Ten-Year Impacts of Burkina Faso’s BRIGHT Program

APPENDIX E
BURKINA FASO
MATHEMATICA POLICY RESEARCH
HOUSEHOLD QUESTIONNAIRE
HELLO. MY NAME IS __________________. THE FOLLOWING IS A SURVEY OF HEADS OF HOUSEHOLDS AND PEOPLE WHO TAKE CARE OF
HOUSEHOLD CHILDREN IN SELECTED BURKINABE VILLAGES AS PART OF A PROJECT CONCERNED WITH FAMILY HEALTH AND EDUCATION. WE ARE
ALSO CONDUCTING A RELATED SURVEY IN SELECTED BURKINABE SCHOOLS. PART OF THIS SURVEY INCLUDES ASSESSMENTS OF STUDENT LEARNING
IN MATH AND FRENCH. THIS SURVEY WILL ASK YOU QUESTIONS ABOUT YOUR HOUSEHOLD CHARACTERISTICS, THE SCHOOL ENROLLMENT AND
ATTENDANCE STATUS OF THE CHILDREN OF THE HOUSEHOLD, AND ANY LABOR ACTIVITIES HOUSEHOLD CHILDREN PARTICIPATE IN. THIS SURVEY IS
JUST FOR RESEARCH PURPOSES. ALL OF THE INFORMATION YOU OR YOUR CHILD PROVIDE WILL BE CONFIDENTIAL AND WILL BE COMBINED WITH THE
RESPONSES OF OTHER PARENTS AND CHILDREN TO HELP US LEARN ABOUT THE EDUCATION EXPERIENCES OF YOUTH. YOUR NAME AND YOUR
CHILD’S NAME WILL NOT BE ASSOCIATED WITH ANY OF YOUR RESPONSES IN THE ANALYSIS AND SUBSEQUENT REPORTING. YOU CAN FEEL FREE NOT
TO RESPOND TO ANY QUESTION THAT YOU DO NOT WANT TO ANSWER. YOU ALSO DO NOT HAVE TO PARTICIPATE IN THIS INTERVIEW IF YOU DO NOT
WISH TO DO SO. IT WILL TAKE APPROXIMATELY 40 MINUTES FOR YOU TO COMPLETE THIS SURVEY. DO YOU HAVE ANY QUESTIONS? DO YOU
UNDERSTAND AND WOULD YOU LIKE TO PARTICIPATE?
□ YES □ NO
HOUSEHOLD CHARACTERISTICS
HC1. REGION__________ ID: ___ ___ ___ HC2. PROVINCE: ____________ ID: ___ ___
HC
HC3. COMMUNE:
HC4. VILLAGE:
_________________________
ID___ ___
NAME
ID___ ___
HC5. NAME OF HEAD OF HOUSEHOLD:
__________________________________________________
HC6. HOUSEHOLD ID:
________________________________
HC7. HOUSEHOLD NUMBER WITHIN THE VILLAGE
ACCORDING TO THE CENSUS (SEE RC1):
HC9. DAY/MONTH/YEAR OF INTERVIEW:
___ ___ / ___ ___ / ___ ___ ___ ___
HC10. INTERVIEWER NAME AND NUMBER:
NAME
ID___ ___
HC12. HOUSEHOLD GEO-REFERENCE:
HC11. SUPERVISOR NAME AND NUMBER:
NAME_____________________ ID___ ___
LONGITUDE: DG | | | MN | | | SC | | | |
LATITUDE: DG | | | MN | | | SC | | | |
HC13. RESPONDENT RELATIONSHIP TO HEAD OF HOUSEHOLD: _____
01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 GRANDCHILD
05 PARENT
06 BROTHER OR SISTER
07 UNCLE/AUNT
08 NIECE/NEPHEW
09 ADOPTED/FOSTER/STEPCHILD
10 OTHER RELATIVE
11 NOT RELATED
98 DON’T KNOW
HC14. TOTAL NUMBER OF
HOUSEHOLD
MEMBERS:
_____
HC15A. TOTAL NUMBER OF CHILDREN
UNDER 6 YEARS OLD WHO ARE
PART OF THIS HOUSEHOLD (EVEN IF
THEY DON’T LIVE IN THE HOME):
_____
HC15B. TOTAL NUMBER OF CHILDREN
AGES 6-22 WHO ARE PART OF
THIS HOUSEHOLD (EVEN IF
NOT LIVING IN THE HOME)
_____
AFTER THE QUESTIONNAIRE HAS BEEN COMPLETED, FILL IN THE FOLLOWING INFORMATION:
HC16.
RESULT OF HH INTERVIEW: _____
COMPLETED .................................................... 1
EFFORT ENDED ............................................... 2
REFUSED ........................................................ 3
OTHER (SPECIFY) ........................................ 96
_______________________________
Prepared by Mathematica Policy Research E.5