HOUSEHOLD QUESTIONNAIRE
PLACE NAME _____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION _____
VILLAGE _____
RURAL 2
OTHER CITY 2
RURAL 3
ANEMIA TEST/HIV TEST/MEN'S QUESTIONNAIRE:
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD 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 2003
INT. NUMBER _____
RESULT _____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ______ 9
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____
SUPERVISOR
NAME _____
DATE _____
FIELD EDITOR
NAME _____
DATE _____
OFFICE EDITOR _____
KEYED BY _____
We would like some information about people who usually live in your household or are staying with you now.
01. LINE NUMBER:
02. 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.
03. 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 CHILD ADOPTED/BEING TAKEN CARE OF
10 CHILD OF PARTNER
11 NIECE OR NEPHEW
12 COUSIN
13 OTHER RELATIVE
14 NOT RELATED
98 DOESN'T KNOW
04. SEX: Is (NAME) male or female?
FEMALE 2
05. RESIDENCE: Does (NAME) usually live here?
NO 2
06. RESIDENCE: Did (NAME) stay here last night?
NO 2
ELIGIBILITY:
08. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
ELIGIBILITY:
08A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.
ELIGIBILITY:
09. CIRCLE LINE NUMBER OF ALL CHILDREN LESS THAN 6 YEARS OLD.
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF LESS THAN 15 YEARS:
10. Is (NAME)'s natural mother alive?
NO 2
DOESN'T KNOW 8
11. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name? IF NO, RECORD '00'.
12. Is (NAME)'s natural father alive?
NO 2
DOESN'T KNOW 8
13. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name? IF NO, RECORD '00'.
EDUCATION, IF AGE 5 YEARS OR OLDER:
14. Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE/PERSON)
15. What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level? (SEE CODES BELOW)
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
98 DOESN'T KNOW
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
5 FPP
98 DOESN'T KNOW
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
4 FPB
98 DOESN'T KNOW
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
98 DOESN'T KNOW
16. Is (NAME) currently attending school?
IF THE INTERVIEW HAPPENS DURING A SCHOOL VACATION, USE THE FOLLOWING WORDING: Did (NAME) attend school during the school year that has just finished?
NO 2
17. Has (NAME) attended school at any time during the current school year?
IF THE INTERVIEW HAPPENS DURING A SCHOOL VACATION, USE THE FOLLOWING WORDING: Did (NAME) ever attend school at any time during the school year that has just finished?
NO 2 (GO TO 19)
18. During this school year, what level and grade is/was (NAME) attending?
IF THE INTERVIEW HAPPENS DURING A SCHOOL VACATION, USE THE FOLLOWING WORDING: During the school year that has just finished, what level and grade did (NAME) attend?
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
98 DOESN'T KNOW
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
5 FPP
98 DOESN'T KNOW
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
4 FPB
98 DOESN'T KNOW
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
98 DOESN'T KNOW
19. Did (NAME) attend school at any time during the previous school year?
NO 2 (GO TO NEXT LINE/PERSON)
20. During that school year, what level and grade did (NAME) attend?
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
98 DOESN'T KNOW
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
5 FPP
98 DOESN'T KNOW
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
4 FPB
98 DOESN'T KNOW
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
98 DOESN'T KNOW
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
21. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 23)
PUBLIC TAP/STANDPIPE 13
IN THE YARD/PLOT 22 (GO TO 23)
PUBLIC 23
IN THE YARD/PLOT 32 (GO TO 23)
PUBLIC 33
RIVER 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) ______ 96
22. How long does it take to go there, get water, and come back?
ON SITE 996
23. What kind of toilet facility do most members of your household use?
VENTILATED IMPROVED PIT LATRINE 22
OTHER (SPECIFY) _____ 96
24. Do you share this toilet facility with other households?
NO 2
Electricity?
A radio?
A television?
A telephone?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
WOOD 07
DUNG 08
OTHER (SPECIFY) _____ 96
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
28. Does any member of this household own:
A donkey cart?
A bicycle?
A motorcycle or motor scooter?
A car or truck?
NO 2
NO 2
NO 2
NO 2
Now I would like to ask you some questions about mosquito netting.
29. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 33)
29A. How many mosquito nets do you have in your household?
29B. ASK RESPONDENT TO SHOW YOU THE MOSQUITO NETS. ASK THE FOLLOWING QUESTIONS FOR EACH NET. IF THERE ARE MORE THAN 3 NETS, USE AN ADDITIONAL QUESTIONNAIRE.
29C. How long has your household had (net number...)?
THREE YEARS OR MORE 96
29D. OBSERVE OR ASK BRAND OF MOSQUITO NET.
OLYSET 12 (GO TO 29H)
SERENA 13 (GO TO 29H)
DELTA METHRINE 22
CYFULTHRINE 23
DOESN'T KNOW BRAND 28
DOESN'T KNOW/NOT SURE 98
(NOTE: "PERMANENT" MOSQUITO NET MEANS IT IS TREATED IN A PERMANENT MANNER. "PRE-TREATED" MEANS IT WAS TREATED BUT WILL HAVE TO BE TREATED AGAIN AFTER 6-12 MONTHS.)
29E. Since you have had the mosquito net, have you dipped it or soaked it in a liquid to repel mosquitos or insects?
NO 2 (GO TO 29H)
DOESN'T KNOW/NOT SURE 8 (GO TO 29H)
29F. How much time has passed since the net was dipped/soaked for the last time?
IF LESS THAN 1 MONTH, RECORD '00'.
3 YEARS OR MORE 96
29G. Has the mosquito net been washed since the last time it was treated?
NO 2
DOESN'T KNOW/NOT SURE 8
29H. Last night, did someone sleep under this mosquito net?
NO 2 (GO TO 31A)
DOESN'T KNOW/NOT SURE 8 (GO TO 31A)
31. Who slept under this mosquito net last night?
RECORD THE LINE NUMBER ACCORDING TO THE LIST OF HOUSEHOLD MEMBERS. REPEAT FOR ALL WHO SLEPT UNDER NET.
31A. RETURN TO 29B FOR THE NEXT NET; OR, IF NO MORE NETS IN HOUSEHOLD, CONTINUE TO 33.
33. In your household, where do you usually wash your hands?
ELSEWHERE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)
34. ASK TO SEE THE PLACE MOST OFTEN USED FOR HANDWASHING AND CHECK TO SEE IF THE FOLLOWING OBJECTS ARE FOUND THERE:
NO 2
NO 2
NO 2
35. ASK RESPONDENT FOR A TEASPOONFUL OF THE SALT USED FOR HOUSEHOLD NEEDS, THEN TEST THE SALT TO IDENTIFY THE PRESENCE OF IODINE. RECORD PPM (PARTS PER MILLION).
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HOUSEHOLD 5
SALT NOT TESTED 6
ANEMIA TEST NO (GO TO OBSERVATIONS)
HEIGHT, WEIGHT, AND HEMOGLOBIN LEVEL MEASUREMENT
CHECK COLUMNS 8 AND 9: RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
36. LINE NUMBER FROM COLUMN 8:
FOR CHILDREN UNDER AGE 6 ONLY:
39. What is (NAME'S) date of birth?
FOR CHILDREN UNDER AGE 6 ONLY:
42. MEASURED LYING DOWN OR STANDING UP?
STANDING 2
NOT PRESENT 2
REFUSED 3
OTHER 6
TICK HERE IF CONTINUATION SHEET USED ____
MEASURE OF HEMOGLOBIN LEVEL IN WOMEN 15-49 YEARS.
44. VERIFY COLUMN 38:
AGE 18-49 YEARS 2 (GO TO 46)
45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
DECLARATION OF CONSENT FOR ANEMIA TEST:
As part of this survey, we would like to know anemia levels in women and children. Anemia is a serious health problem that is caused by poor nutrition. The results of this survey will help the government to put in place programs to treat and prevent anemia.
We would like you (and all of your children born in 1998 or later) to participate in the anemia test by giving a few drops of blood from your finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. Results are confidential.
Now, can you tell me if you agree to participate in the anemia test?
46. READ CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT:
CIRCLE CODE AND SIGN.
