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CONTINUED DEMOGRAPHIC AND HEALTH SURVEY (EDS - CONTINUED 2016)
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 _____

PLOT NUMBER ______

CLUSTER NUMBER ____

REGION ____

DEPARTMENT ____

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

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

INTERVIEWER'S NAME ______
DATE _____
RESULT*

*RESULT CODES

1 COMPLETED
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)

FINAL VISIT:
DAY ____
MONTH ___
YEAR ____
INTERVIEW NUMBER ____
RESULT* _____

NEXT VISIT:
DATE _____
TIME ____

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF QUESTIONNAIRE: 01

LANGUAGE OF INTERVIEW:

01 FRENCH
02 WOLOF
03 POULAR
04 SERER
05 MANDINGUE
06 DIOLA
07 OTHERS

NATIVE LANGUAGE OF RESPONDENT

01 FRENCH
02 WOLOF
03 POULAR
04 SERER
05 MANDINGUE
06 DIOLA
07 OTHERS

TRANSLATOR USED

YES 1
NO 2

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
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100) RECORD THE TIME.

HOURS ____
MINUTES _____

HOUSEHOLD SCHEDULE

1) LINE NUMBER

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?

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 _____

IF AGE 15 OR OLDER

8) MARITAL STATUS
What is (NAME)'s current marital status?

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

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

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

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

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'.

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 _____

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20FA)

17) What is the highest level of school (NAME) has attended?

PRIMARY 1
MIDDLE 2
SECONDARY 3
HIGHER 4
PRESCHOOL 5
DON'T KNOW 8

What is the highest grade (NAME) completed at that level?

LESS THAN ONE YEAR COMPLETED 00

CI (FIRST YEAR, PRIMARY) 01
CP (SECOND YEAR, PRIMARY) 02
CE1 (THIRD YEAR, PRIMARY) 03
CE2 (FOURTH YEAR, PRIMARY) 04
CM1 (FIFTH YEAR, PRIMARY) 05
CM2 (SIXTH YEAR, PRIMARY) 06

SIXTH 07
FIFTH 08
FOURTH 09
THIRD 10

SECOND 11
FIRST 12
FINAL 13

FIRST YEAR 14
SECOND YEAR 15
THIRD YEAR 16
FOURTH YEAR OR HIGHER 17

DON'T KNOW 98

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2015-2016) 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
MIDDLE 2
SECONDARY 3
HIGHER 4
PRESCHOOL 5
DON'T KNOW 8
GRADE ____

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

YES 1
NO 2 (GO TO 20FA)

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

CARE FOR CHILDREN AGE 3-5

20D) During this school year, did (NAME) attend any type of student/child monitoring entities outside the home, like a preschool, an early childhood development program, a community center, or other?

YES 1
NO 2

20E) What establishment did (NAME) attend?
RECORD THE APPROPRIATE CODE.

PRESCHOOL 01
KINDERGARTEN 02
EARLY CHILDHOOD DEVELOPMENT PROGRAM 03
DAARA (RELIGIOUS), CORAN, ARABIC SCHOOL 04
COMMUNITY CENTER 05
OTHER 96

20F) For how many years?
RECORD THE APPROPRIATE CODE.

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

UNIVERSAL HEALTH COVERAGE FOR ALL MEMBERS OF THE HOUSEHOLD

Now I would like to ask you some questions about universal health coverage.

20FA) Does (NAME) benefit from a health insurance plan? What type?

COM. HEALTH INSURANCE A
PROF. HEALTH INSURANCE B
COMPL. HELATH INSURANCE C
DISEASE PREVENTION INSTITUTION HEALTH INSURANCE D (GO TO 20FC)
BUDGET ALLOCATION E (GO TO 20FC)
PRIVATE INSURANCE F (GO TO 20FC)
RETIREE HEALTH INSURANCE (PRES) G (GO TO 20FC)
RETIREE HEALTH INSURANCE (FNR) H (GO TO 20FC)
CARE FOR CHILDREND AGE 0-4 I (GO TO 20FC)
PLAN FOR AGE 60+ J (GO TO 20FC)
NONE Y (GO TO 20FC)

20FB) Who primarily pays for the health insurance dues?

