COTE D'IVOIRE 1998-99
HOUSEHOLD QUESTIONNAIRE
NATIONAL STATISTICAL INSTITUTE
REPUBLIC OF IVORY COAST
DEPARTMENT___
SUB PREFECTURE___
CENSUS DISTRICT___
CLUSTER NUMBER___
STRUCTURE NUMBER___
HOUSEHOLD NUMBER___
OTHER CITIES 2
RURAL 3
NO 2
NAME OF HEAD OF HOUSEHOLD: ___
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
HOUSEHOLD ABSENT 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 [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
HOUSEHOLD ABSENT 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 NUMBER OF RESPONDENT FOR HOUSEHOLD QUESTIONNAIRE: ___
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 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
FATHER OR MOTHER 06
FATHER-IN-LAW OR MOTHER-IN-LAW 07
BROTHER OR SISTER 08
ADOPTED/FOSTER CHILD 09
STEPCHILD 10
NEPHEW OR NIECE 11
COUSIN 12
OTHER RELATIVE 13
NOT RELATED 14
DON'T KNOW 98
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?
F 2
IF 95 YEARS OR MORE, RECORD '95'.
8) EDUCATION:
IF AGE 6 YEARS OR OLDER:
Has (NAME) ever been to school?
NO 2 (GO TO 15)
9) IF ATTENDED SCHOOL:
What is the highest level of school (NAME) has attended?
SECONDARY, 1ST CYCLE 2
SECONDARY, 2ND CYCLE 3
HIGHER 4
DK 8
What is the highest grade (NAME) completed at that level?
CP2 2
CE1 3
CE2 4
CM1 5
CM2 6
DK 8
5TH 2
4TH 3
3RD 4
DK 8
1ST 2
FINAL 3
DK 8
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR OR MORE 5
DK 8
10) IF LESS THAN 25 YEARS:
Is (NAME) still in school?
NO 2
15) WOMEN'S ELIGIBILITY:
CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15 - 49.
15A) MEN'S ELIGIBILITY:
CIRCLE THE LINE NUMBER OF ALL MEN 15 - 59.
(IF MEN'S SURVEY IS PLANNED IN THIS HOUSEHOLD)
TICK HERE IF CONTINUATION SHEET USED: ___
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 many 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) What is the main source of drinking water for members of your household?
PUBLIC TAP 13
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51 (GO TO 18)
OTHER (SPECIFY): ___ 96
17) How long does it take to go there, get water, and come back?
ON PREMISES 996
18) What kind of toilet facility does your household have?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY): ___ 96
Electricity?
A radio?
A television?
A telephone?
A refrigerator?
A portable stove/gas stove/electric stove?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
20) How many rooms in your household are used for sleeping?
21) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
TILES 32
OTHER FINISHED 33
22) Does any member of your household own:
A bicycle?
A motorcycle or moped?
A car?
NO 2
NO 2
NO 2