Data Cart

Your data extract

0 variables
0 samples
View Cart


CDR1 Household Questionnaire

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


• How many times have you visited this household?

[] 1st time
[] 2nd time
[] 3rd time

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

[] Yes
[] No

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

Interviewer's Name _____

• Current Date and Time
Is this date and time correct?

[] Yes
[] No

• Record the correct date and time

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

• Region
Select the name of the region where the household is found.
For this survey, there is only Kinshasa.
[] Bandundu
[] Bas-Congo
[] Equateur
[] Kasai-Occidental
[] Kasai-Oriental
[] Katanga
[] Kinshasa
[] Maniema
[] Nord-Kivu
[] P. Orientale
[] Sud-Kivu

• 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?

[] Yes
[] No

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?

[] Oui
[] Non

• 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.]

[] Yes
[] No

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

NAME________

• Sex

[] Man
[] Woman

• Age (years)
If less than one year, note '0'
Age________

• Marital status

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

• Relationship to head of household

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response

• Household ID

[] ___________

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

[] Usual member of the household who slept here last night
[] Usual member of the household who did not sleep in the house last night
[] Visitor who slept in the house last night
[] No response

8. Eligible female respondent

[] Yes
[] No
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:

[] Yes
[] No

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

[] Yes
[] No

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.
[] Electricity?
[] A wall clock?
[] A radio?
[] A black/white television?
[] A color television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A freezer?
[] Electric generator/invertor(s)?
[] A washing machine?
[] A computer?
[] A digital photo camera?
[] A non digital photo camera?
[] A video deck?
[] A DVD/CD player?
[] A sewing machine?
[] A bed?
[] A table?
[] A cabinet/cupboard?
[] A bicycle?
[] A motorcycle or motor scooter?
[] A car or truck?
[] A boat with a motor?
[] A boat without a motor?
[] None of the above
[] No response

11. Do you have livestock, herds, other farm animals, or poultry?

[] Yes
[] No

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.
Goats or Sheep ___
Chickens, ducks or geese___
Cattle, horses, or donkeys___
Pigs ___
Other ___

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

13. Main material of the floor
Observe.
Natural Floor
[] Earth / sand
[] Dung
Rudimentary Floor
[] Wooden boards
[] Palm / bamboo
Finished Floor
[] Parquet or polished wood
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] Lineoleum / rubber
[] Other
[] No answer

14. Main material of the roof
Observe.
Natural Roof
[] No roof
[] Thatch / soil
Rudimentary Roofing
[] Rustic mattress
[] Palm / bamboo
[] Wood planks
[] Cardboard
Finished Roofing
[] Metal / Tin sheets
[] Wood
[] Carbon / Fiber cement
[] Tiles / bricks
[] Cement
[] Shingles / wood planks
[] Adobe
[] No answer

15. Main material of the exterior walls
Observe.
Natural Walls
[] No wall
[] Bamboo / cane / palm / trunk
Rudimentary Walls
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood
Finished Walls
[] Cement
[] Stone
[] Brick
[] Cement blocks
[] Covered adobe
[] Wood planks/shingles
[] No response

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?

[] Yes
[] No
[] Don't know

17. Can you show it to me?

[] Yes
[] No

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

Soap is present

[] Yes
[] No

Water source is present: stored water

[] Yes
[] No

Water source is present: running water

[] Yes
[] No

Handwashing area is near a sanitation facility

[] Yes
[] No

None of the above

[] Yes

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

[] Yes
[] No

Piped water: Piped to yard / plot

[] Yes
[] No

Piped water: Piped to public tap/standpipe

[] Yes
[] No

Tube well or borehole

[] Yes
[] No

Dug and protected well

[] Yes
[] No

Dug and unprotected well

[] Yes
[] No

Water from protected spring

[] Yes
[] No

Water from unprotected spring

[] Yes
[] No

Rainwater

[] Yes
[] No

Tanker Truck

[] Yes
[] No

Cart with Small Tank

[] Yes
[] No

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

[] Yes
[] No

Bottled Water

[] Yes
[] No

Sachet Water

[] Yes
[] No

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.
Piped water
[] Piped into dwelling / indoor
[] Piped to yard / plot
[] Piped to public tap/standpipe
[] Tube well or borehole
Dug well
[] Protected well
[] Unprotected well
Water from spring
[] Protected spring
[] Unprotected spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water

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.
Piped water
[] Piped into dwelling / indoor
[] Piped to yard / plot
[] Piped to public tap/standpipe
[] Tube well or borehole
Dug well
[] Protected well
[] Unprotected well
Water from spring
[] Protected spring
[] Unprotected spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water

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

[] Yes
[] No

Cooking

[] Yes
[] No

Laundry

[] Yes
[] No

Livestock

[] Yes
[] No

Gardening / agriculture

[] Yes
[] No

Business venture

[] Yes
[] No

23. Is [WATER SOURCE] typically available:

[] All of the year
[] Some of the year
[] Small part of the year

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

[] Yes, always
[] No, intermittent and predictable
[] No, intermittent and unpredictable

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?

[] Yes
[] No

27. Do members of your household use any of the following toilet facilities?
Read all types and select all that apply.
[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Unsure / Don't know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] No facility / bush / field
[] Other

28. What is the main toilet facility used by members of your household?

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Unsure / Don't know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

29. How often does your household typically use: [TOILET FACILITY]
Read all types and select those used.
[] Always
[] Most of the time
[] Occasionally
[] Rarely

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.
Number of people ____

31. Are there household members age 5 or younger?

[] Yes
[] No

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

[] Yes
[] No

Leave waste where it is

[] Yes
[] No

Bury waste in field / yard

[] Yes
[] No

Dispose of waste in latrine / toilet

[] Yes
[] No

Dispose of waste with rubbish / garbage

[] Yes
[] No

Dispose of waste with waste water

[] Yes
[] No

Use it as manure

[] Yes
[] No

Burn it

[] Yes
[] No

Other

[] Yes
[] No
Specify.

Don't know

[] Yes
[] No

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

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant or address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period