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CIR1 Household Questionnaire

IDENTIFICATION
Please record the following information prior to beginning the interview.


001a. Your ID: Is this your ID?
[ODK will display the ID linked with the telephone number]
Check the button next to the ID if that is your ID and select 'yes' here. Do not check the button if that is not your ID and select 'no' here (long press to remove response next to the ID if needed).
[] Yes
[] No

001b. Enter your ID below.
Please record your ID

002a. Current date and time.
[ODK will display it on the screen]

Is this date and time correct?

[] Yes
[] No

002b. Record the correct date and time.

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

003a. Region

[] AGNEBY-TIASSA
[] AUTONOME D'ABIDJAN
[] BAGOUE
[] BERE
[] CAVALLY
[] GBEKE
[] GBÔKLE
[] GÔH
[] GONTOUGO
[] GRANDS-PONTS
[] GUEMON
[] HAMBOL
[] HAUT-SASSANDRA
[] IFFOU
[] INDENIE-DJUABLIN
[] LA ME
[] LÔH-DJIBOUA
[] MARAHOUE
[] MORONOU
[] NAWA
[] N'ZI
[] PORO
[] SAN-PEDRO
[] SUD-COMOE
[] TCHOLOGO
[] TONKPI
[] YAMOUSSOUKRO

003b. Department
ODK will populate a list of departments based on the selected region.

003c. Sub-prefecture
ODK will populate a list of sub-prefectures based on the selected department.

004. Enumeration area
ODK will populate a list of enumeration areas based on the selected sub-prefecture.

005. Structure number
Please record the structure number from the household listing form.
[] Structure number ________

006. Household number
Please record the household number from the household listing form.
[] Household number ________

007. 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

WARNING: Contact your supervisor before sending this form again.

008. 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)

009a. 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 work for the Institut National de la Statistique (INS) in collaboration with the Ministry of Health. We are conducting a national survey about various health issues in Côte D'Ivoire. 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?

010a. Then, ask:
May I begin the interview now?

[] Yes
[] No

010b. Respondent's signature
Collect the signature:

Checkbox:

[] NA

010c. Interviewer's ID
Please record your ID as a witness to the consent process. You previously entered "[Name from 001]".

011. 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

101. Name of household member / visitor
Start with the head of the household

102. What is [NAME]'s relationship to the 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

103. Is [NAME] Male or Female?

[] Male
[] Female

104. How old was [NAME] at their last birthday?
If less than one year old, record 0

105. What is [NAME]'s current marital status?
If not married, probe to determine if they have ever been married and, if so, if they are divorced/separated or widowed.
[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

106. Does [NAME] usually live here?

[] Yes
[] No
[] No response

107. Did [NAME] stay here last night?

[] Yes
[] No
[] No response

LCL_101. What is the religion of [NAME]?

[] Muslim
[] Catholic
[] Methodist
[] Evangelica
[] Other Christian Religion
[] Animast
[] Other religion
[] No religion
[] No response

LCL_102. What is the ethnicity of [NAME]?

[] Akan
[] Mandé du sud
[] Mandé du nord
[] Gur
[] Krou
[] Other Ivorian
[] Other non-Ivorian
[] No response

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

[] Yes
[] No

109. READ THIS CHECK OUT LOUD: There are ${num_HH_members} household members who are named ${names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

[] Yes
[] No

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

201. 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 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

202a. 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

202b.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.
[] Cows or bulls ___________
[] Horses, donkeys or mules ___________
[] Goats ____________
[] Sheep ____________
[] Pigs ________
[] Poultry ____________

203a. 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

203b. 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.
[] Cows or bulls ___________
[] Horses, donkeys or mules ___________
[] Goats ____________
[] Sheep ____________
[] Pigs ________
[] Poultry ____________

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

301. 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

302. Main material of the roof
Observe.

Natural Roof
[] No roof
[] Thatch / straw
[] Soil
Rudimentary Roofing
[] Mats
[] Palm / bamboo
[] Wood planks
[] Cardboard
Finished Roofing
[] Metal
[] Wood
[] Zinc
[] Tiles
[] Cement
[] Shingles
[] Other
[] No answer

303. 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.

401a. Do you have a place to wash your hands?

