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mADDS Ethiopia Household Roster - Round 1

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
[] Yes 1
[] No 0

B2. If not, please record your name:

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

[] Yes 1
[] No 0

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.
[] Tigray 1
[] Afar 2
[] Amhara 3
[] Oromia 4
[] Ethiopia Somali 5
[] Benishangul Gumuz 6
[] SNNPR 7
[] Gambella 8
[] Harari 9
[] Addis Ababa 10
[] Dire Dawa 11

F. Zone
PLEASE RECORD THE NAME OF THE ZONE WHERE THE HOUSEHOLD IS LOCATED.

ODK will populate a list of appropriate zones based on the region selected for HQE

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

ODK will populate a list of appropriate districts based on the zone selected for HQF

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

ODK will populate a list of appropriate localities based on the district selected in HQG. There may be only one choice.

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

ODK will populate the appropriate EA

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.
[] Yes 1
[] No 0

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

[] Yes 1
[] No 0

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?

[] Yes 1
[] No 0

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

GATHER SIGNATURE:

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

NAME________

2. Sex

[] Male 1
[] Female 2

3. Age (years)

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

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:

Electricity?
[] Yes 1
[] No 0

A wall clock?
[] Yes 1
[] No 0

A radio?
[] Yes 1
[] No 0

A black/white television?
[] Yes 1
[] No 0

A color television?
[] Yes 1
[] No 0

A mobile phone?
[] Yes 1
[] No 0

A landline telephone?
[] Yes 1
[] No 0

A refrigerator?
[] Yes 1
[] No 0

A freezer?
[] Yes 1
[] No 0

Electric generator/invertor(s)?
[] Yes 1
[] No 0

A washing machine?
[] Yes 1
[] No 0

A computer?
[] Yes 1
[] No 0

A digital photo camera?
[] Yes 1
[] No 0

A non digital photo camera?
[] Yes 1
[] No 0

A video deck?
[] Yes 1
[] No 0

A DVD/CD?
[] Yes 1
[] No 0

A sewing machine?
[] Yes 1
[] No 0

A bed?
[] Yes 1
[] No 0

A table?
[] Yes 1
[] No 0

A cabinet/cupboard?
[] Yes 1
[] No 0

A bicycle?
[] Yes 1
[] No 0

A motorcycle or motor scooter?
[] Yes 1
[] No 0

A car or truck?
[] Yes 1
[] No 0

A boat with a motor?
[] Yes 1
[] No 0

A boat without a motor?
[] Yes 1
[] No 0

[] None of the above -77
[] No response -99
READ OUT ALL TYPES AND SELECT ALL THAT APPLY.

11. Are livestock kept on the homestead?

[] Yes 1
[] No 0

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

Sheep / goats / pig on homestead ____
Sheep / goats / pig owned ____
Chicken / ducks / geese on homestead ____
Chicken / ducks / geese owned ____
Cattle / horses / donkeys / camels on homestead ____
Cattle / horses / donkeys / camels 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
Natural Floor
[] Earth/Sand 11
[] Dung 12

Rudimentary Floor
[] Wood Planks 21
[] Palm/Bamboo 22

Finished Floor
[] Parquet or polished wood 31
[] Vinyl/Asphalt strips 32
[] Ceramic Tile/Terazzo 33
[] Cement 34
[] Woolen Carpet/Synthetic Carpet 35
[] Linoleum/rubber carpet 36
[] Other 96

[] No response -99

14. Main material of the roof
OBSERVE
Natural Roof
[] No Roof 11
[] Thatch/Palm Leaf/ Sod 12

Rudimentary Roofing
[] Rustic Mat 21
[] Palm/Bamboo 22
[] Wood Planks 23
[] Cardboard 24

Finished Roofing
[] Metal 31
[] Wood 32
[] Calamine/Cement Fiber 33
[] Ceramic Tiles/Brick Tiles 34
[] Cement 35
[] Roof Shingles 36
[] Asbestos/Slate Roofing Sheets 37
[] Other 96

[] No response -99

15. Main material of the exterior walls
OBSERVE

Natural Walls
[] No Walls 11
[] Cane/Palm/Trunks 12

Rudimentary Walls
[] Bamboo with Mud 21
[] Stone with Mud 22
[] Uncovered Adobe 23
[] Plywood 24
[] Cardboard 25
[] Reused Wood 26

Finished Walls
[] Cement 31
[] Stone with Lime/Cement 32
[] Bricks 33
[] Cement Blocks 34
[] Covered Adobe 35
[] Wood Planks/Shingles 36
[] Other 96

[] 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: tap water
[] Handwashing area is near a sanitation facility
[] None of the above -77

[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.
Piped Water
[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Piped to 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
[] No response -99

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.

Piped Water
[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Piped to public tap/standpipe 3

[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6

Water from Spring
[] Protected Spring 7
[] Unprotected Spring 8

[] Rainwater 9
[] Tanker Truck 10
[] Cart with Small Tank 11
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel) 12
[] Bottled Water 13
[] Sachet Water 14
[] No response -99

[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.

Piped Water
[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Public tap/standpipe 3

[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6

Water from Spring
[] Protected Spring 7
[] Unprotected Spring 8

[] Rainwater 9
[] Tanker Truck 10
[] Cart with Small Tank 11
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel) 12
[] Bottled Water 13
[] Sachet Water 14
[] No response -99

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:

Drinking
[] Yes 1
[] No 0

Cooking
[] Yes 1
[] No 0

Livestock
Gardening / agriculture
[] Yes 1
[] No 0

Business venture
[] Yes 1
[] No 0

[] No response -99
The same question will be generated by the ODK software for all water sources selected in HQ19

23. Is [WATER SOURCE] typically available:

[] All of the year 1
[] Some of the year 2
[] Small part of the year 3
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?

[] Yes, always 1
[] No, intermittent and predictable 2
[] No, intermittent and unpredictable 3
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
Minutes____

26. Does your family have a garden?

[] 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 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 (please explain):
[] No facility / bush / field
[] No response -99

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.

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: No facility / bush / field 11
[] No facility/bush/field 12
[] No response -99

[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]

[] 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 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.

Number of people ____

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.
Children use a latrine / toilet
[] Yes 1
[] No 0

Leave waste where it is
[] Yes 1
[] No 0

Bury waste in field / yard
[] Yes 1
[] No 0

Dispose of waste in latrine / toilet
[] Yes 1
[] No 0

Dispose of waste with rubbish / garbage
[] Yes 1
[] No 0

Dispose of waste with waste water
[] Yes 1
[] No 0

Use it as manure
[] Yes 1
[] No 0

Burn it
[] Yes 1
[] No 0

Don't know
[] Yes 1
[] No 0

[] No response -99
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.

Instructions are given directly by the ODK software
RECORD LOCATION

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

[] Yes 1
[] No 0

Qb. Ensure that no people are in the photo

Instructions are given directly by the ODK software
TAKE PICTURE
CHOOSE IMAGE

R. Record the result of the Household Survey

[] 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