Data Cart

Your data extract

0 variables
0 samples
View Cart

Household Questionnaire - First round Core Questionnaire

Please record the following identifying information prior to beginning the interview.
A. How many times have you visited this household?

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

B. Your name: Is this your name?
[ODK will display the name associated with the phone's serial number.]
Check the button next to the name if that is your name and select ???yes' here. Do not check the button if that is not your name and select ???no' here (long press to remove response next to the name if needed).
[] Yes 1
[] No 0

Enter your name below. Please record your name Interviewer's Name
C. Current date and time: Is this date and time correct?
[ODK will display on screen]

[] Yes 1
[] No 0

D. Record the correct date and time.
Date:
Month____ Day____ Year____
Time: Hour____ Minutes____ AM/PM
E1. Select [ADMINISTRATIVE SUBDIVISION 1]
[ODK will display a list of the largest subnational administrative subdivisions for the country, e.g. states, regions, provinces]

[] ADMINISTRATIVE SUBDIVISION 1a 1
[] ADMINISTRATIVE SUBDIVISION 1b 2
[] ADMINISTRATIVE SUBDIVISION 1c 3

E2 Select [ADMINISTRATIVE SUBDIVISION 2]
[ODK will populate a list of the next-largest administrative sub-divisions based on response in E1, e.g. counties, departments]

[] ADMINISTRATIVE SUBDIVISION 2a 1
[] ADMINISTRATIVE SUBDIVISION 2b 2
[] ADMINISTRATIVE SUBDIVISION 2c 3
E3 Select [ADMINISTRATIVE SUBDIVISION 3]
[ODK will populate a list of the next-largest administrative sub-divisions based on response in E2, e.g. municipalities]

[] ADMINISTRATIVE SUBDIVISION 3a 1
[] ADMINISTRATIVE SUBDIVISION 3b 2
[] ADMINISTRATIVE SUBDIVISION 3c 3

E4 Select [ADMINISTRATIVE SUBDIVISION 4]
[ODK will populate a list of the next-largest administrative sub-divisions based on response in E3, e.g. districts, cities]

[] ADMINISTRATIVE SUBDIVISION 4a 1
[] ADMINISTRATIVE SUBDIVISION 4b 2
[] ADMINISTRATIVE SUBDIVISION 4c 3

E5 Select enumeration area
[ODK will populate a list of appropriate enumeration areas located in administrative subdivision E4.]

[] ENUMERATION AREA 1. 1
[] ENUMERATION AREA 2. 2
[] ENUMERATION AREA 3. 3

F. Structure number
Please record the structure number from the household listing form. Structure number:_________
G. Household number
Please record the household number from the household listing form. Household 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 1
[] No 0

WARNING: Contact your supervisor before sending this form again.
CHECK: Why are you resending this form?
Select all that apply.
[] There are new household members on this form 1
[] I am correcting a mistake made on a previous form 2
[] The previous form disappeared from my phone without being sent 3
[] I submitted the previous form and my supervisor told me that is was not received 4
[] Other reason(s) 5

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

[] Yes 1
[] No 0

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 [COUNTRY PARTNER] in collaboration with [OTHER PARTNERS]. 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?
I. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

[] Yes 1
[] No 0

Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
J. Interviewer's name
Please record your name as a witness to the consent process. You previously entered
"[NAME FROM HQ B].???

K. Respondent's first name.
Please record the first name of the respondent.
SECTION 1 - Household Roster
I am now going to ask you a series of questions about each usual member of the household or anyone who slept in the house last night.
1. First name

NAME________

2. Sex

[] Male 1
[] Female 2

3. Age (years). If less than one year old, record 0.

AGE____

4. Marital Status

[] Married 1
[] Living with a partner 2
[] Divorced / separated 3
[] Widow / widower 4
[] Single 5

5. Relationship to head of household

[] Head 1
[] Wife/Husband 2
[] Son/Daughter 3
[] Son/Daughter-in-law 4
[] Grandchild 5
[] Parent 6
[] Parent in law 7
[] Brother/Sister 8
[] Other 9
[] Don't know -88

6. Family ID

ID____

7. 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 here last night 1
[] Usual member of the household who did not sleep in the house last night 2
[] Visitor who slept in the house last night 3

8. Eligible female respondent

[] Yes 1
[] No 0
ODK will determine and display eligibility based on age and sex.

