Ministry of Planning, Development, and Cooperation
National Institute of Statistics, Economic Study, and Demography
Second Demographic and Health survey
Household questionnaire
NAME OF HEAD OF HOUSEHOLD
SUBPREFECTURE
MUNICIPALITY
CLUSTER NUMBER (EDST) __ __ __
STRUCTURE NUMBER __ __ __
HOUSEHOLD NUMBER IN THE STRUCTURE __ __
SEQUENTIAL NUMBER OF SELECTED HOUSEHOLD (01-24 URBAN; 01-33 RURAL) HOUSEHOLD/SEQUENTIAL
URBAN/RURAL
RURAL 2
N'DJAMENA=1; ABECHE/MOUNDOU/SARH=2; OTHER DEPARTMENTAL ADMINISTRATIVE CENTER=3; OTHER SMALL CITIES=4; RURAL=5
INTERVIEWER'S NAME_________
RESULT*
SECOND INTERVIEWER VISIT
INTERVIEWER'S NAME_________
RESULT*
THIRD INTERVIEWER VISIT
INTERVIEWER'S NAME_________
RESULT*
FINAL VISIT
MONTH __ __
YEAR 200_
NAME________
RESULT_______
NEXT VISIT
TIME_______
Total no. of visits
*Result codes
1Completed
2 No household member at home or no competent respondent at home at time of visit
3 Entire household absent for extended period of time
4 Postponed
5 Refused
6 Dwelling vacant or address not a dwelling
7 Dwelling destroyed
8 Dwelling not found
9 Other (Specify)
TOTAL ELIGIBLE WOMEN __ __
TOTAL ELIGIBLE MEN __ __
LINE NO. OF SURVEYED HOUSEHOLD __ __
DATE________
Field editor
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 no.
Usual residents and visitors
2) 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 household.
Relationship to head of household
3) What is the relationship of (NAME) to the head of household?*
Sex
4) Is (NAME) male or female?
FEMALE 2
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) live here last night?
NO 2
7) How old is (NAME)?
If 95 years or more mark '95'
Education
If age 6 years or older
8) Has (NAME) ever attended school?
NO 2 (GO TO 11)
9) What is the highest level of school (NAME) has attended?***
What is the highest grade (NAME) completed at that level?
GRADE __
10) If age 25 or under
Is (NAME) currently attending school?
NO 2
Parental survivorship and residence for persons less than 18 years old**
11) If (NAME)'s natural mother alive?
NO 2 (GO TO A13)
DK 8 (GO TO A13)
12) If Alive: Does (NAME)'s natural mother live in this household? If yes, what is her name? Record mother's line number
13) If (NAME)'s natural father alive?
NO 2 (GO TO A15)
DON'T KNOW 8 (GO TO A15)
14) If Alive
Does (NAME)'s natural father live in this household? If yes, what is his name? Record father's line number
Eligibility
15) Circle the line number of all women age 15-49
15a) Check cover:
IF MEN'S SURVEY = YES
CIRCLE THE LINE NUMBER OF ALL MEN AGE 15-59
*Codes for column 3: Relationship to head of household:
01 HEAD
02 WIFE OR HUSBAND
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 ADOPTED/FOSTER CHILD/STEPCHILD
12 NOT RELATED
98 DON'T KNOW
**Codes for Q. 11 through Q.14
These questions refer to the biological parents of the child.
In Q. 121 and Q. 14, record '00' if parent not listed in household schedule
***codes for q 9
(Including Madrasa)
Level/class
2=CP2
3=CE1
4=CE2
5=CM1
6=CM2
8=DON'T KNOW
2=5TH
3=4TH
4=3RD
5=2ND
6=1ST
7=FINAL
8=DON'T KNOW
2=2ND YEAR
3=3RD YEAR
4=4TH YEAR +
8=DON'T KNOW
2=5TH OR 2ND YEAR
3=4TH OR 3RD YEAR
4=3RD OR 4TH YEAR
5=2ND OR 5TH YEAR
6=1ST OR 6TH YEAR
7=FINAL OR 7TH YEAR
8=DON'T KNOW
2=2ND YEAR
3=3RD YEAR
4=4TH YEAR +
8=DON'T KNOW
DON'T KNOW =8
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 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) CHECK COLUMN 5 AND 7: RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 17 LIVING IN THIS HOUSEHOLD.
NONE (GO TO 26)
17) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 IN THE HOUSEHOLD SCHEDULE
18) RECORD THE NAME OF EACH CHILD
ASK THE FOLLOWING QUESTIONS OF THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 5 CHILDREN, USE A SUPPLEMENTAL QUESTIONNAIRE)
Now I would like to ask you some questions on the types of work that children in your household do.
