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

A. How many times have you visited this household?

B. Your name: Is this your name?
ODK will display the name associated with the phone's serial number
B2. If not, please record your name:

C. CURRENT DATE AND TIME DISPLAYED ON SCREEN
Is this date and time correct?

D. Record the correct date and time
Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

E. Region
PLEASE SELECT THE NAME OF THE REGION WHERE THE HOUSEHOLD IS LOCATED.
F. Zone
PLEASE RECORD THE NAME OF THE ZONE WHERE THE HOUSEHOLD IS LOCATED.

G. District
PLEASE RECORD THE NUMBER OF THE DISTRICT WHERE THE HOUSEHOLD IS LOCATED.

H. Locality name
PLEASE RECORD THE NAME OF THE LOCALITY WHERE THE HOUSEHOLD IS LOCATED.

I. Enumeration area
PLEASE RECORD THE NUMBER OF THE ENUMERATION AREA WHERE THE HOUSEHOLD IS LOCATED.

J. Structure number
PLEASE RECORD THE NUMBER OF THE STRUCTURE OF WHICH THIS HOUSEHOLD IS A PART FROM THE HOUSEHOLD LISTING FORM.

[pg. 2]
K. Household number
PLEASE RECORD THE NUMBER OF THE HOUSEHOLD FROM THE HOUSEHOLD LISTING FORM.
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.
L. Is a member of the household and competent respondent present and available to be interviewed today?

INFORMED CONSENT Find the competent member of the household. Read the following greeting:
Hello. My name is ________________________________ and I am working for the Addis Ababa University, and Federal 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.
At this time, do you want to ask me anything about the survey?

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

N. Interviewer's name
PLEASE RECORD YOUR NAME AS A WITNESS TO THE CONSENT PROCESS.

O. Respondent's first name.
PLEASE RECORD THE FIRST NAME OF THE RESPONDENT.

[pg. 2]
SECTION 1 - Household Roster
I will now ask you questions about all members of the household. Let's begin with you. For each person who usually lives here or slept in the house last night, please record the following information:

1. First name

2. Sex

3. Age (years)

4. Marital Status

5. Relationship to head of household

6. Family ID

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

8. Eligible female respondent

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?

Section 2 - Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.

10. Does your household have:

READ OUT ALL TYPES AND SELECT ALL THAT APPLY.

11. Are livestock kept on the homestead?

12. For each livestock, how many livestock are kept on the homestead? How many are owned?

ZERO IS A POSSIBLE ANSWER. ENTER -88 FOR DO NOT KNOW. ENTER -99 FOR NO RESPONSE.

Section 3 - Household Observation
Please observe the floors, roof and exterior walls.

13. Main material of the floor
OBSERVE
14. Main material of the roof
OBSERVE
15. 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.

16. Do you have a place to wash your hands?

17. Can you show it to me?

18. AT THE PLACE WHERE THE HOUSEHOLD WASHES THEIR HANDS, OBSERVE IF:
[pg. 6]
19. Which of the following water sources does your family use on a regular basis for any part of the year for any household purpose?
READ OUT ALL TYPES AND CHECK ALL THAT ARE USED. SCROLL TO BOTTOM TO SEE ALL CHOICES.
20. What is the main source of drinking water for members of your household?
READ OUT ALL TYPES AND CHECK THE MAIN SOURCE. MUST BE A SELECTION IN HQ19.

[pg. 8]
21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
READ OUT ALL TYPES AND CHECK THE MAIN SOURCE. MUST BE A SELECTION IN HQ19.

22. QUESTIONS HQ22 TO HQ25 WILL REPEAT X TIMES, ONCE FOR EACH WATER SOURCE SELECTED IN HQ19. THESE SOURCES INCLUDE:
The ODK software will list all sources selected in HQ19
You mentioned you used [WATER SOURCE]. At any time of the year, does your family use water from this source for:

The same question will be generated by the ODK software for all water sources selected in HQ19

23. Is [WATER SOURCE] typically available:

The same question will be generated by the ODK software for all water sources selected in HQ19

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

The same question will be generated by the ODK software for all water sources selected in HQ19

[pg. 9]
25. How many minutes does it take to make a one-way trip to [WATER SOURCE]?
ZERO IS A POSSIBLE ANSWER. INCLUDES WAITING TIME IN LINE. ENTER -88 FOR DO NOT KNOW, -99 FOR NO RESPONSE.
The same question will be generated by the ODK software for all water sources selected in HQ19
26. Does your family have a garden?

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 BOTTOM TO SEE ALL CHOICES.
28. What is the main toilet facility used by members of your household?
READ OUT ALL TYPES AND CHECK THE MAIN FACILITY. MUST BE SELECTED IN HQ27.

[pg. 10]
29. QUESTIONS HQ29-29c WILL REPEAT X TIMES, ONCE FOR EACH SANITATION FACILITY SELECTED IN HQ27. THESE FACILITIES INCLUDE:
The ODK software will list all sources selected in HQ27
How often does your family typically use [TOILET FACILITY TYPE]?
REGULAR PRACTICES AT THE HOUSEHOLD ONLY
The same question will be generated by the ODK software for all toilet facility types selected in HQ27

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

29c. Enter the number of households that share the main toilet facility.
MUST BE BETWEEN 0 AND 10. IF 10 OR GREATER, SWIPE BACK TO HQ29b AND CHOOSE "SHARED WITH TEN OR MORE HOUSEHOLDS". ENTER -99 FOR NO RESPONSE.
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. ENTER -99 FOR NO RESPONSE.

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 RESPONSES OUT LOUD.The ODK software will only ask this question to households that listed children under 5 in the household roster (HQ3)

Thank the respondent for his/her time.
THE RESPONDENT IS FINISHED, BUT THERE ARE STILL TWO MORE QUESTIONS FOR YOU TO COMPLETE OUTSIDE THE HOME.

[pg. 11]
LOCATION AND QUESTIONNAIRE RESULT
P. Take a GPS point outside near the entrance to the household.
Record location when the accuracy is smaller than 6m.
GPS COORDINATES CAN ONLY BE COLLECTED WHEN OUTSIDE.

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

Qb. Ensure that no people are in the photo

R. Record the result of the Household Survey