PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER ______
CLUSTER NUMBER _____
VILLAGE/SECTOR _____
HOUSEHOLD UNIT NUMBER _____
OUAGA, BOBO/KOUD, OTHER CITIES, OR RURAL?
BOBO/KOUD 2
OTHER CITIES 3
RURAL 4
NAME OF PERSON INTERVIEWED ______
LINE NUMBER OF RESPONDENT FROM HOUSEHOLD QUESTIONNAIRE _____
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
MOORE 2
DIOULA 3
FULFULDE 4
OTHERS 5
NO 2
SUPERVISOR
NAME ______
DATE ______
FIELD EDITOR
NAME ______
DATE ______
KEYED BY (NAME) _____
KEYED BY (DATE) _____
KEYED BY (CODE) _____
We would like some information about people who usually live in your household or are staying with you now.
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.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 HUSBAND OR WIFE
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 CHILDREN ADOPTED/BEING TAKEN CARE OF
12 NOT RELATED
98 DOESN'T KNOW
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. RESIDENCE: Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
FEMALE 2
7. AGE: How old is (NAME)?
IF 97 OR OLDER, RECORD '97'.
EDUCATION, IF AGE 6 YEARS OR OLDER:
8. Has (NAME) ever attended school?
NO 2 (GO TO 11)
9. IF ATTENDED: What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SECONDARY (FIRST CYCLE) 2
SECONDARY (SECOND CYCLE) 3
POST-SECONDARY 4
DOESN'T KNOW 8
1 CP 1
2 CP 2
3 CE 1
4 CE 2
5 CH 1
6 CH 2
8 DOESN'T KNOW
1 6TH
2 5TH
3 4TH
4 3RD
5 FPP
8 DOESN'T KNOW
1 2ND
2 1ST
3 THIRD
4 FPS
8 DOESN'T KNOW
1 FIRST YEAR
2 SECOND YEAR
3 THIRD YEAR
4 FOURTH YEAR
8 DOESN'T KNOW
EDUCATION, IF LESS THAN 25 YEARS:
10. IF ATTENDED: Is (NAME) still attending school?
NO 2
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS FOR PERSONS YOUNGER THAN 15 YEARS:
11. Is (NAME)'s natural mother alive?
NO 2 (GO TO 13)
DOESN'T KNOW 8 (GO TO 13)
12. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
13. Is (NAME)'s natural father alive?
NO 2 (GO TO 15)
DOESN'T KNOW 8 (GO TO 15)
14. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
MARITAL STATUS, FOR PERSONS 15 YEARS AND OLDER:
15. Is (NAME) currently married/in a union, widowed, divorced/separated, or single?
WIDOWED 2
DIVORCED/SEPARATED 3
SINGLE 4
ELIGIBILITY OF WOMEN:
16. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49. (SEE 6 AND 7)
17. LINE NUMBER OF HUSBANDS:
INDICATE THE LINE NUMBER OF THE HUSBAND OF EACH ELIGIBLE WOMAN.
IF NOT MARRIED OR IF HUSBAND DOES NOT RESIDE IN THE HOUSEHOLD, RECORD '00'.
ELIGIBILITY OF MEN:
18. MEN'S QUESTIONNAIRE?
IF YES, CIRCLE LINE NUMBER OF ALL MEN AGE 18 AND OLDER. (SEE 6 AND 7).
NO ____
CHECK HERE IF ANOTHER SHEET IS USED AND NOTE THE SHEET NUMBER ON THE FIRST PAGE. ______
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO
2) 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 other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
18. What is the main source of water used by your household for hand washing and dish washing?
PUBLIC TAP/STANDPIPE 12
PUBLIC WELL/BORE HOLE 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
WATER VENDOR 51
BOTTLED WATER 61 (GO TO 20)
OTHER (SPECIFY) _____ 71
19. How long does it take to go there, get water, and come back?
ON SITE 996
20. Does your household use the same water for drinking purposes?
NO 2
21. What is the main source of drinking water for members of your household?
PUBLIC TAP/STANDPIPE 12
PUBLIC WELL/BORE HOLE 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
WATER VENDOR 51
BOTTLED WATER 61
OTHER (SPECIFY) _____ 71
22. What kind of toilet facility does your household use?
SHARED FLUSH TOILET 12
PUBLIC FLUSH TOILET 13
VENTILATED IMPROVED PIT LATRINE 22
OTHER (SPECIFY) ______ 41
Electricity?
A radio?
A television?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
24. In your household, how many rooms do you use for sleeping?
25. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
EARTH 12
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
26. Does any member of this household own:
A bicycle?
A motorcycle or motor scooter?
A car?
NO 2
NO 2
NO 2