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Côte D'Ivoire Round 2 - Household Questionnaire

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

002b. Record the correct date and time.
Day:
Month:
Year:

003a. Region

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

003b. Department

003c. Sub-prefecture

004. Enumeration area

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

006. Household number
Please record the household number from the household listing form.

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

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 reasons

009a. Is a member of the household and competent respondent present and available to be interviewed today?

[] Yes
[] No

009b. Did this household participate in a previous PMA2020 survey?

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

INFORMED CONSENT Find a competent member of the household. Read the greeting on the following screen.

Bonjour. Je m'appelle ____________________________________ et je travaille pour l'Institut National de la Statistique de Côte d'Ivoire (INS-Côte d'Ivoire). Nous menons une enquête locale auprès des femmes sur plusieurs questions de santé. Nous apprécierons grandement votre participation à cette étude. Ces informations nous aideront à informer le gouvernement afin d'offrir de meilleurs services de santé. L'enquête dure généralement 15 minutes. Je vous poserais des questions sur votre famille et les membres de votre ménage. Ensuite, nous aimerions poser une série de questions différentes à toutes les femmes du ménage qui ont entre 15 et 49 ans. Toute information que vous voudrez bien nous communiquer sera strictement confidentielle, et seules les données rendues complètement anonymes seront utilisées pour mener des analyses, en présenter les résultats et partager les données. La participation à cette enquête est entièrement volontaire. Si nous rencontrons une question à laquelle vous ne souhaitez pas répondre, faites-le moi savoir et je passerai à la suivante. Vous êtes libre de ne pas participer à cette enquête du tout, ou de l'interrompre à tout moment. Cependant, nous espérons que vous voudrez bien y participer car votre opinion est très importante. Si vous avez des questions sur cette étude et sur vos droits en tant que participant à une recherche, vous pouvez me les poser ou contacter M. Aka Doré à l'Institut National de la Statistique de Côte d'Ivoire (INS-Côte d'Ivoire) au +225 09 34 14 94. Jusqu'ici, avez-vous des questions sur l'enquête ? Puis-je commencer l'interview à présent ?

010a. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

[] Yes
[] No

010b. Respondent's signature Please ask the respondent to sign or check the box in agreement of their participation.

010c. Interviewer's name Please record your name as a witness to the consent process.
You previously entered [NAME FROM 001]

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.

101a. Is this person the respondent?

102. What is [NAME] relationship to the head of household?

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Other
[] Do not 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

[] Male
[] Female

105. What is [NAME]'s current marital status?

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

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

ERROR: Members on household roster must usually live here or must have stayed here last night. Go back and remove this household member.

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
[] Mande du sud
[] Mande du nord
[] Gur
[] Krou
[] Other Ivorian
[] 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

There are other members of the household.
Move forward and select "Add Group"

There are no other members of the household.
Move forward and select "Do Not Add"

ERROR: There is no household head.
Go back, select a head.
For each member, check that the relationship to the household head is accurate.

ERROR: There are [NUMBER] household heads selected: [HOUSEHOLD HEAD NAMES ENTERED]
Go back, select only one head.
For each member, check that the relationship to the household head is accurate.

101a NO RESPONDENT ERROR. The checkbox for 101a (Is this person the respondent?) was never selected for any of the household members. You entered the following household members: {names}. If the respondent was entered in the roster but never selected as the respondent in 101a: Please go back and select the checkbox in 101a for the correct respondent. If the respondent is a household member but left out of the list of household members: Add the respondent to the list. If the respondent is not a household member: Stop the interview. Find a household member and interview that person. Be sure to ask for consent.

101a TOO MANY RESPONDENTS ERROR.
The checkbox for 101a (Is this person the respondent?) was selected more than once. Please go back and make sure that it is only selected once.

109. 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.

