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CONTINUED DEMOGRAPHIC AND HEALTH SURVEY (EDS - CONTINUED 2015) - HOUSEHOLD QUESTIONNAIRE

REPUBLIC OF SENEGAL
MINISTRY OF THE ECONOMY, FINANCE, AND PLANNING
MINISTRY OF HEALTH AND SOCIAL ACTION

ICF INTERNATIONAL

IDENTIFICATION

PLACE NAME ____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER ______
HOUSEHOLD PLOT NUMBER ______
CLUSTER NUMBER ____
REGION ____

URBAN/RURAL

URBAN 1
RURAL 2

LOCATION

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

LOCATION (detail) _______

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*

FINAL VISIT

DAY _____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT*

NEXT VISIT:

DATE ______
TIME _____

TOTAL NUMBER OF VISITS __________

*RESULT CODES:

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)

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 now?

SIGNATURE OF INTERVIEWER __________
DATE _____
RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100) RECORD THE TIME

HOURS ________
MINUTES _________

HOUSEHOLD SCHEDULE

1) 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 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-2c to be sure that the listing is complete.

Then ask appropriate questions in columns 5-20 for each person.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
DON'T KNOW 98

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 ____________

IF AGE 15 OR OLDER

8) MARITAL STATUS

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 AGE 15-49

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

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

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

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'.

________.

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'.

___________

IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL

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

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the (2014-2015) school year?

YES 1
NO 2 (GO TO 19A)

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

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

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 ______

GRADE ______

IF AGE 0-4 YEARS
BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

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

Just to make sure that I have a complete listing:

2A) 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

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?

NURSERY SCHOOL [EDUCATIONAL] 1
NURSERY SCHOOL [NON-EDUCATIONAL] 2
PRIMARY SCHOOL 3
DAARA, KORAN, ARAB [RELIGIOUS SCHOOL, ISLAM] 4
COMMUNITY CENTER 5
OTHER 96

20F) For how many years?

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

SELECTION OF A SINGLE CHILD 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 252)
NONE (GO TO 100 292)

TABLE 1: CHILDREN AGE 5-17 YEARS ELIGIBLE FOR QUESTIONS REGARDING CHILDREN'S "WORK"
Record each child age 5-17 years below in the same order from the household registration sheet. Do not include members of the household whose age is outside of 5-17 years.
Record the line number, name, sex and age for each child.
Then record the total number of children age 5-17 years in the space provided (Q 20M)

20h) RANK NUMBER

RANK __

20i) LINE NUMBER FROM Q1

LINE NUMBER________

20j) FIRST NAME FROM Q2

FIRST NAME _______

20k) SEX FROM Q4

MALE 1
FEMALE 2

20L) AGE FROM Q7

AGE ________

20M. TOTAL NUMBER OF CHILDREN AGE 5-17 YEARS

TOTAL __________

TABLE 2: RANDOM SELECTION OF THE CHILD FOR QUESTIONS ON "WORK"

Use this table to select one of the children between 5 and 17 years.

a) Check the last digit of the household number from the cover page.
b) This is the line number to select.
c) Check the total number of eligible children in Q. 20M.
d) This is the column number to select.
e) Find the space where the line and column meet and circle the number.
f) This is the rank number of the child chosen for "work."

EXAMPLE:
The household number is 36: Select line 6.
There are three eligible children in this household. Select column 3.
The space where the line 6 and column 3 intersect has the number 2: The second eligible child listed in the household table will be selected. If the line number of the three eligible children is 07, 11, and 16, the child selected is the second one listed, then it is the one with line number 11.

20N) [see PDF for table]

20o) RECORD THE RANK (Q20H), THE LINE NUMBER (Q20I), THE NAME (Q20J), AND THE AGE (Q20L) OF THE SELECTED CHILD.

RANK OF CHILD ___
LINE NUMBER OF CHILD ____
NAME OF CHILD _____
AGE OF CHILD_____

20P) Now I would like to talk to you about all the work that the children in this household can do.

