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

A. How many times have you visited this household?

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

B. Enter your name below.
Please record your name
C. Current date and time.
[CURRENT DATE AND TIME DISPLAYED]
Is this date and time correct?

D. Record the correct date and time.

E. Commune
[ODK will generate a list of appropriate communes.]

E. Neighborhood
[ODK will generate a list of appropriate neighborhoods.]

F. Address
Please select the number of the street / avenue where the household is found.

G. Structure
Please select the number of the structure where the household is found.

H. Household
Please select the number of the household in the neighborhood list.

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.
WARNING: Contact your supervisor before sending this form again.

CHECK: Why are you resending this form?
Choose all that apply.
WARNING: Each household should have ONLY ONE household roster with all household members listed on the same form.
Please contact your supervisor before sending this form.

H1. Is a member of the household and competent respondent present and available to be interviewed today?

H2. Did this household participate in a previous PMA2020 survey?

INFORMED CONSENT
Find a competent member of the household. Read the greeting on the following screen.

Hello. My name. ______________________________ I am here representing the Ministry of Health and the School of Public Health Kinshasa to learn more about health services in Kinshasa. Now I will read a statement explaining this investigation. Our team collects information on family planning in the Democratic Republic of Congo. We would like to ask you about the characteristics of your household, as well as activities related to family planning. Information about you may be used for activities and family planning services in the Democratic Republic of Congo. Data collected will be analyzed by researchers, but your name will be removed from all analyzes, so that your information remains anonymous. You can refuse to answer questions you will be asked many times as you want, and decide to stop the survey at any time. Do you have questions about this survey?

I. Provide a paper copy of the Consent Form to the respondent and explain it. 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.
[] Checkbox

J. Interviewer's name
Mark your name as a witness to the consent process.
[ODK will display the name linked to the telephone number.]

K. Interviewer's name
Please record your name as a witness to the consent process. You previously entered
[NAME]
That is not what you entered for your name earlier in this survey.

L. 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.

Household member

HQ1. First name

HQ2. Sex

HQ3. Age (years)
If less than one year old, record 0
HQ4. Marital Status

HQ5. Relationship to head of household
HQ4 must be "Married" or "Living with a partner" if HQ5 is wife/husband.
HQ6. Family ID

HQ6: Must be greater than 0.

HQ7. 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.

HQ9. 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.

HQ10. Please tell me about items that your household owns. Does your household have:

HQ11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
HQ11b. 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.
HQ12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these animals?

HQ12b. 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.

HQ13. Main material of the floor
Observe.
HQ14. Main material of the roof
Observe.
HQ15. 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.

HQ16. Do you have a place to wash your hands?

HQ17. Can you show it to me?

HQ18. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
HQ19. 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 are used. Scroll to bottom to see all choices.
HQ20. What is the main source of drinking water for members of your household?
Selections from HQ19: [SOURCE]

HQ21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Selections from HQ19: [SOURCE]

Questions HQ22 to HQ25 will repeat [NUMBER OF SOURCES] times, once for each water source selected in HQ19. These sources include:
[SOURCES]

HQ22. You mentioned that you use [SOURCE] water. At any time of the year does your household use water from this source for:

HQ23. Is piped water to your indoor typically available:
Read all choices out loud.
HQ24. At a time when you expect to have water from the piped source in your dwelling, is it usually available?

HQ25. How long does it take to go to the [SOURCE], get water, and come back?
0 is a possible answer. Convert answer to minutes. Includes waiting time in line.

HQ26. Does your household have a garden?

HQ27. Do members of your household use any of the following toilet facilities?
Read out all types. Check all that are used. Scroll to bottom to see all choices.
HQ27. Other, please explain:

HQ28. What is the main toilet facility used by members of your household?
[SANITATION FACILITY]
The main facility must be selected in HQ27.
Question HQ29 will repeat once for each sanitation facility selected in HQ27. These facilities include:
[SANITATION FACILITY]

HQ29. How often does your household typically use:
[SANITATION FACILITY]
Regular practices at the household only.
HQ29b. Do you share this toilet facility with other households or the public?
[SANITATION FACILITY]

HQ29c. Enter the number of households that share this facility (including your own).
[SANITATION FACILITY]
Must be between 2 and 9. If 10 or greater, swipe back to HQ29b and choose "Shared with ten or more households."
HQ30. How many people within your household regularly use the bush / field at home or at work?
Must be between zero and the number of household members.
HQ31. 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.
HQ32. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?

Thank the respondent for his/her time.
The respondent is finished, but there are still 3 more questions for you to complete outside the home.

Location and Questionnaire Result

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

N. Ensure that no people are in the photo.
Take the photo. Choose image.

O. Questionnaire result
Record the result of the household questionnaire.