[] Yes
[] No
[] Do not know
[] No response

401b. Can you show it to me?

[] Yes
[] No

401c. At the place where the household washes their hands, observe if:
Check all that apply.
[] Soap is present

[] Yes
[] No
[] Water source is present: stored water

[] Yes
[] No
[] Water source is present: running water

[] Yes
[] No
[] Handwashing area is near a sanitation facility

[] Yes
[] No
[] None of the above

402. 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
[] Piped Water: Pipe to yard/plot

[] Yes
[] No
[] Piped Water: Public tap/standpipe

[] Yes
[] No
[] Tube well or borehole

[] Yes
[] No
[] Dug Well: Protected Well

[] Yes
[] No
[] Dug Well: Unprotected Well

[] Yes
[] No
[] Water from Spring: Protected Spring

[] Yes
[] No
[] Water from Spring: Unprotected Spring

[] Yes
[] No
[] Rainwater

[] Yes
[] No
[] Tanker Truck

[] Yes
[] No
[] Cart with Small Tank

[] Yes
[] No
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)

[] Yes
[] No
[] Bottled Water

[] Yes
[] No
[] Sachet Water

[] Yes
[] No
[] No response

Check here to acknowledge you considered all options.

[] NA

403. What is the main source of drinking water for members of your household?
Selections from 402: [ODK will display the sources selected in Q402]
Read out 402 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

404. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Selections from 402: [ODK will display sources selected in Q402]
Read out 402 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

Questions 405 to 408 will repeat X times, once for each water source selected in 402. These sources include:
[ODK will display sources selected in Q402]

405. You mentioned that you use [SOURCE]. At any time of the year, does your household use water from this source for:

[] Drinking
[] Yes
[] No
[] Cooking
[] Yes
[] No
[] Livestock
[] Yes
[] No
[] Gardening / agriculture
[] Yes
[] No
[] Business venture
[] Yes
[] No
[] Washing
[] Yes
[] No
[] No response

406. How many months out of the year is [SOURCE] usually available:
Zero is a possible answer. Please record the number of completed months.

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

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

408. How long does it take to go to the [SOURCE], get water, and come back?
0 is a possible answer. Convert answer to minutes. Includes waiting time in line.
_____ Minutes

409. Do members of your household use any of the following toilet facilities?
Read out all types. Check all that are used. Scroll to bottom to see all choices.
Cannot select 'no response' with other options.
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

409. Other, please explain:

410. What is the main toilet facility used by members of your household?
Selections from Q409: [ODK will display the facilities selected in Q409].
The main facility must be selected in 409.
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

Question 411, 412a, 412b will repeat [number of facilities] times, once for each sanitation facility selected in 409. These facilities include:
[TYPE OF SANITATION FACILITY]

411. How often does your household typically use:
[TYPE OF SANITATION FACILITY]
Regular practices at the household only.
[] Always
[] Most of the time
[] Occasionally
[] No response

412a. 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

412b. Enter the number of households that share this facility (including your own).
[TYPE OF SANITATION FACILITY]
Must be between 2 and 9.
If 10 or greater, move back to 412a and choose "Shared with ten or more households."
Number of households: ______________

413. 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: ______________

414. 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.
PROBE: anything else?
[] Children use a latrine / toilet
[] Yes
[] No
[] Leave waste where it is
[] Yes
[] No
[] Bury waste in field / yard
[] Yes
[] No
[] Dispose of waste in latrine / toilet
[] Yes
[] No
[] Dispose of waste with rubbish / garbage
[] Yes
[] No
[] Dispose of waste with waste water
[] Yes
[] No
[] Use it as manure
[] Yes
[] No
[] Burn it
[] Yes
[] No
[] Don't know
[] Yes
[] No response
[] Yes

095a. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?

[] 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

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

097. How many times have you visited this household?

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

098. In what language was this interview conducted?

[] English
[] French
[] Arabic
[] Baoule
[] Senoufo
[] Yacouba
[] Agni
[] Attie
[] Guere
[] Bete
[] Dioula
[] Abbey
[] Mahou
[] Wobe
[] Lobi
[] Other

099. Questionnaire result
Record the result of the household questionnaire.
Check answer to 009 and the consent.
[] 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