Since (DAY OF THE WEEK), did (NAME) do any of the following activities, even if it was just for an hour?

a) Did (NAME) work on his or her own field/farm/garden or help with the household's or tended to animals? For example: make grow products at the farm, harvest, feed animals, take them to pasture, or milk them?

b) Did (NAME) help with the family business, that of other relatives, with or without payment or worked for his or her own company?

c) Did (NAME) produce, sell anything, artisanal products, clothes, food, or agricultural products?

d) Since (DAY OF THE WEEK), was (NAME) involved in any other kind of activity in exchange for payment in cash or in kind, even for just one hour?

IF NO, PROBE.
Please, include any type of activity that (NAME) might have done as regular or temporary work, for his/her own company or as an employee, or as an unpaid family worker to help in the affairs of the home or farm.

WORKED IN FIELD/FARM/GARDEN OR TENDED TO ANIMALS
YES 1
NO 2
HELPED IN FAMILY BUSINESS/BUSINESS OF OTHER RELATIVE/IN HIS OR HER OWN BUSINESS
YES 1
NO 2
PRODUCED/SOLD ANYTHING/ARTISANAL PRODUCTS /CLOTHS/ FOOD/ AGRICULTURAL PRODUCTS
YES 1
NO 2
ANY OTHER ACTIVITIES
YES 1
NO 2

20q) CHECK 20 A TO D:

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

20r) Since last (DAY OF THE WEEK), approximately how many hours did (NAME) spend working on (this activity/these activities)? IF LESS THAN ONE HOUR, RECORD '00'.

NUMBER OF HOURS _________

20S) Did (this activity/these activities) require carrying large loads?

YES 1 (GO TO 20V)
NO 2

20T) Did (this activity/these activities) require working with dangerous tools (knives, etc.) or to run 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 the cold, the heat, or to extreme humidity?
YES 1 (GO TO 20V)
NO 2
C. Is (NAME) exposed to loud noises or intense vibrations?
YES 1 (GO TO 20V)
NO 2
D. Is (NAME) exposed to working at an elevated height?
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, procedures, or conditions that are bad for his/her health or safety?
YES 1 (GO TO 20V)
NO 2

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

YES 1
NO 2 (GO TO 20X)

20W) In total, since last (DAY OF WEEK), how many house has (NAME) spent fetching water or collecting firewood for the household? IF LESS THAN ONE HOUR, RECORD 00.

NUMBER OF HOURS __________

20x) Since last (DAY OF WEEK), has (NAME) performed any of the following household tasks:

a) shopping for the household?
b) fixed any type of household equipment?
c) cooked or cleaned utensils or the house?
d) washed clothes?
e) took care of children?
f) took care of elderly or sick people?
g) any other chores?

SHOPPING FOR HOUSEHOLD
YES 1
NO 2
FIX EQUIPMENT
YES 1
NO 2
COOK/CLEANED UTENSILS/HOUSE
YES 1
NO 2
WASHED CLOTHES
YES 1
NO 2
TOOK CARE OF CHILDREN
YES 1
NO 2
TOOK CARE OF ELDERLY OR SICK PEOPLE
YES 1
NO 2
OTHER HOUSEHOLD TASKS
YES 1
NO 2

20Y) CHECK 20W, A TO G:

LESS THAN ONE YES (GO TO 20Z)
NOT A SINGLE YES (GO TO 101A)

20Z) Since last (day of the week), approximately how many hours did (NAME) spend doing this activity/these activities? IF LESS THAN ONE HOUR, RECORD '00'.

NUMBER OF HOURS ________

HOUSEHOLD CHARACTERISTICS

101a) What is the ownership/tenant status of 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 104B)
PIPED INTO YARD/PLOT 12 (GO TO 104B)
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 104B)
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 104B)
IN OWN YARD/PLOT 2 (GO TO 104B)
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 the water source to fetch the water for your household?

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

104B) Has it happened that in the last two weeks that water wasn't available at this water source for at least the entire day?

YES 1
NO 2
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.

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

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

107a) Where is this toilet facility located?

IN OWN DWELLING 1
IN OWN YARD/PLOT 2
ELSEWHERE 3

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?

NUMBER 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 video/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 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 car?
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 OR 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?
________
Camels?
______
Horses, donkeys, or mules?
_______
Goats?
______
Sheep?
_____
Pigs?
_____
Poultry?
_______

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

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

YES 1
NO 2

123B) Have you sent funds to a place in Senegal or internationally?

