD TABLE RECORD '00' IF NOT LISTED.

LINE NUMBER_______

210) ASK CONSENT FOR ANEMIA TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop and set up programs to prevent and treat anemia.

We ask that all children born in 2009 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.

Will you allow (NAME OF CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN____)
REFUSED 2 (SIGN____)
REFUSED 5
OTHER 6

212) Ask for consent for the malaria test from the parent/other adult identified in 209 as responsible for child.

As part of this survey, we are asking people all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop and set up programs to prevent and treat malaria.

We ask that all children born in 2009 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use the blood from the anemia test).

The blood will be tested for malaria immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.

Will you allow (NAME OF CHILD) to participate in the malaria test?

213) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN____)
REFUSED 2 (SIGN____)
REFUSED 5
OTHER 6

214) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEXTS THAT YOU GOT CONSENT FOR AND CONTINUE WITH THE TESTS.

215) BAR CODE LABEL FOR MALARIA TEST

PUT THE 1ST BAR CODE LABEL HERE. PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

216) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA AND MALARIA PACKET.

G/DL____.___

ABSENT 994
REFUSED 995
OTHER 996

217) RECORD TDR MALARIA RESULT CODE [TDR=RAPID DIAGNOSTIC TEST]

TESTED 1
ABSENT 2 (GO TO 219)
REFUSED 3 (GO TO 219)
OTHER 6 (GO TO 219)

218) RECORD TDR MALARIA RESULT CODE HERE AND IN ANEMIA AND MALARIA PAMPHLET.

POSITIVE FALCIPARUM 1 (GO TO 221)
POSITIVE ESPECES (OMV) 2 (GO TO 221)
POSITIVE P (F AND OMV) 3 (GO TO 221)
NEGATIVE 4
OTHER 6

219) CHECK 216: HEMOGLOBIN LEVEL

BELOW 8.0 G/DL SEVERE ANEMIA 1
8.0 G/DL OR HIGHER 2 (GO TO 232)

NOT PRESENT 4 (GO TO 232)
REFUSED 5 (GO TO 232)
OTHER 6 (GO TO 232)

220) REFERENCE DECLARATION FOR SEVERE ANEMIA
The anemia diagnostic test shows that (NAME OF CHILD) has severe anemia. You child is seriously ill and needs to be taken to a health care establishment immediately.
(GO TO 232)

221) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms?
IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y

A EXTREME WEAKNESS?
B HEART PROBLEMS?
C LOSS OF CONSCIOUSNESS?
D RAPID OR DIFFICULTY BREATHING?
E CONVULSIONS?
F ABNORMAL BLEEDING?
G JAUNDICE/YELLOW SKIN?
H DARK URINE?
Y NO SYMPTOMS

222) CHECK 221:
IS A CODE A-H CIRCLED?

CODE(S) A-H CIRCLED 1 (GO TO 224)
CODE 'Y' CIRCLED 2

223) CHECK 216:
HEMOGLOBIN LEVEL

UNDER 6.0 G/DL 1
6.0 D/DL OR HIGHER 2 (GO TO 225)
NOT PRESENT 4 (GO TO 225)
REFUSED 5 (GO TO 225)
OTHER 6 (GO TO 225)

224) REFERENCE DECLARATION FOR SERIOUS MALARIA

The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. You child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and needs to be taken to a health care establishment immediately.
(GO TO 231)

225) In the last two weeks, has (NAME) taken or is (NAME) taking CTA [##translator note: CTA is an antimalarial drug, combination therapy] given to him/her by a doctor or health care establishment to treat malaria?
CHECK BY ASKING TO SEE THE TREATMENT.

YES 1
NO 2 (GO TO 227)

226) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.

You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to a nearby health care establishment for further testing.
(GO TO 231)

227) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.

The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

228) CIRCLE THE APPROPRIATE CODE AND SIGN.

DRUG ACCEPTED (SIGN ____) 1
REFUSED 2 (GO TO 231)
OTHER 6 (GO TO 231)

230) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST

CHILD LESS THAN ONE YEAR OLD OR LESS THAN 8 KGS: 25 MG TABLET OF ARTESUNATE AND 67.5 MG OF AMODIAQUINE (ROSE STRIPED BROCHURE)

DAY 1 (1 TABLET) _____
DAY 2 (1 TABLET) _____
DAY 3 (1 TABLET) _____

CHILD AGE 1-5 YEARS OR 8-17 KGS: 50 MG TABLET OF ARTESUNATE AND 135 MG OF AMODIAQUINE (PURPLE STRIPED BROCHURE)

DAY 1 (1 TABLET) _____
DAY 2 (1 TABLET) _____
DAY 3 (1 TABLET) _____

TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: IF (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you will bring him/her to a health professional for treatment immediately.

231) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET

DRUG GIVEN 1
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TAKING CTA 4
OTHER 6

232) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRES(S); IF THERE ARE NO MORE, END THE INTERVIEW.

[##translator note: questions 202-232 repeated for child 4-6]