After recording information for one household member, the following prompt is asked to activate a looping script to record the information for another member if needed:

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

[] Yes 1
[] No 0

READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named, [NAMES OF ENTERED HOUSEHOLD MEMBERS]. Is this a complete list of the household members? Remember to include all children in the household.

[] Yes 1
[] No 0

Section 2 - Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.
10. Please tell me about the items you're your household owns. Does your household have:
[ODK populates a list of country-specific household assets, e.g. bed, television, electricity. The asset list may vary between countries, but is constant within each country for each round of data collection.]
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.
[ASSET 1]

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

[ASSET 2]

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

[ASSET 3]

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

11a. Does this household own any livestock, herds, other farm animals, or poultry?
[ODK populates a list of country-specific livestock and poultry. The asset list may vary between countries, but is constant within each country for each round of data collection.]
These livestock can be kept anywhere, not necessarily on the homestead.
[] Yes 1
[] No 0
[] No response -99

11b. How many of the following animals does this household own? Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
The household can keep the livestock anywhere but must own the livestock recorded here.
[ANIMAL 1]: _______
[ANIMAL 2]: _______
[ANIMAL 3]: _______
12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock? Homestead includes the structure and yard that is close to the structure.

[] Yes 1
[] No 0
[] No response -99

12b. How many of the following animals does this household keep on the homestead? Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
[ODK populates a list of animals typically found in the country, including livestock, herds and poultry.]
The household does not need to own the livestock recorded here.
[ANIMAL 1]: _______
[ANIMAL 2]: _______
[ANIMAL 3]: _______

Section 3 - Household Observation
Please observe the floors, roof and exterior walls.
13. Main material of the floor
Observe.
[ODK populates a list of floor types specific to each country, e.g. earth/sand (natural), wood planks (rudimentary) or cement (finished).]
Natural floor:

[] [TYPE 1a] 1
[] [TYPE 1b] 2

Rudimentary floor:

[] [TYPE 2a] 3
[] [TYPE 2b] 4

Finished floor:

[] [TYPE 3a] 5
[] [TYPE 3b] 6
[] Other 7
[] No response -99

14. Main material of the roof
Observe.
[ODK populates a list of roof types specific to each country, e.g. thatch (natural), palm/bamboo (rudimentary) or metal (finished).]
Natural roof:

[] [TYPE 1a] 1
[] [TYPE 1b] 2

Rudimentary roof:

[] [TYPE 2a] 3
[] [TYPE 2b] 4

Finished roof:

[] [TYPE 3a] 5
[] [TYPE 3b] 6
[] Other 7
[] No response -99

15. Main material of the exterior walls
Observe.
[ODK populates a list of exterior wall types specific to each country, e.g. mud (natural), plywood (rudimentary) or brick (finished).]
Natural walls:

[] [TYPE 1a] 1
[] [TYPE 1b] 2

Rudimentary walls:

[] [TYPE 2a] 3
[] [TYPE 2b] 4

Finished walls:

[] [TYPE 3a] 5
[] [TYPE 3b] 6
[] Other 7
[] No response -99

Section 4 - Water, Sanitation and Hygiene
Now I would like to ask you a few questions about water, sanitation and hygiene.
16. Do you have a place to wash your hands?

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

17. Can you show it to me?

[] Yes 1
[] No 0

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

[] 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

19. 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 the bottom to see all choices.
Piped Water

[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole

Dug Well

[] Protected Well
[] Unprotected Well

Water from Spring

[] Protected Spring
[] Unprotected Spring

[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River/Dam/Lake/Pond/Stream/Canal/Irrigation Channel)
[] Bottled Water
[] Sachet Water
20. What is the main source of drinking water for members of your household?
[ODK will populate the list of water sources selected for HQ19]
Selections from HQ19:
Piped Water

[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole

Dug Well

[] Protected Well
[] Unprotected Well

Water from Spring

[] Protected Spring
[] Unprotected Spring

[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River/Dam/Lake/Pond/Stream/Canal/Irrigation Channel)
[] Bottled Water
[] Sachet Water

