Is this your ID?

001b. Enter your ID below.

Please record your ID

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2018-08-01 and 2019-09-01.

003a. Province

003b. District

003b. Zone de Santé

003c. Aire de Santé

003c. Quartier

003d. Village

003d. Localité / rue

004. EA

005. Please note the street or avenue number where the household is located

The supervisor will give you the street or avenue name.

005. Structure number

Please record the structure number from the household listing form.

Invalid response.

006. Household number

Please record the household number from the household listing form.

Invalid response.

007. 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.

008. 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.

009a. Is a member of the household and competent respondent present and available to be interviewed today?

009b. 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 ________________________________ and I am working for the School of Public Health of Kinshasa in collaboration with the Ministry of Health. We are conducting a local survey about various health issues. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. 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 am going to ask you questions about your family and other household members. We would then like to ask a different set of questions to female members of this household who are between the ages of 15 and 49 years.
At this time, do you want to ask me anything about the survey?

010a. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

010b. Respondent's signature

Please ask the respondent to sign or check the box in agreement of their participation.

Checkbox

WARNING: The respondent has not signed or checked the box, despite agreeing to be interviewed in the previous question. To conduct the survey, the respondent must sign or touch the checkbox.

You may go back to obtain a signature or check the box or you should go back to the previous question to indicate the respondent does not want to be interviewed.

010c. Interviewer's ID: ${your_name}

Mark your ID as a witness to the consent process.

010c. Interviewer's ID

Please record your ID as a witness to the consent process. You previously entered "${name_typed}."

That is not what you entered for your ID earlier in this survey.

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

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

102. What is ${firstname}'s relationship to the head of household?

103. Is ${firstname} male or female?

104. How old was ${firstname} at their last birthday?

If less than one year old, record 0

Age must be less than 130 and greater than zero.

105. What is ${firstname}'s current marital status?

If not married, probe to determine if they have ever been married and, if so, if they are divorced/separated, or widowed.

106. Does ${firstname} usually live here?

107. Did ${firstname} stay here last night?

ERROR: Members on household roster must usually live here or must have stayed here last night.

Go back and remove this household member.

LCL_101. What is the religion of ${firstname}?

LCL_102. What is the ethnicity of ${firstname}?

This person IS NOT eligible for the female respondent questionnaire.

This person IS eligible for the female respondent questionnaire.

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

There are other members of the household. Move forward and select "Add Group"

There are no other members of the household. Move forward and select "Do Not Add"

ERROR: There is no household head.

Go back, select a head.

For each member, check that the relationship to the household head is accurate.

ERROR: There are ${heads} household heads selected:
${head_name_joined}

Go back, select only one head.

For each member, check that the relationship to the household head is accurate.

101a NO RESPONDENT ERROR.

The checkbox for 101a (Is this person the respondent?) was never selected for any of the household members.

You entered the following household members: ${names}.

If the respondent was entered in the roster but never selected as the respondent in 101a: Please go back and select the checkbox in 101a for the correct respondent.

If the respondent is a household member but left out of the list of household members: Add the respondent to the list.

If the respondent is not a household member: Stop the interview. Find a household member and interview that person. Be sure to ask for consent.

101a TOO MANY RESPONDENTS ERROR.

The checkbox for 101a (Is this person the respondent?) was selected more than once.

Please go back and make sure that it is only selected once.

109. READ THIS CHECK OUT LOUD: There are ${num_HH_members} household members who are named ${names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

Section 2 -- Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

201. 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.

Cannot select 'no response' or 'none of the above' with other options.

Check here to acknowledge you considered all options.

202a. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

202b. 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 ________

[] Hens/cocks/other poultry_______

[] Other________

Section 3 -- Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor
Observe.

302. Main material of the roof

Observe.

303. 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.

401a. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

401c. At the place where the household washes their hands, observe if:

Check all that apply.

Cannot select 'none of the above' with other options.

402. 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.

Cannot select 'no response' with other options.

Check here to acknowledge you considered all options.

403. What is the main source of drinking water for members of your household?

Selections from 402:
${source_labels}

Read out 402 selections only.

You did not select that choice in 402.

404. What is the main source of water used by your household for other purposes such as cooking and hand washing?

Selections from 402:
${source_labels}

Read out 402 selections only.

You did not select that choice in 402.

405. You mentioned that you used ${main_drinking_water_lab}. At any time of the year, does your household use water from this source for:

Cannot select 'no response' with other options.

406. How many months out of the year is ${main_drinking_water_lab} usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have ${main_drinking_water_lab}, is it usually available?

408. How long does it take to go to the ${main_drinking_water_lab}, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

409. 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.

Cannot select 'no response' with other options.

Check here to acknowledge you considered all options.

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

Selections from 409:
${sanitation_labels}

The main facility must be selected in 409.

You did not select that choice in the previous question.

SN_411.ii. When was the last time your ${the_sanitation_lab} was emptied?

Probe: How many months or years ago?

If less than one month, select months.

Enter ${sanitation_empty_lab}:

If less than one month, enter 0 months.

SN_411.iii. The last time your ${the_sanitation_lab} was emptied, who emptied it?

Probe: Was it emptied by household members or by neighbors or by a service provider?

SN_411.iv. The last time your ${the_sanitation_lab} was emptied, where were the contents emptied to?

SN_411.v. Where is your toilet facility located?

${the_sanitation_lab}

411. How often does your household typically use:

${the_sanitation_lab}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

${the_sanitation_lab}

412b. Enter the number of households that share this facility (including your own).

${the_sanitation_lab}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

413. How many people within your household regularly use the bush / field at home or at work?

There are ${num_HH_members} people in this household.

Enter -88 for do not know, -99 for no response.

Must be between zero and the number of household members.

WARNING: The respondent entered zero for the previous question, 413, but listed open defecation as a household sanitation facility in 409.

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

PROBE: Other methods?

Do not read the possible responses out loud.

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

096. Location

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

097. How many times have you visited this household?

098. In what language was this interview conducted?

099. Questionnaire Result

Record the result of the questionnaire.