BFR3 Household Questionnaire
IDENTIFICATION
Please record the following identifying information prior to beginning the interview.
A. 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
[] No
Enter your name below.
Please record your name
B. Is this date and time correct?
[THE CURRENT DATE AND TIME WILL BE DISPLAYED ON SCREEN]
[] Yes
[] No
[] No
C. Record the correct date and time
Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____
Time____ Hour____ Minutes____ AM/PM____
D. Region
[] Boucle du Mouhoun
[] Cascades
[] Centre
[] Centre-Est
[] Centre-Nord
[] Centre-Ouest
[] Centre-Sud
[] Est
[] Hauts-Bassins
[] Nord
[] Plateau-Central
[] Sahel
[] Sud-Ouest
[] Cascades
[] Centre
[] Centre-Est
[] Centre-Nord
[] Centre-Ouest
[] Centre-Sud
[] Est
[] Hauts-Bassins
[] Nord
[] Plateau-Central
[] Sahel
[] Sud-Ouest
D. Province
ODK will populate a list of provinces based on the selected region.
D. Commune, Village
ODK will populate a list of communes or villages based on the selected province.
D. Enumeration Area
ODK will populate a list of enumeration areas based on the selected commune or village.
E. Structure number
Please record the structure number from the household listing form.
[] Structure number ________
F. Household number
Please record the household number from the household listing form.
[] Household number ________
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
[] No
WARNING: Contact your supervisor before sending this form again.
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)
[] 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)
G. Is a member of the household and competent respondent present and available to be interviewed today?
[] Yes
[] No
[] No
G2. Did this household participate in a previous PMA2020 survey?
[] Yes
[] No
[] Do not know
[] No response
[] No
[] Do not know
[] No response
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?
H. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?
[] Yes
[] No
[] No
Respondent's signature
GATHER SIGNATURE:
Checkbox
[] NA
I. Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ 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.
Household member
HQ1. First name
HQ2. Sex
[] Male
[] Female
[] Female
HQ3. Age (years)
If less than one year old, record 0
HQ4. Marital Status
[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response
HQ5. Relationship to head of household
HQ4 must be "Married" or "Living with a partner" if HQ5 is wife/husband.
[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response
HQ6. Family ID
HQ6: Must be greater than 0.
ID____
HQ7. 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 in the household 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
[] Usual member of the household who did NOT sleep in the house last night
[] Visitor who slept in the house last night
[] No response
HQ8. Eligible female respondent
[] Yes
[] No
ODK will determine and display eligibility based on age and sex.
[] No
After recording information for one household member, the following prompt is asked to activate a looping script to record information for another member if necessary.
HQ9. Are there any other usual members of your household or persons who slept in the house last night?
[] Yes
[] No
[] No
READ THIS CHECK OUT LOUD: There are [number of household members entered] household members who are named [first names]. Is this a complete list of household members?
Remember to include all children in the household.
[] Yes
[] No
[] No
Section 2 -- Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.
HQ10. 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.
Cannot select 'no response' or ;none of the above' with other options.
[] Electricity?
[] A radio?
[] A television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A TV Antenna?
[] A cable subscription?
[] A washing machine?
[] A gas or electric stove?
[] An improved woodstove?
[] A DVD/CD player?
[] An air conditioner?
[] A computer?
[] Home internet?
[] A wall clock?
[] A plow?
[] A bicycle?
[] A motorcycle or motor scooter?
[] Animal-drawn cart?
[] A canoe or fishing nets?
[] A car or truck?
[] A boat with a motor?
[] None of the above
[] No response
Check here to acknowledge you considered all options.
[] A radio?
[] A television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A TV Antenna?
[] A cable subscription?
[] A washing machine?
[] A gas or electric stove?
[] An improved woodstove?
[] A DVD/CD player?
[] An air conditioner?
[] A computer?
[] Home internet?
[] A wall clock?
[] A plow?
[] A bicycle?
[] A motorcycle or motor scooter?
[] Animal-drawn cart?
