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

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

INTERVIEWER'S NAME ______
DATE _____
RESULT

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: FRENCH 01

LANGUAGE OF INTERVIEW:

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

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 _____

100) RECORD THE TIME.

HOUSEHOLD SCHEDULE

1) 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-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?

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

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

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

IF AGE 15 OR OLDER

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

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:

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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

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?

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?

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

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

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2015-2016) school year?

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

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

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

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?

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?

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

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

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?

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

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

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

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

HOUSEHOLD CHARACTERISTICS

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

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

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

103) Where is the water source located?

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

104A) Who usually goes to the water source to fetch the water for your household?

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

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

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

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

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

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

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

112) Where is this toilet facility located?

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

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

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

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

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

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

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?

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

121) Does your household have:

122) Does any member of your household own:

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

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

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

123C) Have you (or any member of your family) received funds from a place in Senegal or internationally?

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

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

126) Who sprayed the dwelling?

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

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

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

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

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

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

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

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

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).

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.

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.

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

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

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.

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

135) Where did you get the net?

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

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.

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

137B) CHECK 136:

137C) Why did no one sleep under this mosquito net last night?
IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN ONE.

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

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

137F) a-- Has this mosquito net been washed since you obtained it?
b-- Has this mosquito net been washed since it was last soaked?

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

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

137I) What are these other purposes?

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

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?

138B) How many?

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?

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

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

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

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

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

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

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.

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

145B) What was the main event for your household?

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

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

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

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

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

155) RECORD THE TIME.

SELECTION TABLE FOR WOMEN AND MEN FOR THE DOMESTIC VIOLENCE MODULE

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

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

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).

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)

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 ___________________________