21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
[ODK will populate the list of water sources selected for HQ19]
Selections from HQ19:
Piped Water

[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole

Dug Well

[] Protected Well
[] Unprotected Well

Water from Spring

[] Protected Spring
[] Unprotected Spring

[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River/Dam/Lake/Pond/Stream/Canal/Irrigation Channel)
[] Bottled Water
[] Sachet Water

Questions HQ 22 to HQ 25 will repeat x times, once for each water source selected in HQ 19. These sources include:
[ODK will display HQ19 selections.]
22. You mentioned that you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:

[] Drinking
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing

23. Is [WATER SOURCE] typically available:
Read all choices out loud.
[] All of the year 1
[] Some of the year 2
[] Small part of the year 3
[] No response -99

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

[] Yes, always 1
[] No, intermittent and predictable 2
[] No, intermittent and unpredictable 3
[] No response -99

25. How long does it take to go to [WATER SOURCE], get water, and come back?
Zero is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.
Time in minutes:______
26. Does your household have a garden?
A garden is a place to grow vegetables.
[] Yes 1
[] No 0
[] No response -99

27. Do members of your household use any of the following toilet facilities?
Read out all types and check all that are used. Scroll to the bottom to see all choices.
Flush/pour flush toilets connected to:

[] Piped sewer system
[] Septic tank
[] Elsewhere
[] 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

28. What is the main toilet facility used by members of your household? HQ27: [ODK will populate the list of facilities selected in HQ27]. The main facility must be selected in HQ 27. Flush/pour flush toilets connected to:

[] Piped sewer system 1
[] Septic.tank 2
[] Elsewhere 3
[] Unknown / Not sure / Don't know 4
[] Ventilated improved pit latrine 5
[] Pit latrine with slab 6
[] Pit latrine without slab 7
[] Composting toilet 8
[] Bucket toilet 9
[] Hanging toilet /Hanging latrine 10
[] Other 11
[] No facility / bush / field 12
[] No response -99

Question HQ 29 will repeat x times, once for each sanitation facility selected in HQ27. These facilities include:
HQ27: [ODK will populate the list of facilities selected in HQ27].
29. How often does your household typically use: [TOILET FACILITY TYPE]? Regular practices at the household only.

[] Always 1
[] Most of the time 2
[] Occasionally 3
[] Rarely 4
[] No response -99

29b. Do you share this toilet facility with other households or the public?

[] Not shared 1
[] Shared with less than ten households 2
[] Shared with ten or more households 3
[] Shared with the public. 4
[] No response -99

29c. Enter the number of households that share this facility (including your own).
[TOILET FACILITY TYPE]
Must be between 2 and 9. If 10 or greater, swipe back to HQ29b and choose "shared with ten or more households.??? Enter -99 for no response.
Number of people:__________
30. How many people within your household regularly use the bush / field at home or at work? There are x people in this household. Enter -88 for do not know, -99 for no response.
Number of people:__________
CHECK HQ 3: Are there any household members aged 5 years or under?
31. For all children under age five: what methods, if any, does your household use to dispose of children's waste?
Do not read the possible answers out loud.
[] Children use a latrine / toilet
[] Leave waste where it is
[] Bury waste in field / yard
[] Dispose of waste in latrine / toilet
[] Dispose of waste with rubbish / garbage
[] Dispose of waste with waste water
[] Use it as manure
[] Burn it
[] Don't know -88
[] No response -99

32. Ask permission to take a photo of the entrance of the house. Did you get consent to take the photo?

[] Yes 1
[] No 0

Thank the respondent for her/his time.
The respondent is finished, but there is still more for you to complete outside the home.
L. Location
Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6m.
RECORD LOCATION:__________
CHECK 32: Permission to take photo?
M. Ensure that no people are in the photo
TAKE PICTURE CHOOSE IMAGE
N. Questionnaire result
Record the result of the Household Questionnaire

[] Completed 1
[] No household member at home or no competent respondent at home at time of visit 2
[] Postponed 3
[] Refused 4
[] Partly completed 5
[] Dwelling vacant or address not a dwelling 6
[] Dwelling destroyed 7
[] Dwelling not found 8
[] Entire household absent for extended period 9