001a. Your name: {your_name}

Is this your name?

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2020-07-01 and 2021-09-01.

003a. Region

003b. Commune / Departement

003c. Locality / Commune

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.

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

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 (INS) en collaboration avec le Ministère de la Sante Publique. Nous menons actuellement une enquête nationale sur plusieurs thèmes lies à la sante reproductive des femmes. Nous apprecions beaucoup que vous fassiez partie de cette enquête. Les informations que nous collecterons aideront à informer le gouvernement à mieux planifier les services de sante. Le questionnaire prend generalement entre 15 et 20 minutes. Toutes les informations que vous nous donnerez seront strictement confidentielles et ne seront partagees avec personne d'autre que les membres de notre equipe.

La participation à cette enquête est volontaire, et s'il y a une question à laquelle vous ne souhaitez pas repondre, faîtes le moi savoir et je passerai à la suivante; ou vous pouvez egalement interrompre l'entretien à tout moment. Cependant, nous esperons que vous accepterez de participer à cette enquête car votre point de vue est important.

Avant de continuer, avez-vous des questions sur cette enquête?

010a. Read the verbal consent text.

Then, ask:
May I begin the interview now?

010b. Respondent's signature

Please ask the respondent to sign or check the box in agreement of their participation.

Checkbox

011. Interviewer's name: {your_name}

Mark your name as a witness to the consent process.

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?

If yes, check this box.

102. What is {firstname}'s relationship to the head of household?

103. Is {firstname} male or female?

104. How old was {firstname} at their last birthday?

If less than one year old, record 0

Age must be less than 130 and greater than 0.

105. What is {firstname}'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.

106. Does {firstname} usually live here?

107. Did {firstname} stay here last night?

LCL_101. What is the religion of {firstname}?

Only recorded for the head of the household.

LCL_102. What is the ethnicity of {firstname}?

Only recorded for the head of the household.

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

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.

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.

Cannot select 'no response' or 'none of the above' with other options.

Check here to acknowledge you considered all options.

202. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

203. 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. Enter -88 for do not know. Enter -99 for no response.
Cows or bulls

Enter -88 for do not know.
Enter -99 for no response.

Horses, donkeys or mules

Enter -88 for do not know.
Enter -99 for no response.

Goats

Enter -88 for do not know.
Enter -99 for no response.

Sheep

Enter -88 for do not know.
Enter -99 for no response.

Camels:

Enter -88 for do not know.
Enter -99 for no response.

Chickens

Enter -88 for do not know.
Enter -99 for no response.

Geese

Enter -88 for do not know.
Enter -99 for no response.

Other

Enter -88 for do not know.
Enter -99 for no response.

Section 3 ? Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor

Observe.

302. Main material of the roof

Observe.

303. Main material of the exterior walls

Observe.

Section 4 ? Water Sanitation and Hygiene

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

401. What is the main source of drinking water for members of your household?

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

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?

098. In what language was this interview conducted?

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.