PLACE NAME (COMMUNE/VILLAGE) _____
NAME OF HEAD OF HOUSEHOLD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____
REGION_____
RURAL 2
LARGE CITIES (THIES, KAOLACK, ZIGUINCHOR, SAINT-LOUIS, DJOURBEL) 2
CITY (OTHER COMMUNES) 3
COUNTRYSIDE (RURAL) 4
NAME/LINE NUMBER OF RESPONDENT ON THE HOUSEHOLD SHEET:
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS):
DATE____
INTERVIEWER NAME______
RESULT*___
NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ____ 9
NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 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 _____
INTERVIEWER_____
RESULT*_____
NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT 2
HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME 3
POSTPONED 4
REFUSED 5
EMPTY DWELLING OR NO DWELLING AT THE ADDRESS 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ____ 9
TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____
SUPERVISOR
NAME_____
DATE_____
FIELD EDITOR
NAME_____
DATE_____
OFFICE EDITOR_____
KEYED BY______
Now I would like information on the people who usually live in your household or who are currently visiting your household.
1. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)
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 slept 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
GRANDSON OR GRANDDAUGHTER 05
FATHER OR MOTHER 06
FATHER-IN-LAW OR MOTHER-IN-LAW 07
BROTHER OR SISTER 08
CO-WIFE 09
OTHER RELATIVE 10
FOSTERED CHILD 11
ADOPTED CHILD 12
NOT RELATED 13
DOESN'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?
FEMALE 2
7. AGE: How old is (NAME)?
RECORD '97' FOR 97 YEARS OR MORE.
EDUCATION. IF 6 YEARS OR MORE:
8. Has (NAME) attended school?
NO 2 (GO TO NEXT LINE)
9. What is the highest level of education attained by (NAME)?
What is the last grade completed by (NAME) at this level?
SECONDARY 2
SUPERIOR 3
DOESN'T KNOW 8
DOESN'T KNOW 98
EDUCATION. IF LESS THAN 25 YEARS OLD:
10. Does (NAME) currently attend school?
NO 2
SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:
11. Is (NAME)'s biological mother still alive?
NO 2 (GO TO 13)
DOESN'T KNOW 8
12. IF ALIVE: Does (NAME)'s biological mother live in the household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
13. Is (NAME)'s biological father still alive?
NO 2 (GO TO 15)
DOESN'T KNOW 8
14. IF ALIVE: Does (NAME)'s biological father live in the household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
15. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN RESIDENTS OR VISITORS BETWEEN 15-49 YEARS. (SEE QUESTIONS 5, 6 AND 7)
16. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL MEN RESIDENTS OR VISITORS AGED 20 YEARS OR MORE. (SEE QUESTIONS 5, 6 AND 7)
MARK HERE IF ANOTHER SHEET WAS USED____
TOTAL NUMBER OF ELIGIBLE PEOPLE____
Just to be sure that I have a complete list:
1) Are there other persons such as small children or infants that we have not recorded on the list?
NO
2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?
NO
3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?
NO
17. What is the main source of water that the members of your household use to wash their hands and to wash the dishes?
PUBLIC TAP/STANDPIPE 12
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
TANKER 51
BOTTLED WATER 61 (GO TO 19)
OTHER (SPECIFY) ____ 71
18. How long does it take to go there, get water, and come back?
ON SITE 996
19. Do the members of your household get water from the same source to drink?
NO 2
20. From where does the drinking water for your household come?
PUBLIC TAP/STANDPIPE 12
OPEN PUBLIC WELL 22
PROTECTED WELL 23
SWAMP/LAKE/POND 32
SPRING 33
DAM 34
TANKER 51
BOTTLED WATER 61
OTHER (SPECIFY) ____ 71
21. What kind of toilet facility do the members of your household use?
COMMUNAL FLUSH 12
LATRINES 22
OTHER (SPECIFY) ____41
Electricity?
Radio?
Television?
Refrigerator or freezer?
Video?
NO 2
NO 2
NO 2
NO 2
NO 2
23. How many rooms in your household do you use to sleep in?
24. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.
DUNG 12
VINYLE OR LINO/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
25. Is there anyone in your household who owns:
A bicycle?
A scooter or motorcycle?
A car?
NO 2
NO 2
NO 2
26. END OF HOUSEHOLD QUESTIONNAIRE.
MINUTES___