How many times have you visited this household?

Your name: Is this your name?
[ODK will display the name associated with the phone's serial number.]
Check the button next to the name if that is your name and select 'yes' here. Do not check the button if that is not your name and select 'no' here (long press to remove response next to the name if needed).

Enter your name below.
Please record your name

Interviewer's Name _____
Is this date and time correct?
[THE CURRENT DATE AND TIME WILL BE DISPLAYED ON SCREEN]

D. Record the correct date and time

E1. Region

E2. Province
ODK will populate a list of appropriate provinces based on the selected region.

E3. Commune
ODK will populate a list of appropriate communes based on the selected province.

E4. Enumeration area
ODK will populate a list of appropriate enumeration areas based on the selected commune.

F. Structure number: [#]
Please record the structure number from the household listing form.

G. Household number: [#]
Please record the household number from the household listing form.

CHECK: Have you already sent a form for this structure and household?
DO NOT DUPLICATE ANY FORM UNLESS YOU ARE CORRECTING A MISTAKE IN AN EARLIER FORM.
CHECK: Why are you resending this form?
Choose all that apply.
H. 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.
Hello. My name is ____________ and I am working for the Institut Supérieur des Sciences de la Population (ISSP). We are conducting a local survey about various health issues in Burkina Faso. Your household has been selected for this survey. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. Whatever information you provide will be kept strictly confidential and will not be shown to anyone other than members of our survey team. Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important. I am going to ask you questions about your family and other household members. We would then like to ask a different set of questions to female members of this household who are between the ages of 15 and 49 years. At this time, do you want to ask me anything about the survey?

I. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

J. Respondent's signature

K1. Interviewer's name: Please record your name as a witness to the consent process. You previously entered "[NAME FROM B]."

J. Respondent's first name.
Please record the first name of the respondent.

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. Let's start with the head of the household. For each person who usually lives here or slept in the house last night, please provide the following information:


First name

2. Sex

3. Age (years)

4. Marital status

5. Relationship to head of household

6. Family ID

7. Is this person a usual member of the household or has he/she slept in the house last night?

8. Eligible female respondent

ODK will determine and display eligibility.

After recording information for one household member, the following prompt is asked to activate a looping script to record the information for another member if needed:

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

READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named [NAMES]. Is this a complete list of the household members?
Remember to include all children in the household.
Section 2 -- Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.

10. 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.

Check here to acknowledge you considered all options. []

11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
[] Yes
[] No

11b. How many of the following animals does this household own?
Zero is a possible answer.
The household can keep the livestock anywhere, but must own the livestock recorded here.

12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?
Homestead includes the structure and yard that is close to the structure
12b. How many of the following animals does this household keep ON THE HOMESTEAD? Zero is a possible answer.
The household does not need to own the livestock recorded here.

Section 3 -- Household Observation
Please observe the floors, roof and exterior walls.

13. Main material of the floor
Observe.

14. Main material of the roof
Observe.

15. 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.

16. Do you have a place to wash your hands?

17. Can you show it to me?

18. At the place where the household washes their hands, observe if:

19. Which of the following water sources does your household use on a regular basis for any part of the year for any purpose?:
Read out all types and check all that apply. Scroll all the way to the bottom to see all sources.
Check here to acknowledge you considered all options. []

20. What is the main source of drinking water for members of your household? Selections from HQ19: [ODK will show the sources selected in HQ19]
Read out HQ19 selections only.
21. What is the main source of water used by your household for other purposes such as cooking and hand washing? Selections from HQ19: [ODK will show the sources selected in HQ19]
Read out HQ19 selections only.
22. Questions HQ22 to HQ25 will repeat [number of sources] times, once for each water source selected in HQ19. These sources include: [The ODK software will list all sources selected in HQ19.]
You mentioned that you used [MAIN WATER SOURCE]. At any time of the year, does your household use water from this source for:

23. Is [WATER SOURCE] typically available:

24. At a time when you expect to have water from [WATER SOURCE], is it usually available?

25. How long does it take to go to the [MAIN WATER SOURCE], and come back?
Zero is a possible answer. Convert response to minutes. Include waiting time in line.
26. Does your family have a garden?
A garden is a space to grow vegetables.
Check here to acknowledge you considered all options. []

27. Do members of your household use any of the following toilet facilities?
Probe: Are there other places, including outdoors? Please observe all choices mentioned.
Check here to acknowledge you considered all options. []

28. What is the main toilet facility used by members of your household? Selections from HQ27: [The ODK software will list all sources selected in HQ27.]
The main facility must be selected in HQ27.
29. Questions HQ29-29b will repeat [number of facilities] times, once for each sanitation facility selected in HQ27. These facilities include: [The ODK software will list all sources selected in HQ27]
How often does your household typically use: [TOILET FACILITY]
Regular practices at the household only.
29b. Do you share this toilet facility with other households or the public? [MAIN SANITATION FACILITY]

29c. Enter the number of households that share this facility (including your own).
[MAIN SANITATION FACILITY]
Must be between 2 and 9. If 10 or greater, move back to 412a and choose "Shared with 41. 0 ? -99 ten or more households."

30. How many people within your household regularly use the bush / field at home or at work?
There are [x number] people in this household.

Check HQ3: Are there household members age 5 or younger? Go to question 32 if not.

31. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?
Do not read the possible responses out loud.
32. Ask permission to take a photo of the entrance of the house. Did you get consent to take the photo? [Skip R if No]

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

Q. Location
Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

Check 32: Did you ask permission to take the photo? [Go to R if No]

R. Ensure that no people are in the photo

R. Record the result of the Household Survey