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).
[] No
A. Enter your name below.
Please record your name
B. Current date and time.
[The current date and time will be displayed on screen]
Is this date and time correct?
[] No
C. Record the correct date and time.
Time____ Hour____ Minutes____ AM/PM____
D. Region
D. Department
D. Commune
[] Niamey Commune II
[] Niamey Commune III
[] Niamey Commune IV
[] Niamey Commune V
D. Locality
ODK will populate a list of localities based on the selected commune.
D. Enumeration Area
ODK will populate a list of enumeration areas based on the selected locality.
E. Structure number
Please record the structure number from the household listing form.
F. 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.
[] No
WARNING: Contact your supervisor before sending this form again.
CHECK: Why are you resending this form?
Choose all that apply.
[] 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?
[] 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). 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. Ask: May I begin the interview now?
[] No
Respondent's signature
GATHER SIGNATURE:
Checkbox
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
[] Female
HQ3. Age (years)
If less than one year old, record 0
HQ4. Marital Status
[] 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.
[] 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.
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 did NOT sleep in the house last night
[] Visitor who slept in the house last night
[] No response
HQ8. Eligible female respondent
[] 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?
[] No
READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS] household members who are named [FIRST NAMES]. Is this a complete list of household members?
Remember to include all children in the household.
[] 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.
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
[] No
Check here to acknowledge you considered all options.
HQ11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
[] 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.
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Camel: Number _______
[] Chickens, Guinea Fowl, Pigeons: Number _______
[] Ducks, Geese: 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.
[] 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.
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Camel: Number _______
[] Chickens, Guinea Fowl, Pigeons: Number _______
[] Ducks, Geese: Number _______
[] Other: Number _______
Section 3 -- Household Observation
Please observe the floors, roof and exterior walls.
HQ13. Main material of the floor
Observe.
[] Palm / bamboo
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] No answer
HQ14. Main material of the roof
Observe.
[] Thatch / leaves
[] Soil
[] Palm / bamboo
[] Wooden boards
[] Cardboard
[] Animal hide
[] Wood
[] Zinc / fiber cement
[] Tile
[] Cement
[] No answer
HQ15. Main material of the exterior walls
Observe.
[] Bamboo / cane / palm / trunk
[] Earth
[] Straw
[] Plywood
[] Cardboard
[] Recovered wood
[] Stones with lime / cement
[] Bricks
[] Cement blocks
[] Wood board / shingles
[] Sheet metal
[] No answer
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?
[] No
[] Do not know
[] No response
HQ17. Can you show it to me?
[] No
HQ18. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
[] Water source is present: stored water
[] Water source is present: running water
[] Handwashing area is near a sanitation facility
[] 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: 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.
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: 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: 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.
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing
[] No response
HQ23. Is [WATER SOURCE] water typically available:
Read all choices out loud.
[] 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?
[] 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.
[] 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.
Cannot select 'no response' with other options.
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: 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.
HQ28. What is the main toilet facility used by members of your household?
Selections from HQ27: [ODK will display sources selected in Q27]
The main facility must be selected in HQ27.
You did not select that choice in the previous question.
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: 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.
[] 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]
[] 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.
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.
HQ31. 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?
[] 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
HQ32. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?
[] 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?
[] No
L. Ensure that no people are in the photo.
[] TAKE A PHOTO
[] SELECT IMAGE
M. How many times have you visited this household?
[] 2nd time
[] 3rd time
N. Questionnaire result
Record the result of the household questionnaire.
[] 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