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 TV5 Antenna?
[] A cabel subscription?
[] A washing machine?
[] A gas or electric stove?
[] An improved stove?
[] A DVD/CD?
[] An air conditioner?
[] A computer?
[] Home internet?
[] A wall clock?
[] Charruees?
[] A bicycle/tricycle?
[] A motorcycle or motor scooter?
[] Animal-drawn cart?
[] A canoe or fishing nets?
[] A tractor?
[] A car or truck?
[] A boat with a motor?
[] None of the above
[] No response

Check here to acknowledge you considered all options.

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.

[] Cows or bulls
[] Horses, donkeys or mules
[] Goats
[] Sheep
[] Porks
[] Fowl
[] Other

Section 3 - Household Observation

Please observe the floors, roof and exterior walls

301. Main material of the floor.
Observe:

[] Earth / sand
[] Cow dung
[] Wooden boards
[] Palm / bamboo
[] Parquet or polished wood
[] Tapes vinyl / asphalt
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer

302. Main material of the roof.
Observe:

[] No roof
[] Thatch / palm
[] Earth mottes
[] Mats
[] Palm / bamboo
[] Wooden boards
[] Cardboard
[] Sheet metal
[] Wood
[] Zinc / fiber cement
[] Tile
[] Cement
[] Shingles
[] Other
[] No answer

303. Main material of the exterior walls.
Observe:

[] No wall
[] Bamboo / cane / palm / trunk
[] Earth
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood
[] Cement
[] Stones with lime / cement
[] Bricks
[] Cement blocks
[] Covered adobe
[] Wood board / shingles
[] Other
[] No answer

Section 4 - Water Sanitation

Now I would like to ask you a few questions about water, sanitation and hygiene

401a. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

[] Observed, fixed place
[] Observed, mobile
[] Not observed, not in dwelling/yard/plot
[] Not observed, no permission to see
[] Not observed, other reason
[] No response

401b. At the place where the household washes their hands, observe if:
Check all that apply.

[] Soap is present
[] Stored water is present
[] Running water is present
[] Handwashing area is near a sanitation facility
[] 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.

[] 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

Check here to acknowledge you considered all options.

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

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

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

406. How many months out of the year is [MAIN WATER 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 [MAIN WATER 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 [MAIN WATER SOURCE], and come back?
0 is a possible answer. Convert answer to minutes. Includes waiting time in line.

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.

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

Check here to acknowledge you considered all options.

410. What is the main toilet facility used by members of your household?

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

SN_411.ii. When was the last time your [MAIN SANITATION FACILITY] was emptied?
Probe: How many months or years ago? If less than one month, select months.

[] X months ago
[] X years ago
[] Never emptied
[] Do not know
[] No response

Enter [Months OR Years]: If less than one month, enter 0 months.

SN_411.iii. The last time your [MAIN SANITATION FACILITY] was emptied, who emptied it?
Probe: Was it emptied by household members or by neighbors or by a service provider?

[] By household members or neighbors
[] By a service provider
[] Other
[] Do not know
[] No response

SN_411.iv. The last time your [MAIN SANITATION FACILITY] was emptied, where were the contents emptied to?

[] To a covered and sealed hole buried
[] To an open drain or to a water body
[] To an open hole not buried, open ground, bush, beach or to agricultural land
[] Taken away by the service provider to a treatment facility
[] Taken away by the service provider to do not know where
[] Other
[] Do not know
[] No response

SN_411.v. Where is your toilet facility located? [MAIN SANITATION FACILITY]

[] In own dwelling
[] In own yard / plot
[] Elsewhere
[] No response

411. How often does your household typically use: [TOILET 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? [MAIN SANITATION PLACE]

[] 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). [MAIN SANITATION PLACE]
Must be between 2 and 9. If 10 or greater, move back to 412a and choose "Shared with ten or more 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.

414. For all children under age five: what methods, if any, does your household use to dispose of children's waste?
PROBE: Other methods?
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
[] Do not know
[] No response

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 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