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BFR1 Household Questionnaire

How many times have you visited this household?

[] 1st time
[] 2nd time
[] 3rd time

Your name: Is this your name?
[ODK will display the name associated with the phone's serial number.]
Check the button next to the name if that is your name and select 'yes' here. Do not check the button if that is not your name and select 'no' here (long press to remove response next to the name if needed).
[] Yes
[] No

Enter your name below.
Please record your name

Interviewer's Name _____
Is this date and time correct?
[THE CURRENT DATE AND TIME WILL BE DISPLAYED ON SCREEN]

[] Yes
[] No

D. Record the correct date and time

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

E1. Region

[] Boucle du Mouhoun
[] Cascades
[] Centre
[] Centre-Est
[] Centre-Nord
[] Centre-Ouest
[] Centre-Sud
[] Est
[] Hauts-Bassins
[] Nord
[] Plateau-Central
[] Sahel
[] Sud-Ouest

E2. Province
ODK will populate a list of appropriate provinces based on the selected region.

E3. Commune
ODK will populate a list of appropriate communes based on the selected province.

E4. Enumeration area
ODK will populate a list of appropriate enumeration areas based on the selected commune.

F. Structure number: [#]
Please record the structure number from the household listing form.

G. Household number: [#]
Please record the household number from the household listing form.

CHECK: Have you already sent a form for this structure and household?
DO NOT DUPLICATE ANY FORM UNLESS YOU ARE CORRECTING A MISTAKE IN AN EARLIER FORM.
[] Yes
[] No

CHECK: Why are you resending this form?
Choose all that apply.
[] There are new household members on this form
[] I am correcting a mistake made on a previous form
[] The previous form disappeared from my phone without being sent
[] I submitted the previous form and my supervisor told me that it was not received
[] Other reason(s)

H. Is a member of the household and competent respondent present and available to be interviewed today?

[] Yes
[] No

INFORMED CONSENT
Find a competent member of the household. Read the greeting on the following screen.
Hello. My name is ____________ and I am working for the Institut Supérieur des Sciences de la Population (ISSP). We are conducting a local survey about various health issues in Burkina Faso. Your household has been selected for this survey. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. Whatever information you provide will be kept strictly confidential and will not be shown to anyone other than members of our survey team. Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. I am going to ask you questions about your family and other household members. We would then like to ask a different set of questions to female members of this household who are between the ages of 15 and 49 years. At this time, do you want to ask me anything about the survey?

I. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

[] Yes
[] No

J. Respondent's signature

K1. Interviewer's name: Please record your name as a witness to the consent process. You previously entered "[NAME FROM B]."

J. Respondent's first name.
Please record the first name of the respondent.

Section 1 -- Household Roster
I am now going to ask a series of questions about each usual member of the household or anyone who slept in the house last night. Let's start with the head of the household. For each person who usually lives here or slept in the house last night, please provide the following information:


First name

NAME________

2. Sex

[] Male
[] Female

3. Age (years)

AGE____

4. Marital status

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

5. Relationship to head of household

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response

6. Family ID

ID____

7. Is this person a usual member of the household or has he/she slept in the house last night?

[] Usual member of the household who slept here last night
[] Usual member of the household who did not sleep in the house last night
[] Visitor who slept in the house last night
[] No response

8. Eligible female respondent

[] Yes
[] No
ODK will determine and display eligibility.

After recording information for one household member, the following prompt is asked to activate a looping script to record the information for another member if needed:

[] Yes
[] No

9. Are there any other usual members of your household or persons who slept in the house last night?

[] Yes
[] No

READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named [NAMES]. Is this a complete list of the household members?
Remember to include all children in the household.
[] Yes
[] No

Section 2 -- Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.

10. Please tell me about items that your household owns. Does your household have:
Read out all types and select all that apply. Scroll to bottom to see all choices.
If an item is reported broken but said to be out of use only temporarily, select the item. Otherwise, do not select the item.
[] Electricity?
[] A wall clock?
[] A radio?
[] A black/white television?
[] A color television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A freezer?
[] Electric generator/invertor(s)?
[] A washing machine?
[] A computer?
[] A digital photo camera?
[] A non digital photo camera?
[] A video deck?
[] A DVD/CD player?
[] A sewing machine?
[] A bed?
[] A table?
[] A cabinet/cupboard?
[] A bicycle?
[] A motorcycle or motor scooter?
[] A car or truck?
[] A boat with a motor?
[] A boat without a motor?
[] None of the above
[] No response

Check here to acknowledge you considered all options. []

11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
[] Yes
[] No

11b. How many of the following animals does this household own?
Zero is a possible answer.
The household can keep the livestock anywhere, but must own the livestock recorded here.

Pigs ___
Cows or bulls ___
Horses, donkeys or mules ___
Goats ___
Sheep ___
Chickens ___
Other ___

12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?
Homestead includes the structure and yard that is close to the structure
[] Yes
[] No

12b. How many of the following animals does this household keep ON THE HOMESTEAD? Zero is a possible answer.
The household does not need to own the livestock recorded here.
Pigs ___
Cows or bulls ___
Horses, donkeys or mules ___
Goats ___
Sheep ___
Chickens ___
Other ___

Section 3 -- Household Observation
Please observe the floors, roof and exterior walls.

