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

A. Your name:

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

A. Enter your name below.

Please record your name

B. Current date and time.
Is this date and time correct?

C. Record the correct date and time.

D. Commune
ODK will generate a list of appropriate communes.

D. Neighborhood
ODK will generate a list of appropriate neighborhoods.

D. Please note the street or avenue number where the household is located
The supervisor will give you the street or avenue name.

E. Structure number
Please record the structure number from the household listing form. The supervisor will give you the structure number.

F. Household number
Please record the household number from the household listing form. The supervisor will give you the structure number.

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

G2. 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 is ______________________________. 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 analyses, 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?

H. 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

I. Interviewer's name
Please record your name as a witness to the consent process. You previously entered [NAME]

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.

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

HQ7. Is this person a usual member of the household or has he/she slept in the house last night?

HQ8. Eligible for the female respondent questionnaire.

HQ9. 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] household members who are named [NAMES]. Is this a complete list of 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.

HQ10. 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.
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?
The household can keep the livestock anywhere, but must own the livestock recorded here. Zero is a possible answer.


HQ12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these animals?
Homestead includes the structure and yard that is in close to the structure.
HQ12b. How many of the following animals does this household keep ON THE HOMESTEAD.
The household does not need to own the livestock recorded here. Zero is a possible answer.
[] Cows or bulls:____________
[] Horses, donkeys or mules:____________
[] Goats:____________
[] Sheep:____________
[] Hogs/pigs:____________
[] Ducks/canes:____________
[] Hens/cocks/other poultry:____________
[] Other:____________

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, or do you have a movable container that is not kept in a fixed location, such as a bowl or kettle, that is commonly used for hand washing?
If the container is always in the same location, then count it as a fixed place.
HQ17a. Can you show it to me?

HQ18a. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
HQ17b. Can you show me any soap, water, and movable container available in the household used for hand washing?

HQ18b. Anywhere within the household, 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]
Read out HQ19 selections only.
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]
Read out HQ19 selections only.
Questions HQ22 to HQ25 will repeat 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 [SOURCE] water to your indoor typically available:
Read all choices out loud.
HQ24. At a time of year when you expect to have water from [SOURCE], 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?
A garden is a place to grow vegetables.
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?
There are [NUMBER] people in this household.
Must be between zero and the number of household members.
HQ31. 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 is still more for you to complete outside the home.

Location and Questionnaire Result

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

L. Ensure that no people are in the photo.

M. How many times have you visited this household?

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