SENEGAL 1
INTERNATIONALLY 2
NO 3
DON'T KNOW 8

123C) Have you received funds from a place in Senegal or internationally?

SENEGAL 1
INTERNATIONALLY 2
NO 3 (GO TO 124)
DON'T KNOW 8 (GO TO 124)

123D) What was the origin of the cash transfer?

STATE PROGRAM A
PRIVATE STRUCTURE/NGO/COMPANY B
POVERTY-FIGHTING PROGRAM C
RELATIVES/FRIENDS D
OTHER (SPECIFY) _____ X

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

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

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 NETS 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 aren't there mosquito nets that can be used in your household?

PROBLEM OF RESOURCES A (GO TO 136A)
NOT NECESSARY B (GO TO 136A)
USE SOMETHING ELSE C (GO TO 136A)
DON'T HAVE MOSQUITOS D (GO TO 136A)
DON'T LIKE NETS E (GO TO 136A)
OTHER (SPECIFY) _____ X (GO TO 136A)
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'. RECORD THE NUMBER 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 (SPECIFY) ____ 16 (GO TO 134)
OTHER TREATED MOSQUITO NET
K-ONET 21 (GO TO 132)
NETTO 22 (GO TO 132)
SENTINELLE 23 (GO TO 132)
OTHER (SPECIFY) _____ 26 (GO 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'.
ENTER THE NUMBER OF MONTHS

MONTHS AGO _______
MORE THAN 24 MONTHS AGO 95
NOT 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 having 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
RELATIVES/NEIGHBORS/FRIENDS 08
OTHER (SPECIFY) _____07
DON'T KNOW 88

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

PRICE ____________
DON'T KNOW 9998

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

Q. 130: LLIN: (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?

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

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 no 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 the household most frequently wash their hands?

UPON LEAVING THE TOILET A
AFTER EATING B
AFTER PREPARING MEALS C
AFTER TAKING CARE OF CHILDREN D
AFTER WASHING CHILDREN E

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

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

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

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) ______ 6

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

YES 1
NO 2 (GO TO 201)

142) 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

SELECTION OF A SINGLE WOMAN FOR "TOBACCO USE"

20g) CHECK COLUMN (5) AND (7): NUMBER OF RESPONDENTS AGED 15 OR OLDER LIVING IN THIS HOUSEHOLD:

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

Table 1: woman aged 15 years or older eligible for questions regarding "tobacco use"
Record each woman aged 15 years or older below in the same order from the household registration sheet. Do not include members of the household whose age is under 15 years.
Record the line number, name, sex and age for each woman.
Then record the total number of woman aged 15 years or older in the space provided (Q. 20M)

20h) RANK NUMBER

Rank ____

20i) LINE NUMBER FROM Q. 1

_____

20j) FIRST NAME FROM Q. 2

NAME ______

20k) SEX FROM Q. 4

MALE 1
FEMALE 2

20l) AGE FROM Q. 7

AGE _____

20m. TOTAL NUMBER OF WOMEN AGED 15 YEARS OR OLDER

TOTAL _____

TABLE 2: RANDOM SELECTION OF THE WOMAN FOR QUESTIONS ON "TOBACCO USE"
Use this table to select one of the woman aged 15 years or older.

a) Check the last digit of the household number from the cover page.
b) This is the line number to select.
c) Check the total number of eligible women in Q. 20M.
d) This is the column number to select.
e) Find the space where the line and column meet and circle the number.
f) This is the rank number of the woman chosen for "tobacco use."

Example:
The household number is 36: Select line 6.
There are three eligible women in this household. Select column 3.
The space where the line 6 and column 3 intersect has the number 2: The 2nd eligible woman listed in the household table will be selected. If the line number of the three eligible women is 07, 11, and 16, the woman selected is the 2nd one listed, then it is the one with line number 11.

20N) [see pdf for table]

20O) RECORD THE RANK (Q. 20H), THE LINE NUMBER (Q. 20I), THE NAME (Q. 20J), AND THE AGE (Q. 20L) OF THE SELECTED WOMAN.

