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[Burkina Faso 1985]
Census Questionnaire (household sheet)

Concession _ _ _
Household _ _
Sheet number _
Number of sheets _
Nationality of head of household ____
Language fluently spoken in the household ____

Deaths in the last 12 months

[] No
[] Yes
If yes, how many? _

First and last name of deceased ____
Sex of deceased ____
Age at death ____

Household summary
Present residents

Male _
Female _
Total _

Absent residents

Male _
Female _
Total _

Emigrants

Male _
Female _
Total _

Visitors

Male _
Female _
Total _

Total males _
Total females_
Household total _

All persons
[Questions 1-8 were asked for all persons.]

1. Order Number _

2. First and last name ____

3. Sex _

4. Relationship to household head ____

5. Residential status ____

6. Age or date of birth

____ Age in months or years
____ Date of birth

7. Place of birth ____

8. Place of residence one year ago ____

Residents 10 years of age and older
[Questions 9-15 were asked for residents age 10 and older.]

9. Knows how to read and write (in which language) ____

10. Level of schooling ____

Economic activity

11. Employment status ____

12. Principal occupation ____

13. Employment situation in principal occupation ____

14. Secondary occupation ____

15. Employment situation in secondary occupation ____

Residents 12 years of age and older
[Questions 16-20 were asked for residents age 12 and older.]

16. Marital status ____

Women only
[Questions 17-20 were asked for females age 12 and older.]

17. Total number of children born alive ____

18. Total number of children still alive ____

Births in the last 12 months

19. Male _ _
20. Female _ _

Handicap
[Question 21 was asked of all persons.]
21. Type of handicap ____