[] A canoe or fishing nets?
[] A car or truck?
[] A boat with a motor?
[] None of the above
[] No response
HQ11a. 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
[] No response
[] No
[] No response
HQ11b.How many of the following animals does this household own?
The household can keep the livestock anywhere, but must own the livestock recorded here.
Zero is a possible answer.
[] Pigs: Number _______
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Chickens: Number _______
[] Other: Number _______
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Chickens: Number _______
[] Other: Number _______
HQ12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these animals?
Homestead includes the structure and yard that is close to the structure.
[] Yes
[] No
[] No response
[] No
[] No response
HQ12b. How many of the following animals does this household keep ON THE HOMESTEAD.
The household does not need to own the livestock recorded here.
Zero is a possible answer.
[] Pigs: Number _______
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Chickens: Number _______
[] Other: Number _______
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Chickens: Number _______
[] Other: Number _______
Section 3 -- Household Observation
Please observe the floors, roof and exterior walls.
HQ13. Main material of the floor
Observe.
Natural Floor
[] Earth / sand
[] Dung
[] Dung
Rudimentary Floor
[] Wooden boards
[] Palm / bamboo
[] Palm / bamboo
Finished Floor
[] Parquet or polished wood
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer
HQ14. Main material of the roof
Observe.
Natural Roof
[] No roof
[] Thatch / straw
[] Soil
[] Thatch / straw
[] Soil
Rudimentary Roofing
[] Woven leaves
[] Palm / bamboo
[] Wood planks
[] Cardboard
[] Palm / bamboo
[] Wood planks
[] Cardboard
Finished Roofing
[] Metal
[] Wood
[] Zinc
[] Tiles
[] Cement
[] Shingles
[] Other
[] No answer
[] Wood
[] Zinc
[] Tiles
[] Cement
[] Shingles
[] Other
[] No answer
HQ15. Main material of the exterior walls
Observe.
Natural Walls
[] No wall
[] Bamboo / cane / palm / trunk
[] Soil
[] Bamboo / cane / palm / trunk
[] Soil
Rudimentary Walls
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood
[] 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
[] 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.
HQ16. Do you have a place to wash your hands, or do you have a movable container that is not kept in a fixed location, such as a bowl or kettle, that is commonly used for hand washing?
If the container is always in the same location, then count it as a fixed place.
[] Yes, fixed place
[] Yes, movable container
[] No
[] Don't know
[] Refuse to answer
[] Yes, movable container
[] No
[] Don't know
[] Refuse to answer
HQ17a. Can you show it to me?
[] Yes
[] No
[] No
HQ18a. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
[] Soap is present
[] Yes
[] No
[] No
[] Water source is present: stored water
[] Yes
[] No
[] No
[] Water source is present: running water
[] Yes
[] No
[] No
[] Handwashing area is near a sanitation facility
[] Yes
[] No
[] No
[] None of the above
HQ17b. Can you show me any soap, water, and movable container available in the household used for hand washing?
[] Yes
[] No
[] No
HQ18b. Anywhere within the household, observe if:
Cannot select 'none of the above' with other options.
[] Soap is present
[] Yes
[] No
[] No
[] Water source is present: stored water
[] Yes
[] No
[] No
[] Water source is present: running water
[] Yes
[] No
[] No
[] Hand washing container is observed
[] Yes
[] No
[] No
[] None of the above
HQ19. 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 are used. Scroll to bottom to see all choices.
Cannot select 'no response' with other options.