RANK OF WOMAN _____
LINE NUMBER OF WOMAN _____
NAME OF WOMAN _____
AGE OF WOMAN _____

SELECTION OF A SINGLE MAN FOR "TOBACCO USE"

900g) CHECK COLUMN (5) AND (7): NUMBER OF RESPONDENTS AGED 15 OR OLDER LIVING IN THIS HOUSEHOLD:

TWO OR MORE (CONTINUE)
ONLY ONE (GO TO 2900G)
NONE (END)

Table 1: man aged 15 years or older eligible for questions regarding "tobacco use"
Record each man aged 15 years or older below in the same order from the household registration sheet. Do not include members of the household whose age is under 15 years.
Record the line number, name, sex and age for each man.
Then record the total number of man aged 15 years or older in the space provided (Q. 900F)

900b) RANK NUMBER

RANK ____

900c) LINE NUMBER FROM Q. 1

_____

900d) NAME FROM Q. 2

NAME ______

900E) AGE FROM Q. 7

AGE _____

9000E) TOTAL NUMBER OF MAN AGED 15 YEARS OR OLDER

TOTAL ____

TABLE 2: RANDOM SELECTION OF THE MAN FOR QUESTIONS ON "TOBACCO USE"

Use this table to select one of the man aged 15 years or older.

a) Check the last digit of the household number from the cover page.
b) This is the line number to select.
c) Check the total number of eligible men in Q. 900E.
d) This is the column number to select.
e) Find the space where the line and column meet and circle the number.
f) This is the rank number of the man chosen for "tobacco use."

Example:
The household number is 26: Select line 6.
There are three eligible men in this household. Select column 3.
The space where the line 6 and column 3 intersect has the number 2: The 2nd eligible man listed in the household table will be selected. If the line number of the three eligible men is 07, 11, and 16, the man selected is the 2nd one listed, then it is the one with line number 11.

900F) [see pdf for table]

900G) RECORD THE RANK (Q. 900B), THE LINE NUMBER (Q. 900C), THE NAME (Q. 900D), AND THE AGE (Q. 900E) OF THE SELECTED MAN.

RANK OF MAN _____
LINE NUMBER OF MAN _____
NAME OF MAN _____
AGE OF MAN _____

WEIGHT, HEIGHT, ANEMIA AND MALARIA TESTS 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 birth day?

DAY _____
MONTH _____
YEAR _____

204) CHECK 203:
CHILD BORN IN JANUARY 2010 OR LATER?

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

205) WEIGHT IN KILOGRAMS

KG _____
NOT PRESENT 99.94
REFUSED 99.95
OTHER 99.96

206) HEIGHT IN CENTIMETERS
IF UNDER 2 YEARS OLD, MEASURE THE CHILD LYING DOWN, OTHERWISE, 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 SCHEDULE). 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 2010 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?

NAME FROM COLUMN 2 _____

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______
REFUSED 2 (SIGN) ______
NOT PRESENT 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 2010 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. A few drops will be preserved on a slide or two and sent to a lab to be tested. You will not receive the results of the lab test. 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) ______
NOT PRESENT 5
OTHER 6

214) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) THAT YOU GOT CONTENT FOR AND CONTINUE WITH THE TESTS.

215) BAR CODE LABEL FOR MALARIA TEST
PUT THE 1ST BAR CODE LABEL HERE

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

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

G/DL _____
NOT PRESENT 994
REFUSED 995
OTHER 996

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

TESTED 1 (GO TO 219)
NOT PRESENT 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 show that (NAME OF CHILD) has severe anemia. You child is seriously ill and must 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

EXTREME WEAKNESS A
HEART PROBLEMS B
LOSS OF CONSCIOUSNESS C
RAPID OR DIFFICULTY BREATHING D
CONVULSIONS E
ABNORMAL BLEEDING F
JAUNDICE/YELLOW SKIN G
DARK URINE H

NONE OF ABOVE SYMPTOMS Y

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

ONE CODE A-H CIRCLED 1 (GO TO 224)
ONLY 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 must 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 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 the closest 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 1 (SIGN) _______
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)
CHILD AGE 1-5 YEARS OR 8-17 KGS.
50 MG TABLET OF ARTESUNATE AND 135 MG OF AMODIAQUINE (PURPLE STRIPED BROCHURE)

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 MUST TAKE 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 TOOK CTA 4
OTHER 6

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