19) Since last (day of week of interview), did (name) do any work for anyone who is not a member of this household?
IF YES: WAS HE/SHE PAID IN CASH OR IN KIND?
2: YES, NOT PAID
3: NO WORK --SKIP TO 21
20) Since last (day of week of interview), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.
21) In the last 12 months, did (name) do any work for anyone who is not a member of this household?
IF YES: WAS HE/SHE PAID IN CASH OR IN KIND?
2: YES, NOT PAID
3: NO WORK
22) Since (day of week of interview), did (name) help with household chores? For example, doing the dishes, grocery shopping, cleaning, clothes washing, getting water, or watching children?
NO 2 (GO TO 24)
23) Since last (day of week of interview), approximately how many hours did he/she spend doing household chores?
24) Since last (day of week of interview), did (name) do any work on family land or in a family business?
NO 2 (GO TO SKIP LINE)
25) Since last (day of week of interview), approximately how many hours did (name) spend doing this type of work in the fields or for a family business?
26) CHECK COLUMNS 5 AND 7:
Number of children aged 10 and under who usually live in the household
NONE (GO TO 31)
27) RECORD THE LINE NUMBER OF EACH CHILD IN THE ORDER OF COLUMN 1 IN THE HOUSEHOLD SCHEDULE
28) RECORD THE NAME OF EACH CHILD
ASK THE FOLLOWING QUESTIONS OF THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 10 CHILDREN, USE A SUPPLEMENTAL QUESTIONNAIRE)
29) Was (name)'s birth declared to the state?
NO 2 (GO TO NEXT CHILD)
DON'T KNOW 8 (GO TO NEXT CHILD)
30) Was (name)'s birth declared to the state within three months of birth or when (name) was older?
LATER 2
DON'T KNOW 8
Handicap
No.
Questions and filters
Coding categories
Skip
Now I would like to ask some questions about the health of each person usually living in your household, including small children.
31) Is there anyone in your household who is missing a limb, for example, a hand, an arm, a foot, or a leg?
NO 2
DON'T KNOW (GO TO 34)
RECORD THE NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING A LIMB. ASK Q. 33 ABOUT THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(If there are more than 3 people, use an additional questionnaire)
32) Name and line number form q. 1 and q.2
LINE NUMBER______
33) Has (name) had this problem since birth, or is it due to an accident, an illness, or another cause?
IF AN ACCIDENT, PROBE: What type of accident was it?
ROAD ACCIDENT 21
WORK ACCIDENT 22
MINING/ARMY ACCIDENT 23
BURNING ACCIDENT 24
INCORRECTLY DONE CARE/INJECTIONS 25
OTHER ACCIDENT 26
ILLNESS 31
OLD AGE 41
WITCHCRAFT 51
OTHER 61
DON'T KNOW 98
34) Is there anyone in your household with a deformity of an upper or lower extremity and who cannot walk or has difficulty walking and/or using his/her arms or hands?
If yes: Could you tell me the name of these people?
NO 2 (GO TO 38)
RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH A DEFORMITY. ASK Q. 36 AND 37 FOR THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)
35) Name and line number of q. 1 and q. 2
LINE NUMBER______
36) Has (name) had this deformity from birth or was it caused by an accident, and illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
37) Does (name) only have difficulty using his/her arms or legs, or can (name) not use his/her arms or legs at all?
TOTAL HANDICAP 2
38) Is anyone in your household blind or nearly blind?
IF YES: Can you tell me the name of these people?
NO 2 (GO TO 42)
RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH VISION PROBLEMS. ASK Q 40 AND 41 OF THE 1ST PERSON, THEN THE 2ND, ETC.
39) Name and line number from q. 1 and q. 2
LINE NUMBER________
40) Has (name) had vision problems since birth, or were the problems caused by an accident, an illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
41) Does (name) have trouble seeing or is (name) completely blind?
BLIND 2
42) Is there anyone in your household who is almost or completely deaf?
IF YES: Can you tell me the name of these people?
NO 2 (GO TO 46)
Record the name and line number of each person with hearing problems. Ask q. 44 and 45 of the 1st person, then the 2nd person, etc.
43) Name and line number of q. 1 and q. 2
LINE NUMBER_______
44) Did (name) have hearing problems since birth or were they caused by an accident, an illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
45) Does (name) have difficulty hearing or is (name) completely deaf?
DEAF 2
46) Is there anyone in your household that has serious difficulty talking or is mute?
IF YES: Can you tell me the name of these people?
