001b. Enter your ID below.
Please record your ID

002b. Record the correct date and time.
Day:
Month:
Year:

003a. Region

[] AGNEBY-TIASSA
[] AUTONOME D'ABIDJAN
[] BAGOUE
[] BERE
[] CAVALLY
[] GBEKE
[] GBOKLE
[] GOH
[] GONTOUGO
[] GRANDS-PONTS
[] GUEMON
[] HAMBOL
[] HAUT-SASSANDRA
[] IFFOU
[] INDENIE-DJUABLIN
[] LA ME
[] LOH-DJIBOUA
[] MARAHOUE
[] MORONOU
[] NAWA
[] N'ZI
[] PORO
[] SAN-PEDRO
[] SUD-COMOE
[] TCHOLOGO
[] TONKPI
[] YAMOUSSOUKRO

003b. Department

003c. Sub-prefecture

004. Enumeration area

005. Structure number
Please record the structure number from the household listing form.

006. Household number
Please record the household number from the household listing form.

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.

008. CHECK: Why are you resending this form? Choose all that apply.

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.

Bonjour. Je m'appelle ____________________________________ et je travaille pour l'Institut National de la Statistique de Côte d'Ivoire (INS-Côte d'Ivoire). Nous menons une enquête locale auprès des femmes sur plusieurs questions de santé. Nous apprécierons grandement votre participation à cette étude. Ces informations nous aideront à informer le gouvernement afin d'offrir de meilleurs services de santé. L'enquête dure généralement 15 minutes. Je vous poserais des questions sur votre famille et les membres de votre ménage. Ensuite, nous aimerions poser une série de questions différentes à toutes les femmes du ménage qui ont entre 15 et 49 ans. Toute information que vous voudrez bien nous communiquer sera strictement confidentielle, et seules les données rendues complètement anonymes seront utilisées pour mener des analyses, en présenter les résultats et partager les données. La participation à cette enquête est entièrement volontaire. Si nous rencontrons une question à laquelle vous ne souhaitez pas répondre, faites-le moi savoir et je passerai à la suivante. Vous êtes libre de ne pas participer à cette enquête du tout, ou de l'interrompre à tout moment. Cependant, nous espérons que vous voudrez bien y participer car votre opinion est très importante. Si vous avez des questions sur cette étude et sur vos droits en tant que participant à une recherche, vous pouvez me les poser ou contacter M. Aka Doré à l'Institut National de la Statistique de Côte d'Ivoire (INS-Côte d'Ivoire) au +225 09 34 14 94. Jusqu'ici, avez-vous des questions sur l'enquête ? Puis-je commencer l'interview à présent ?

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.

010c. Interviewer's name Please record your name as a witness to the consent process.
You previously entered [NAME FROM 001]

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 [NAME] relationship to the head of household?

103. Is [NAME] male or female?

104. How old was [NAME] at their last birthday?
If less than one year old, record 0

105. What is [NAME]'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 [NAME] usually live here?

107. Did [NAME] 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 [NAME]?

LCL_102. What is the ethnicity of [NAME]?

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 [NUMBER] household heads selected: [HOUSEHOLD HEAD NAMES ENTERED]
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 [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named [NAMES]. Is this a complete list of the 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.

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.

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.

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

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?

401b. At the place where the household washes their hands, observe if:
Check all that apply.

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.

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: [ODK will show the sources selected in 402] Read out 402 selections only.

404. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Selections from 402: [ODK will show the sources selected in 402] Read out 402 selections only.

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

406. How many months out of the year is [MAIN WATER SOURCE] usually available:
Zero is a possible answer. Please record the number of completed months.

407. At a time of year when you expect to have [MAIN WATER SOURCE], is it usually available?

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

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.

Check here to acknowledge you considered all options.

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

SN_411.ii. When was the last time your [MAIN SANITATION FACILITY] was emptied?
Probe: How many months or years ago? If less than one month, select months.

Enter [Months OR Years]: If less than one month, enter 0 months.

SN_411.iii. The last time your [MAIN SANITATION FACILITY] 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 [MAIN SANITATION FACILITY] was emptied, where were the contents emptied to?

SN_411.v. Where is your toilet facility located? [MAIN SANITATION FACILITY]

411. How often does your household typically use: [TOILET FACILITY]. Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public? [MAIN SANITATION PLACE]

412b. Enter the number of households that share this facility (including your own). [MAIN SANITATION PLACE]
Must be between 2 and 9. If 10 or greater, move back to 412a and choose "Shared with ten or more households."

413. How many people within your household regularly use the bush / field at home or at work?
There are [X NUMBER] people in this household.

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.