13. Main material of the floor
Observe.
Natural Floor
[] Earth / sand
[] Dung

Rudimentary Floor
[] Wooden boards
[] Palm / bamboo

Finished Floor
[] Parquet or polished wood
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer

14. Main material of the roof
Observe.

Natural Roof
[] No roof
[] Thatch / straw
[] Soil

Rudimentary Roofing
[] Woven leaves
[] Palm / bamboo
[] Wood planks
[] Cardboard

Finished Roofing
[] Metal
[] Wood
[] Zinc
[] Tiles
[] Cement
[] Shingles
[] Other
[] No answer

15. Main material of the exterior walls
Observe.
Natural Walls
[] No wall
[] Bamboo / cane / palm / trunk
[] Soil

Rudimentary Walls
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood

Finished Walls
[] Cement
[] Stones with cement
[] Bricks
[] Cement blocks
[] Covered adobe
[] Wood planks/shingles
[] Other

[] No response

Section 4 -- Water Sanitation and Hygiene
Now I would like to ask you a few questions about water, sanitation and hygiene.

16. Do you have a place to wash your hands?

[] Yes
[] No
[] Don't know

17. Can you show it to me?

[] Yes
[] No

18. At the place where the household washes their hands, observe if:

[] Soap is present
[] Water source is present: stored water
[] Water source is present: running water
[] Handwashing area is near a sanitation facility
[] None of the above

19. Which of the following water sources does your household use on a regular basis for any part of the year for any purpose?:
Read out all types and check all that apply. Scroll all the way to the bottom to see all sources.
Piped water
[] Piped into dwelling / indoor
[] Piped to yard / plot
[] Piped to public tap/standpipe
[] Tube well or borehole
Dug well
[] Protected well
[] Unprotected well
Water from spring
[] Protected spring
[] Unprotected spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

Check here to acknowledge you considered all options. []

20. What is the main source of drinking water for members of your household? Selections from HQ19: [ODK will show the sources selected in HQ19]
Read out HQ19 selections only.
Piped Water
[] Piped into dwelling/indoor
[] Piped to yard/plot
[] Piped to public tap/standpipe
[] Tube well or borehole
Dug Well
[] Protected Well
[] Unprotected Well
Water from spring:
[] Protected spring
[] Unprotected spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

21. What is the main source of water used by your household for other purposes such as cooking and hand washing? Selections from HQ19: [ODK will show the sources selected in HQ19]
Read out HQ19 selections only.
Piped Water
[] Piped into dwelling/indoor
[] Piped to yard/plot
[] Piped to public tap/standpipe
[] Tube well or borehole
Dug Well
[] Protected Well
[] Unprotected Well
Water from spring:
[] Protected spring
[] Unprotected spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

22. Questions HQ22 to HQ25 will repeat [number of sources] times, once for each water source selected in HQ19. These sources include: [The ODK software will list all sources selected in HQ19.]
You mentioned that you used [MAIN WATER SOURCE]. At any time of the year, does your household use water from this source for:

Drinking
[] Yes
[] No

Cooking
[] Yes
[] No

Livestock
Gardening / agriculture
[] Yes
[] No

Business venture
[] Yes
[] No

[] No response

23. Is [WATER SOURCE] typically available:

[] All of the year
[] Some of the year
[] Small part of the year
[] No response

24. At a time when you expect to have water from [WATER SOURCE], is it usually available?

[] Yes, always
[] No, intermittent and predictable
[] No, intermittent and unpredictable
[] No response

25. How long does it take to go to the [MAIN WATER SOURCE], and come back?
Zero is a possible answer. Convert response to minutes. Include waiting time in line.
Minutes____

26. Does your family have a garden?
A garden is a space to grow vegetables.
[] Yes
[] No

Check here to acknowledge you considered all options. []

27. Do members of your household use any of the following toilet facilities?
Probe: Are there other places, including outdoors? Please observe all choices mentioned.
Flush/pour flush toilets connected to:
[] Piped sewer system
[] Septic tank
[] Elsewhere
[] Unknown / Unsure / Don't know

[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

Check here to acknowledge you considered all options. []

28. What is the main toilet facility used by members of your household? Selections from HQ27: [The ODK software will list all sources selected in HQ27.]
The main facility must be selected in HQ27.
Flush/pour flush toilets connected to:
[] Piped sewer system
[] Septic tank
[] Elsewhere
[] Unknown / Unsure / Don't know

[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

29. Questions HQ29-29b will repeat [number of facilities] times, once for each sanitation facility selected in HQ27. These facilities include: [The ODK software will list all sources selected in HQ27]
How often does your household typically use: [TOILET FACILITY]
Regular practices at the household only.
[] Always
[] Most of the time
[] Occasionally
[] Rarely
[] No response

29b. Do you share this toilet facility with other households or the public? [MAIN SANITATION FACILITY]

[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public
[] No response

29c. Enter the number of households that share this facility (including your own).
[MAIN SANITATION FACILITY]
Must be between 2 and 9. If 10 or greater, move back to 412a and choose "Shared with 41. 0 ≠ -99 ten or more households."
____________________________

30. How many people within your household regularly use the bush / field at home or at work?
There are [x number] people in this household.

Number of people ____

Check HQ3: Are there household members age 5 or younger? Go to question 32 if not.

31. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?
Do not read the possible responses out loud.
[] Children use a latrine / toilet
[] Leave waste where it is
[] Bury waste in field / yard
[] Dispose of waste in latrine / toilet
[] Dispose of waste with rubbish / garbage
[] Dispose of waste with waste water
[] Use it as manure
[] Burn it
[] Don't know
[] No response

32. Ask permission to take a photo of the entrance of the house. Did you get consent to take the photo? [Skip R if No]

[] Yes
[] No

Thank the respondent for his/her time.
The respondent is finished, but there is still more for you to complete outside the home.

Location and Questionnaire result

Q. Location
Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

Check 32: Did you ask permission to take the photo? [Go to R if No]

R. Ensure that no people are in the photo

TAKE PICTURE
CHOOSE IMAGE

R. Record the result of the Household Survey

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant or address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period