Confidential
Ministry of Planning and of Territory Construction
Household Questionnaire
Republic of Togo
REGION ________
PREFECTURE________
CITY/ADMINISTRATIVE DISTRICT ________
RURAL 2
VILLAGE/NEIGHBORHOOD _______
CLUSTER NUMBER ______
PLOT NUMBER ________
HOUSEHOLD NUMBER _______
NAME OF HEAD OF HOUSEHOLD ________
NO 2
LINE NUMBER OF PERSON INTERVIEWED FOR HOUSEHOLD QUESTIONNAIRE ______
DATE______
INTERVIEWER'S NAME_________
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) __________ 9
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ______
MONTH ________
YEAR 1998
NAME ______
RESULT _______
TOTAL IN HOUSEHOLD _________
TOTAL ELIGIBLE WOMEN _________
TOTAL ELIGIBLE MEN ______
LANGUAGE OF INTERVIEW
2 EWE
3 COTOKOLI
4 KABYE
5 MOBA
6 OTHER
NO 2
SUPERVISOR
NAME______
DATE________
FIELD EDITOR
NAME_______
DATE_______
OFFICE EDITOR______
KEYED BY__________
Now we would like information about the people who usually live in your household or who are currently staying with you now.
1) LINE NUMBER _____________
2) USUAL RESIDENTS AND VISITORS: Please give me the name 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.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of household?
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-WIFE 09
OTHER RELATIVE 10
ADOPTED CHILD 11
FOSTER CHILD 12
NOT RELATED 13
DON'T KNOW 98
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) stay here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
7) AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'
EDUCATION: IF AGE 5 YEARS OR OLDER
8) Has (NAME) ever been to school?
NO 2
9) What is the highest level of education that (NAME) attended?
What was the highest grade that he or she completed at this level?
SECONDARY DEGREE 2
TERTIARY DEGREE 3
HIGHER 4
DON'T KNOW 8
10) IF LESS THAN 25 YEARS OLD: Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
11) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
12) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD THE MOTHER'S LINE NUMBER
13) Is (NAME)'s natural father still alive?
NO 2
DON'T KNOW 8
14) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
MARK THE FATHER'S LINE NUMBER
15a) WOMEN'S ELIGIBILITY: CIRCLE THE LINE NUMBER OF WOMEN AGE 15-49
15b) MEN'S ELIGIBILITY: CIRCLE THE LINE NUMBER OF MEN AGE 15-49
TOTAL NUMBER OF ELIGIBLE WOMEN___________
TOTAL NUMBER OF ELIGIBLE MEN___________
Just to make sure that I have a complete listing:
1) Are there any other people such as small children or infants who we have not listed?
NO
2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night that have not been listed?
NO
16) Now I would like to ask you some questions about your household.
What is the main source of drinking water for members of your household?
PIPED ELSEWHERE 12
PUBLIC TAP 13
PROTECTED WELL OR PIPE 22
UNPROTECTED WELL 23
RIVER/BACKWATER/MARSHLAND 32
OTHER RAINWATER 42
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 17)
OTHER (SPECIFY) __________ 96
16B) What is the distance between this source and your house?
1 KM OR LESS 2
MORE THAN 1 KM 3
DON'T KNOW 8
17) What kind of toilet facility does your household have?
OPEN LATRINE 22
SEPTIC PIT 23
AIRTIGHT PIT 24
OTHER (SPECIFY) __________ 96
18) In your household, how many rooms do you use to sleep?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
20) MAIN MATERIAL OF ROOF
RECORD OBSERVATION
SHEET METAL 21
TILES/ALUMINUM 22
EARTH 31
STRAW 41
OTHER (SPECIFY) __________ 96
21) MAIN MATERIAL OF FLOOR
RECORD OBSERVATION
CEMENT 11
EARTH 21
WOOD 31
OTHER (SPECIFY) __________ 96
22) MAIN MATERIAL OF WALLS
RECORD OBSERVATION
EARTH 21
BAMBOO/PLANKS/BRANCHES 31
SEMI-HARD 41
OTHER (SPECIFY) __________ 96
23) We would like to check whether the salt you use contains iodine or not. Can we see a sample of the salt that you use in your cooking?
TEST THE SALT
NO IODINE 2
NO SALT IN HOME 3