SAME ADHERE (NAME) ________ 1
SAME, PERSON IN CHARGE (NAME) __________ 2
HOUSEHOLD MEMBER 3
OTHER RELATIVE (OUT OF THE HOUSEHOLD) 4
PTF/NGO/PRIVATE 5
STATE: FAMILY SAFETY/SECURITY GRANT 6
STATE: EQUAL OPPORTUNITY CARD 7
LOCAL COLLECTIVE 8
OTHER 9

20FC) Over the last 12 months, has (NAME) had a need for health care?

YES 1
NO 2

20FD) Did you (or did someone else in the household) pay for (NAME)'s last consultation?

YES 1
NO 2 (GO TO 101A)

20FE) What was (NAME)'s portion of payment of the last consultation?

PAID IN FULL BY SYSTEM 1
PAID IN FULL BY HOUSEHOLD 2
PARTIALLY PAID BY SYSTEM 3
TOTALLY/PARTIALLY PAID BY SOMEONE ELSE 4
DON'T KNOW 8

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

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED INTO YARD/PLOT 12 (GO TO 106)
PIPED FROM NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 103)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARREL 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER/INDUSTRIALIZED BAG 91
OTHER (SPECIFY) _____ 96 (GO TO 103)

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED INTO YARD/PLOT 12 (GO TO 106)
PIPED FROM NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/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 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

105) CHECK 101 AND 102: CODE 14 OR 21 CIRCLED

YES (GO TO 106)
NO (GO TO 107)

106) In the past two weeks, was the water from this source not available for at least one full day?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 109)
DON'T KNOW 8 (GO TO 109)

108) 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

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 112A)
OTHER (SPECIFY) _____ 96

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

YES 1
NO 2 (GO TO 112)

111) Including your own household, how many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ____
10 OR MORE HOUSEHOLD 95
DON'T KNOW 98

112) Where is this toilet facility located?

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

112A) What is the main source of lighting for your household?

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

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

ELECTRICITY 01
LPG 02
WOOD COAL 03
WOOD, STRAW 04
ANIMAL DUNG 05
MUD 06

NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 116)
OTHER (SPECIFY) _____ 96

114) 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 116)
OUTDOORS 3 (GO TO 116)
OTHER (SPECIFY) _____ 6 (GO TO 1160

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

YES 1
NO 2

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

ROOMS _____

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

YES 1
NO 2 (GO TO 119)

118) 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?

_____

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 your household have:

a) Electricity?
YES 1
NO 2
b) A radio?
YES 1
NO 2
c) A television?
YES 1
NO 2
d) A MMDS/TV5 antenna?
YES 1
NO 2
e) A subscription to Canal?
YES 1
NO 2
f) A non-mobile telephone?
YES 1
NO 2
g) A mobile telephone?
YES 1
NO 2
h) A washing machine?
YES 1
NO 2
i) A refrigerator?
YES 1
NO 2
j) A portable stove/gas or electric stove?
YES 1
NO 2
k) An improved fireplace?
YES 1
NO 2
l) A video/CD/DVD player?
YES 1
NO 2
m) An air conditioner?
YES 1
NO 2
n) A computer?
YES 1
NO 2
o) Internet at home?
YES 1
NO 2

122) Does any member of your household own:

a) A bicycle?
YES 1
NO 2
b) A motorcycle or motor scooter?
YES 1
NO 2
c) A personal car?
YES 1
NO 2
d) A commercial car or truck?
YES 1
NO 2
e) A cart?
YES 1
NO 2
f) A plow?
YES 1
NO 2
g) A canoe/or fishing nets?
YES 1
NO 2

123) Does any member of this household have a bank account or an account in another financial institution?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

123B) Have you (or any member of your household) sent funds to a place in Senegal or internationally?

SENEGAL 1
INTERNATIONALLY 2
NO 3
DON'T KNOW 8

123C) Have you (or any member of your family) 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)

124) Does anyone in your household smoke? Would you say daily, weekly, monthly, less than monthly, or never?

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

125) 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 (GO TO 126A)
DON'T KNOW 8 (GO TO 126A)

126) Who sprayed the dwelling?