REFUSED 2 (GO TO NEXT LINE)
NO/DOESN'T KNOW 2
NOT PRESENT 2
REFUSED 3
OTHER 6
[GO BACK AND COMPLETE 44-49 FOR ALL WOMEN AGE 15-49 YEARS.]
MEASURE OF HEMOGLOBIN LEVEL IN CHILDREN BORN IN 1998 OR LATER
FOR EACH CHILD, ASK QUESTIONS 45, 46, 47 AND 49:
45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
DECLARATION OF CONSENT FOR ANEMIA TEST:
As part of this survey, we would like to know anemia levels in women and children. Anemia is a serious health problem that is caused by poor nutrition. The results of this survey will help the government to put in place programs to treat and prevent anemia.
We would like you (and all of your children born in 1998 or later) to participate in the anemia test by giving a few drops of blood from your finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. The results are confidential.
Now, can you tell me if you agree to participate in the anemia test?
46. READ CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT:
CIRCLE CODE AND SIGN.
REFUSED 2 (GO TO NEXT LINE)
NOT PRESENT 2
REFUSED 3
OTHER 6
MEASURE OF HEMOGLOBIN LEVEL IN MEN 15-59 YEARS
CHECK COLUMN 8A OF HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME AND AGE OF ALL MEN AGE 15-59.
49A. LINE NUMBER FROM COLUMN 9:
AGE 18-59 YEARS 2 (GO TO 49F)
49E. LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
DECLARATION OF CONSENT FOR ANEMIA TEST:
As part of this survey, we would like to know anemia levels in women and children. Anemia is a serious health problem that is caused by poor nutrition. The results of this survey will help the government to put in place programs to treat and prevent anemia.
We would like to participate in the anemia test by giving a few drops of blood from your finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. The results are confidential.
Now, can you tell me if you agree to participate in the anemia test?
49F. READ CONSENT STATEMENT TO THE MAN OR PARENT/RESPONSIBLE ADULT.
CIRCLE CODE AND SIGN.
REFUSED 2 (GO TO NEXT LINE)
NOT PRESENT 2
REFUSED 3
OTHER 6
TICK HERE IF CONTINUATION SHEET USED ____
50. CHECK 47 AND 49G:
NUMBER OF USUAL RESIDENTS WITH HEMOGLOBIN LEVEL UNDER THE CRITICAL THRESHOLD:
CRITICAL THRESHOLD IS 9 G/DL FOR PREGNANT WOMEN AND 7 G/DL FOR CHILDREN AND WOMEN WHO ARE NOT PREGNANT OR DON'T KNOW IF THEY ARE PREGNANT.
IF THERE IS MORE THAN ONE WOMAN OR CHILD THAT FALLS BELOW THE CRITICAL THRESHOLD, READ THE STATEMENT IN 51 TO EACH WOMAN BELOW THE CRITICAL THRESHOLD AND EACH WOMAN/PARENT/RESPONSIBLE ADULT OF THE CHILD THAT FALLS BELOW THE CRITICAL THRESHOLD.
NONE: GIVE RESULTS OF HEMOGLOBIN TEST TO EACH WOMAN/PARENT/RESPONSIBLE ADULT AND THAT IS THE END OF THE HOUSEHOLD QUESTIONNAIRE.
51. We have detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD/CHILDREN). This indicates that (you/NAME OF CHILD/CHILDREN) is/are severely anemic, which is a serious health problem. We would like to inform the doctor at _____ of (your/NAME OF CHILD'S/CHILDREN'S) state. This will help you to obtain the appropriate treatment for the condition.
Do you consent to this information about the hemoglobin level in (your blood/the blood of NAME OF CHILD/CHILDREN) being sent to the doctor?
REPEAT FOR AS MANY PEOPLE AS APPLICABLE.
