IDENTIFICATION
Please record the following information prior to beginning the interview.

How many times have you visited this household?

Interviewer's name: Is this your name?
[ODK will display the name associated with the phone's serial number.]

If no, enter your name below.
Please record your name

Current Date and Time
Is this date and time correct?

Record the correct date and time

Region
Select the name of the region where the household is found.
For this survey, there is only Kinshasa.
Health zone
Please select the name of the health zone where the structure is found.
ODK will generate a list of appropriate health zones.

Neighborhood
Please select the number of the neighborhood where the household is found.
ODK will generate a list of appropriate neighborhoods.

Street / Avenue
Please select the number of the street / avenue where the household is found.

Structure Number
Please select the number of the structure where the household is found.
The supervisor will give you the structure number.

Household Number
Please select the number of the household in the neighborhood list.
The supervisor will give you the household number.

Is a member of the household and competent respondent present and available to be interviewed today?

Hello. My name is _________ and I work for the Public Health School of Kinshasa, as well as the Ministry of Health of the Democratic Republic of the Congo. We are conducting a local survey about several health-related topics. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. The survey usually takes between 15 and 20 minutes to complete. 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 will ask you questions about your family and other members of your household. We would then like to ask a series of questions to women in the household between the ages of 15 and 49 years.
Before continuing, do you have any questions about the survey?

Provide a paper copy of the consent form to the person being interviewed and explain it to her.
Then ask: May I begin the interview now?

Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
GATHER SIGNATURE:
Check box: []

Interviewer's name: Is the name below correct?
[ODK will display the name linked to the telephone number.]

If no, please record your name:

Respondent's name
You may correct the spelling here if it is not correct, but you must be interviewing the person whose name appears below.
PLEASE ENTER THE RESPONDENT'S NAME.

Section 1 -- Household Roster
I am now going to ask a series of questions about the members of your family. Let's start with you. Then, for each person who usually lives here or slept here last night, please provide the following information:

Household member

Name

Sex

Age (years)
If less than one year, note '0'
Marital status

Relationship to head of household

Household 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?

Section 2 -- Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.

10. Does your household have:
Read out all types and select all that apply.
11. Do you have livestock, herds, other farm animals, or poultry?

12. 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:

Soap is present

Water source is present: stored water

Water source is present: running water

Handwashing area is near a sanitation facility

None of the above

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.

Piped water: Piped into dwelling / indoor

Piped water: Piped to yard / plot

Piped water: Piped to public tap/standpipe

Tube well or borehole

Dug and protected well

Dug and unprotected well

Water from protected spring

Water from unprotected spring

Rainwater

Tanker Truck

Cart with Small Tank

Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)

Bottled Water

Sachet Water

20. What is the main source of drinking water for members of your household?
Read all the possible options and only choose those from the proposed list.
21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Read all the possible options and only choose those from the proposed list.
22. You mentioned that you used [MAIN WATER SOURCE]. At any time of the year, does your household use water from this source for:

Drinking

Cooking

Laundry

Livestock

Gardening / agriculture

Business venture

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]?
Zero is a possible answer. Convert response to minutes. Include waiting time in line.

26. Does your family have a garden?

27. Do members of your household use any of the following toilet facilities?
Read all types and select all that apply.
28. What is the main toilet facility used by members of your household?

29. How often does your household typically use: [TOILET FACILITY]
Read all types and select those used.
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.
31. Are there household members age 5 or younger?

32. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?

Children use a latrine / toilet

Leave waste where it is

Bury waste in field / yard

Dispose of waste in latrine / toilet

Dispose of waste with rubbish / garbage

Dispose of waste with waste water

Use it as manure

Burn it

Other

Specify.

Don't know

Thank the respondent for his/her time.
The respondent is finished, but there is still more for you to complete outside the home.

Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.
GPS coordinates can only be collected outside.

Record the result of the Household Survey