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

126A) Are the windows in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

YES 1
NO 2
DON'T KNOW 8

126B) Are the doors in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 128D)

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

NUMBER OF NETS _____

128A) Do you use mosquito nets outside of the bedrooms: for example, in the yard, under trees?

YES 1
NO 2

128B) Do members of your household sleep under the mosquito nets continuously throughout the year?

YES 1 (GO TO 129)
NO 2
DON'T KNOW/DON'T RECALL 8

128C) Why do members of your household not sleep under the mosquito nets continuously throughout the year?

NOT MANY MOSQUITOES 1 (GO TO 129)
BECAUSE OF THE HEAT 2 (GO TO 129)
DON'T LIKE 3 (GO TO 129)
FORGOT/NEGLIGENCE 4 (GO TO 129)
OTHER (SPECIFY) _____ 6 (GO TO 129)
DON'T KNOW/DON'T RECALL 8 (GO TO 129)

128D) Why aren't there mosquito nets that can be used in your household?

PROBLEM OF RESOURCES A (GO TO 139)
NOT NECESSARY B (GO TO 139)
USE SOMETHING ELSE C (GO TO 139)
DON'T HAVE MOSQUITOES D (GO TO 139)
DON'T LIKE E (GO TO 139)
OTHER (SPECIFY) _____ X (GO TO 139)
DON'T KNOW Y (GO TO 139)

MOSQUITO NETS

129) 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

130) 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

131) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

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

131A) 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 you get the net through a [local name of mass distribution campaign], during an antenatal care visit, or during an immunization visit?

YES, [NAME OF MASS DIST. CAMPAIGN] 1 (GO TO 136)
YES, ANC (GO TO 136)
YES, IMMUNIZATION 3 (GO TO 136)
NO 4

135) Where did you get the net?

GOVERNMENT HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
DISTRIBUTION CAMPAIGN 07
OCB/ASSOCIATE 08
OTHER 96
DON'T KNOW 98

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

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

137) 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 _____

137A) Was the net modified after having been obtained?

YES 1
NO 2
DON'T KNOW 8

137B) CHECK 136:

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

137C) 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

137D) How much did you pay for the mosquito net?
RECORD IN CFA FRANCS.

PRICE ____
DON'T KNOW 9998

137E) CHECK 131 AND 132:
LLIN OR OTHER TYPE OF MOSQUITO NET.

Q131: LLIN (GO TO 137Fa)
Q131: CODE 1 (GO TO 137Fb)
Q132: CODES 2 OR 8 (GO TO 137Fa)

137F) 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 137H)
DON'T KNOW/UNSURE 8 (GO TO 137H)

137G) How many times has this mosquito net been washed in the last 12 months?

NUMBER OF WASHES _____
DON'T KNOW/UNSURE 98

137H) Have you ever used this mosquito net for any purpose other than for sleeping?

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

137I) 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

137J) Have you ever tried to fix a hole in this mosquito net?

YES 1
NO 2
DON'T KNOW/UNSURE 8

138) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138A.

138A) Over the last 12 months, have there been mosquito nets in the household that are no longer there?

YES 1
NO 2 (GO TO 139)
DON'T KNOW/NOT SURE 8 (GO TO 139)

138B) How many?

NUMBER ____

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139) We would like to learn about the palaces that households use to watch their hands. Can you please show me where members of your household most often wash their hands?

OBSERVED, FIXED PLACE 1
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (GO TO 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (GO TO 142)
NOT OBSERVED, OTHER REASON 5 (GO TO 142)

139A) When do members of your household wash their hands most often?

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

140) OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

141) OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR DISHWASHING.
RECORD OBSERVATION.

SOAP OR DETERGENT (IN A PIECE, POWDER, OR LIQUID) A
ASH, MUD, SAND B
NONE Y

142) OBSERVE MAIN MATERIALS OF THE FLOOR IN THE DWELLING.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALMS/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ____ 96

143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED FLOORING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) ____ 96

144) OBSERVE MAIN MATERIALS OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
BAMBOO/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 21
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) 96

145) I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?
TEST SALT FOR IODINE.

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

145A) In the last three years, has there been any event that affected life in your household?

