Place and Date | Response |
| |
1 | District Code | |__|__|__| | |
2 | Name of the center/village |
| |
3 | Center/village code | |__|__|__| | |
4 | Consent has been obtained (oral or written) | Yes 1 No 2 | |
5 | Gender (circle the appropriate number) | Male 1 Female 2 | |
6 | Quel âge avez-vous? | ……….. in year | |
7 | In total, how many years did you spend in school or in full-time training (not including pre-school)? |
………….. | |
8 | What is your social and cultural background? | Adja and related 1 Fon and related 2 Bariba and related 3 Dendi and related 4 Yom and related 5 Peulh 6 Otamari 7 Yorouba 8 West African 9 Other African 10 Non-African 11 Refused 0 | |
9 | What is the highest level of education you have achieved? | No official instruction 1 Less than elementary school 2 End of elementary school 3 End of secondary school level 4 End of secondary school level 5 College, University 6 Post-graduate degree obtained 7 Refused 0 | |
10
| Which of the following categories best describes your main work activity over the past 12 months? | Government employee 1 Employee in the private sector 2 Self-employed 3 Volunteer 4 Student 5 Housekeeper 6 Retired 7 Unemployed 8 Disabled person 9 Refused 0 | |
11 | Estimated annual household income | ≤?00,00 1 [101,00 - 200,00] 2 [201,00 - 300,00] 3 [301,00 – 400,00] 4 >?00,00 5 Don’t know 6 Refused 0 |