[] Piped Water: Piped into dwelling/indoor
[] Yes
[] No
[] No
[] Piped Water: Pipe to yard/plot
[] Yes
[] No
[] No
[] Piped Water: Public tap/standpipe
[] Yes
[] No
[] No
[] Tube well or borehole
[] Yes
[] No
[] No
[] Dug Well: Protected Well
[] Yes
[] No
[] No
[] Dug Well: Unprotected Well
[] Yes
[] No
[] No
[] Water from Spring: Protected Spring
[] Yes
[] No
[] No
[] Water from Spring: Unprotected Spring
[] Yes
[] No
[] No
[] Rainwater
[] Yes
[] No
[] No
[] Tanker Truck
[] Yes
[] No
[] No
[] Cart with Small Tank
[] Yes
[] No
[] No
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Yes
[] No
[] No
[] Bottled Water
[] Yes
[] No
[] No
[] Sachet Water
[] Yes
[] No
[] No
[] No response
Check here to acknowledge you considered all options.
[] NA
HQ20. What is the main source of drinking water for members of your household?
Selections from HQ19: [ODK will display sources selected in Q19]
Read out HQ19 selections only.
[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from 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
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from 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
HQ21. 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 display sources selected in Q19]
Read out HQ19 selections only.
You did not select that choice in HQ19.
[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from 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
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from 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
Questions HQ22 to HQ25 will repeat [number of sources] times, once for each water source selected in HQ19. These sources include: [ODK will display sources selected in Q19]
HQ22. You mentioned that you use [water source]. At any time of the year does your household use water from this source for:
Cannot select 'no response' with other options.
[] Drinking
[] Yes
[] No
[] No
[] Cooking
[] Yes
[] No
[] No
[] Livestock
[] Yes
[] No
[] No
[] Gardening / agriculture
[] Yes
[] No
[] No
[] Business venture
[] Yes
[] No
[] No
[] Washing
[] Yes
[] No
[] No
[] No response
HQ23. Is [water source] water typically available:
Read all choices out loud.
[] All of the year
[] Some of the year
[] Small part of the year
[] No response
[] Some of the year
[] Small part of the year
[] No response
HQ24. At a time of year 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
[] No, intermittent and predictable
[] No, intermittent and unpredictable
[] No response
HQ25. How long does it take to go to [water source], get water, and come back?
0 is a possible answer. Convert answer to minutes. Includes waiting time in line.
HQ26. Does your household have a garden?
A garden is a place to grow vegetables.
[] Yes
[] No
[] No response
[] No
[] No response
HQ27. Where do members of your household go to the bathroom?
PROBE: Anything else, including the bush/field? Ask to see each type of facility mentioned.
Flush/pour flush toilets connected to:
[] 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
[] Piped sewer system
[] Septic tank
[] Elsewhere
[] Unknown / Unsure / Don't know
[] 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.
[] NA
HQ28. What is the main toilet facility used by members of your household?
Selections from 27: [ODK will display sources selected in Q27]
The main facility must be selected in HQ27.
Flush/pour flush toilets connected to:
[] 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
[] Piped sewer system
[] Septic tank
[] Elsewhere
[] Unknown / Unsure / Don't know
[] 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
Question HQ29 will repeat [number of facilities] times, once for each sanitation facility selected in HQ27. These facilities include:
[ODK will display sources selected in Q27]
HQ29. How often does your household typically use: [Type of sanitation facility]?
Regular practices at the household only.
[] Always
[] Most of the time
[] Occasionally
[] Rarely
[] No response
[] Most of the time
[] Occasionally
[] Rarely
[] No response
HQ29b. Do you share this toilet facility with other households or the public?
[Type of sanitation facility]
[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public.
[] No response
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public.
[] No response
HQ29c. Enter the number of households that share this facility (including your own).
[Type of sanitation facility]
Must be between 2 and 9.
__________Number of households
HQ30. How many people within your household regularly use the bush / field at home or at work?
There are [x number] people in this household.
Must be between zero and the number of household members.
__________Number of people
HQ31. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?
[] Yes
[] No
[] 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
K. 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 obtain permission to take the photo?
L. Ensure that no people are in the photo.
[] TAKE A PHOTO
[] SELECT IMAGE
M. How many times have you visited this household?
[] 1st time
[] 2nd time
[] 3rd time
[] 2nd time
[] 3rd time
N. Questionnaire result
Record the result of the household questionnaire.
[] 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
[] 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