YES 1
NO 2 (GO TO 150)

145B) 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

SOCIAL TRANSFERS

150) I would like to ask you some questions about various external economic assistance programs provided for households. By external help, I mean support that comes from the government or non-governmental organizations, such as religious, charitable, or community organizations. This excludes the support of the family, other relatives, friends or neighbors.

TYPE OF SUPPORT

FAMILY SAFETY NET GRANT A
STUDENT GRANT B
OTHER STATE TRANSFER C
PRIVATE STRUCTURE PROGRAM/NGO D
ALL OTHER PROGRAMS OFFERING EXTERNAL SUPPORT (SPECIFY) ______ E

151) Do you know of (NAME OF PROGRAM)?

YES 1
NO 2 (GO TO 151 IN THE NEXT COLUMN)
E (GO TO 155)

152) Has your household or any member of your household received support from (NAME OF PROGRAM)?

YES 1
NO 2 (GO TO 151 IN NEXT COLUMN) (E: GO TO 155)
DON'T KNOW 8 (GO TO 151 IN NEXT COLUMN) (E: GO TO 155)

153) How long as it been since you or your household member had or had received support from (NAME OF PROGRAM)?
IF LESS THAN 1 MONTH, CIRCLE '1' AND RECORD '00' IN MONTH
IF LESS THAN 12 MONTHS, CIRCLE '1' AND RECORD IN MONTHS
IF ONE YEAR/12 MONTHS OR MORE, CIRCLE '2' AND RECORD IN YEARS

MONTHS _____ 1
YEARS _____ 2
DON'T KNOW 998

154) GO BACK TO 151 IN NEXT COLUMN. (E: GO TO 155)

155) RECORD THE TIME.

HOURS___
MINUTES ____

SELECTION TABLE FOR WOMEN AND MEN FOR THE DOMESTIC VIOLENCE MODULE

155A) CHECK THE COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE:

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE
HOUSEHOLD NOT SELECTED FOR DOMESTIC VIOLENCE MODULE (END)

156) CHECK COLUMN 9 OF THE HOUSEHOLD TABLE: NUMBER OF ELIGIBLE WOMEN

2 OR MORE ELIGIBLE WOMEN
1 ELIGIBLE WOMAN (GO TO 157A)
NO ELIGIBLE WOMEN (END)

TABLE 1: Women between 15 and 49 eligible for questions on domestic violence
Record each woman aged 15-49 years from household schedule onto table below in order based on her line number (Q1) from household schedule. Do not include other members of the household who are not women age 15-49. Record the name, age and line number of each woman. Then record the total number of women age 15-49 in the blank space (Q 157).

RANK NUMBER _____
NAME OF WOMAN FROM Q2 _______
AGE FROM Q7 _____
LINE NUMBER _____

157) TOTAL WOMEN AGE 15-49 IN HOUSEHOLD

______

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON DOMESTIC VIOLENCE
Use this table to select one woman age 15-49, if there is more than one in the household.

a) Take the last digit of the household number from the cover page.
b) Use this figure as the line number to pick from.
c) Check the total number of eligible women from q. 157
d) Use this figure as the column number to pick from.
e) Find the space that corresponds to the intersection of that line and column and circle the number.
f) This number corresponds to the woman who will be selected for "domestic violence": the 1st, 2nd, 3rd woman, etc.

EXAMPLE:

The household structure number is 36: select line 6
There are 3 eligible women in this household, select column 3.
The intersecting space of line 6 and column 3 is 2: the 2nd eligible woman listed in the household schedule will be selected.
If the line number of the 3 eligible women are 03, 06, and 10, the woman selected is the 2nd woman listed, meaning the one with line number 06.

LAST DIGIT OF HOUSEHOLD NUMBER
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD

157A)

NAME OF WOMAN SELECTED ____________
LINE NUMBER OF WOMAN SELECTED FROM HOUSEHOLD SCHEDULE _____

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT THE INTERVIEW: _______________________

COMMENTS ON SPECIFIC QUESTIONS: ______________________

ANY OTHER COMMENTS: _________________________

SUPERVISOR'S OBSERVATIONS _____________________________

EDITOR'S OBSERVATIONS ___________________________