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