NO 2 (GO TO 50)
RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK. Q. 48 AND 49 FOR THE FIRST PERSON, THEN THE 2ND, ETC.
47) Name and line number from q. 1 and 1. 2
LINE NUMBER__________
48) Has (name) had these problems with talking since birth or were they caused by an accident, an illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
49) Does name have difficulty talking or is (name) completely mute?
MUTE 2
50) Is there anyone in your household who is missing certain bodily extremities, such as finger tips, toes, nose, or ears?
IF YES: Can you tell me the name of these people?
NO 2 (GO TO 54)
RECORD NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING CERTAIN BODY PARTS. ASK Q. 52 AND 53 FOR THE 1ST PERSON, THEN THE 2ND, ETC.
51) Name and line number of q. 1 and q. 2
LINE NUMBER____
52) Has (name) had this problem since birth or was it caused by an accident, an illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
53) Does name have certain extremities that have no feeling?
NO 2
DON'T KNOW 8
54) Does anyone in your household have behavioral problems?
IF YES: Can you tell me the name of these people?
NO 2 (GO TO 58)
RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH BEHAVIORAL PROBLEMS. ASK Q 56 AND 57 FOR THE 1ST PERSON, THEN THE 2ND, ETC.
55) Name and line number from q. 1 and q. 2
LINE NUMBER______
56) Has (name) had this problem since birth or was it caused by an accident, and illness, or another cause?
ACCIDENT 25
INCORRECTLY DONE CARE/INJECTIONS 31
ILLNESS 41
OLD AGE 51
WITCHCRAFT 61
OTHER 71
DON'T KNOW 98
57) Are (name)'s problems mild or serious?
SERIOUS 2
DON'T KNOW 8
58) What is the main source of drinking for members of your household?
PUBLIC TAP 12
WELL WATER IN YARD 21
PUBLIC/COMMUNITY WELL PUMP 22
TRADITIONAL WELL IN YARD 31(GO TO 60)
TRADITIONAL PUBLIC/COMMUNITY WELL 32
UNPROTECTED SPRING 42
RIVER/STREAM/CANAL 43
POND/LACK/BACKWATER 44
WATER SELLER FROM TRADITIONAL WELL 52 (GO TO 60)
WATER SELLER FROM RIVER/STREAM/CANAL 53 (GO TO 60)
WATER SELLER FROM INDETERMINATE SOURCE 54 (GO TO 60)
TANKER TRUCK 71 (GO TO 60)
59) How long does it take you to go there, get water, and come back?
ON PREMISES 996
60) What kind of toilet facilities does your household have?
COMMUNAL FLUSH TOILET 2
VENTILATED IMPROVED PIT LATRINE 3
TRADITIONAL PIT TOILET 4
NO FACILITY/BUSH/FIELD 5
OTHER 6
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
62) What type of lighting does your household mainly use?
GAS LAMP 2
PETROL LAMP 3
TORCH LAMP (WITH BATTERIES) 4
WOOD/STALKS/STRAW 5
TRADITIONAL LAMP (WITH PETROL OR OIL) 6
OTHER 7
63) Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
64) In your household, how many rooms do you use to sleep?
65) Main material of the floor
RECORD OBSERVATION
BRAID/PALMS 2
TILE 3
CEMENT 4
OTHER 6
66) Main material of the walls
RECORD OBSERVATION
SHEET METAL 2
BANCO 3
SEMI-HARD 4
HARD 5
OTHER 6
67) Main material of roof
RECORD OBSERVATION
BANCO 2
SHEET METAL 3
CONCRETE/TILE 4
OTHER 6
68) Does your household have any bednets that can be used while sleeping?
NO 2
69) CHECK COLUMNS 6 AND 7:
Number of children under age 5 who slept in the household last night
ONE (GO TO 70)
TWO OR MORE (GO TO 71)
70) Did (name) sleep under a bednet last night?
NO 2
71) Did all, some, or none of the children under age 5 who slept in the household last night sleep under a bednet?
SOME CHILDREN 2
NONE 3
DON'T KNOW 8
72) ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD RESULTS
IODINE PRESENT (LIGHT COLOR-LESS THAN 15PPM) 2
IODINE NOT PRESENT (NO COLOR) 3
NO SALT AVAILABLE 4
NOT TESTED 5
Interviewer's observations
To be filled in after completing interview
(If the questionnaire is not filled out, explain)
______________________________
______________________________
To be filled in after completing interview
___________________
___________________
Name of supervisor___________
Date______
Editor's observations
To be filled in after completing interview
Name of editor_____________
Date_____