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CDR3 Household Questionnaire

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?

[] Yes
[] No

A. Enter your name below.

Interviewer's Name _____
Please record your name

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

[] Yes
[] No

C. Record the correct date and time.

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

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.
[] Yes
[] No

WARNING: Contact your supervisor before sending this form again.

CHECK: Why are you resending this form?
Choose all that apply.
[] There are new household members on this form
[] I am correcting a mistake made on a previous form
[] The previous form disappeared from my phone without being sent
[] I submitted the previous form and my supervisor told me that it was not received
[] Other reason(s)

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

[] Yes
[] No

G2. Did this household participate in a previous PMA2020 survey?

[] Yes
[] No
[] Do not know
[] No response

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?

[] Yes
[] No

Respondent's signature

[] Checkbox

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

[] Male
[] Female

HQ3. Age (years)

Age __________________
If less than one year old, record 0

HQ4. Marital Status

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

HQ5. Relationship to head of household
HQ4 must be "Married" or "Living with a partner" if HQ5 is wife/husband.
[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response

HQ6. Family ID

[] __________________

HQ7. 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 in the household 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

HQ8. Eligible for the female respondent questionnaire.

[] Yes
[] No

HQ9. Are there any other usual members of your household or persons who slept in the house last night?

[] Yes
[] No

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.
[] Yes
[] No

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.
[] Electricity?
[] A wall clock?
[] A radio?
[] A black/white television?
[] A color television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A freezer?
[] An electric generator/invertor(s)?
[] A washing machine?
[] A computer?
[] A digital photo camera?
[] A non-digital photo camera?
[] A video deck?
[] A DVD/CD?
[] 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?
[] A gas or electric stove?
[] A chair(s)?
[] A lamp(s)?
[] An oven?
[] A hoe(s)?
[] Animal-drawn cart?
[] A canoe or motorized canoe?
[] A rental house?
[] None of the above
[] No response

HQ11a. 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
[] No response

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.

Cows or bulls: ___________
Horses, donkeys or mules: ___________
Goats: ___________
Sheep: ___________
Hogs/pigs: ___________
Ducks/canes: ___________
Hens/cocks/other poultry: ___________
Other: ___________

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.
[] Yes
[] No
[] No response

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.
[] Earth / sand
[] Cow dung
[] Wooden boards
[] Palm / bamboo
[] Parquet or polished wood
[] Tapes vinyl / asphalt
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer

HQ14. Main material of the roof
Observe.
[] No roof
[] Thatch / palm
[] Earth mottes
[] Mats
[] Palm / bamboo
[] Wooden boards
[] Cardboard
[] Sheet metal
[] Wood
[] Zinc / fiber cement
[] Tile
[] Cement
[] Shingles
[] Other
[] No answer

HQ15. Main material of the exterior walls
Observe.
[] No wall
[] Bamboo / cane / palm / trunk
[] Earth
[] Bamboo with mud
[] Stones with mud
[] Adobe not covered
[] Plywood
[] Cardboard
[] Recovered wood
[] Cement
[] Stones with lime / cement
[] Bricks
[] Cement blocks
[] Covered adobe
[] Wood board / shingles
[] Other
[] No answer

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.
[] Yes, fixed place
[] Yes, movable container
[] No
[] Don't know
[] Refuse to answer

HQ17a. Can you show it to me?

[] Yes
[] No

HQ18a. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
[] 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

HQ17b. Can you show me any soap, water, and movable container available in the household used for hand washing?

[] Yes
[] No

HQ18b. Anywhere within the household, observe if:
Cannot select 'none of the above' with other options.
[] Soap is present
[] Water source is present: stored water
[] Water source is present: running water
[] Hand washing container is observed
[] None of the above

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.
[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

HQ20. What is the main source of drinking water for members of your household?
Selections from HQ19: [SOURCE]
Read out HQ19 selections only.
[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

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.
[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

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:

[] Drinking
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing
[] No response

HQ23. Is [SOURCE] water to your indoor typically available:
Read all choices out loud.
[] All of the year
[] Some of the year
[] Small part of the year
[] No response

HQ24. At a time of year when you expect to have water from [SOURCE], is it usually available?

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

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.
[] Yes
[] No
[] No response

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.
[] 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 / Not sure / 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

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.
[] 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 / Not sure / 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

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.
[] Always
[] Most of the time
[] Occasionally
[] Rarely
[] No response

HQ29b. Do you share this toilet facility with other households or the public?
[SANITATION FACILITY]

[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public.
[] No response

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."
[] Number______________

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.
Number of people ____

HQ31. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?

[] 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.

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?

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

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