HOUSEHOLD QUESTIONNAIRE
DEPARTMENT
SUB-PREFECTURE/URBAN DISTRICT
RURAL/URBAN MUNICIPALITY
VILLAGE/DISTRICT
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
NAME OF HEAD OF HOUSEHOLD _________________
NO 2
LINE NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME_____
RESULT**___
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 ____
NAME ____
RESULT__
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHER 8
NO 2
SUPERVISOR
NAME ___________________
DATE_______
FIELD EDITOR
NAME ___________________
DATE _______
OFFICE EDITOR ____
KEYED BY ____
Now we would like some information about the people who usually live in your household or who 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?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
MOTHER-IN-LAW OR FATHER-IN-LAW 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
ADOPTED CHILD 11
FOSTER CHILD 12
NOT RELATED 13
DON'T KNOW 98
4) RESIDENCE: 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
EDUCATION IF AGE 3 YEARS OR OLDER:
8) Has (NAME) ever attended school?
NO 2
9) IF ATTENDED SCHOOL: What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?
PRIMARY 2
SECONDARY 3
HIGHER 4
DON'T KNOW 8
10) Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD***
***Q.11 TO Q.14:
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
RECORD 91 IF THE PARENTS DO NOT LIVE IN THE HOUSEHOLD BUT LIVE IN THE LOCALITY;
92: IF THE PARENTS LIVE IN ANOTHER LOCALITY IN BENIN;
93: IF THE PARENTS LIVE ABROAD
11) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
12) IF ALIVE: Does (NAME)'s natural mother usually live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
13) Is (NAME)'s natural father 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?
RECORD FATHER'S LINE NUMBER.
15a) WOMEN'S ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
15b) MEN'S ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 20-64
TICK HERE IF CONTINUATION SHEET USED ___
TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD ____
TOTAL NUMBER OF ELIGIBLE MEN IN HOUSEHOLD ____
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) 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 stayed here last night, who 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/STANDPIPE 13
PROTECTED WELL/WITH NOZZLE 22
UNPROTECTED WELL 23
RIVER/BACKWATER/POND 32
OTHER RAINWATER 42
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 17)
OTHER (SPECIFY) _____________ 96
16B) How far is this source from your house?
LESS THAN 1 KILOMETER 2
MORE THAN 1 KILOMETER 3
DON'T KNOW 8
17) What kind of toilet facility do members of your household usually use?
UNCOVERED LATRINE 22
SEPTIC PIT/SEALED PIT 23
OTHER (SPECIFY) _____________ 96
CHARCOAL 21
ELECTRICITY 31
GAS 41
PETROLEUM 51
OTHER (SPECIFY) _____________ 96
19) ENERGY METHOD FOR LIGHTING
PETROLEUM 21
GAS 22
OIL 31
OTHER (SPECIFY) _______________ 96
20) How many rooms in your household are used for sleeping?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
23) EVACUATION OF USED WATER (FROM HOUSEHOLD)
SEPTIC TANK 21
OUTDOORS 31
IN COURTYARD 41
OTHER (SPECIFY) _____________ 96
24) EVACUATION OF HOUSEHOLD WASTE
BURIED 21
OUTDOORS 31
BURNED 41
OTHER (SPECIFY) ______________ 96
25) OCCUPATION STATUS: Are you the owner, a renter, or on family property, or something else?
RENTER 21
FAMILY PROPERTY 31
OTHER (SPECIFY) ____________ 96
26) MATERIAL OF ROOF
RECORD OBSERVATION
TILE 21
EARTH 31
STRAW 41
OTHER (SPECIFY) ____________ 96
27) FLOORING MATERIAL
RECORD OBSERVATION
EARTH 21
WOOD 31
OTHER (SPECIFY) ____________ 96
28) MATERIAL OF WALLS
RECORD OBSERVATION
EARTH 21
BAMBOO 31
PARTLY HARD MATERIAL 41
OTHER (SPECIFY) ___________ 96
29a) We would like to check if the salt that you use has iodine or not. Can we see a sample of the salt you use in your cooking?
INTERVIEWER: TEST SALT
SALT WITHOUT IODINE 2
NO SALT IN HOUSEHOLD (END)
29b) TYPE OF SALT?
RECORD OBSERVATION
GRANULATED SALT (SOFT OR HARD) 2
PIECED SALT 3
OTHER (SPECIFY) ___________ 6
29c) CHECK TO SEE IF THE CONTAINER THAT HOLDS THE SALT IS CLOSED OR OPEN
CONTAINER OPEN 2
OTHER (SPECIFY) ____________ 6