WOMEN AGE 18-49 AND MEN AGE 18-59:
NAME OF PERSON SITUATED BELOW CRITICAL THRESHOLD:
CONSENT TO INFORMATION BEING SENT:
NO 2
MEN AND WOMEN AGE 15-17 AND CHILDREN UNDER 5:
NAME OF PERSON SITUATED BELOW CRITICAL THRESHOLD:
NAME OF PARENT/RESPONSIBLE ADULT:
CONSENT TO INFORMATION BEING SENT
NO 2
TOTAL NUMBER OF BLOOD DRAWS:
CHECK COLUMNS 8 AND 8A OF HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME, SEX AND AGE OF ALL WOMEN AGE 15-49 AND ALL MEN AGE 15-59. THIS FILE MUST BE DESTROYED AT THE OFFICE BEFORE THE TEST RESULTS ARE SENT TO THE EDS DATABASE.
52. LINE NUMBER FROM COLUMN 8 OR 8A:
FEMALE 2
18 OR OLDER 2 (GO TO 59)
57. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
INTRODUCTION OF CONSENT STATEMENT FOR HIV TEST TO PARENT/RESPONSIBLE ADULT:
Hello, my name is (YOUR NAME) and I work for the National Institute of Demography and Statistics, which is organizing this national survey on women and children's health. Within the context of the survey, we are inviting all men and women in the country to give a few drops of blood from their fingertip.
HIV is the virus that causes AIDS. AIDS is a serious illness, and often fatal. We are in the process of performing HIV tests in order to measure the seriousness of AIDS in Burkina Faso. For the HIV test, we need a few drops of blood from one of your fingertips. To take these drops of blood as part of the survey, we use completely disinfected and risk-free instruments.
The blood sample will then be sent to a laboratory to be analyzed. No name will be attributed or linked to the result. As such, we will not be able to give you the results of the analysis. No one else will be able to know the results of your blood analysis, either.
Do you have any questions?
You may accept or refuse to participate in the test. The choice is up to you.
Now, will you allow (NAME OF YOUTH AGE 15-17) to participate in the HIV test?
58. READ CONSENT STATEMENT TO PARENT OR RESPONSIBLE ADULT.
CIRCLE THE CODE AND SIGN.
REFUSED 2
NOT READ 3
INTRODUCTION OF CONSENT STATEMENT FOR HIV TEST:
Hello, my name is (YOUR NAME) and I work for the National Institute of Demography and Statistics, which is organizing this national survey on women and children's health. Within the context of the survey, we are inviting all men and women in the country to give a few drops of blood from their fingertip.
HIV is the virus that causes AIDS. AIDS is a serious illness, and often fatal. We are in the process of performing HIV tests in order to measure the seriousness of AIDS in Burkina Faso. For the HIV test, we need a few drops of blood from one of your fingertips. To take these drops of blood as part of the survey, we use completely disinfected and risk-free instruments.
The blood sample will then be sent to a laboratory to be analyzed. No name will be attributed or linked to the result. As such, we will not be able to give you the results of the analysis. No one else will be able to know the results of your blood analysis, either.
Do you have any questions?
You may accept or refuse to participate in the test. The choice is up to you.
Now, will you participate in the HIV test?
59. READ CONSENT STATEMENT TO THE WOMAN/MAN/YOUNG PERSON.
CIRCLE THE CODE (AND SIGN).
REFUSED 2
NOT READ 3
REFUSED 2
NOT PRESENT 3
TECHNICAL PROBLEM 4
OTHER (SPECIFY) ______ 6
61. BAR CODE LABEL:
ATTACH THE FIRST BAR CODE LABEL HERE.
ATTACH THE SECOND TO THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMISSION OF BLOOD DRAW FORM.
[GO BACK TO 52 AND REPEAT FOR AS MANY INDIVIDUALS AS NECESSARY BEFORE CONTINUING.]
TO BE FILLED OUT AFTER COMPLETING THE QUESTIONNAIRE. (IF THE QUESTIONNAIRE WAS NOT FILLED OUT, EXPLAIN) _____
NAME OF THE INTERVIEWER _____
DATE _____
SUPERVISOR'S OBSERVATIONS (TO BE FILLED OUT AFTER CHECKING THE QUESTIONNAIRE) _____
NAME _____
DATE _____
TEAM LEADER'S OBSERVATIONS (TO BE FILLED OUT AFTER CHECKING THE QUESTIONNAIRE) _____
NAME _____
DATE _____