PMA2020 Ethiopia Household Questionnaire - Round 3
IDENTIFICATION
Please record the following identifying information prior to beginning the interview.
A. 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.
[] No 0
Please record your name
Interviewer's Name____
B. Current date and time.
[ODK will display on screen]
Is this date and time correct?
[] Yes 1
[] No 0
[] No 0
C. Record the correct date and time
Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____
Time____ Hour____ Minutes____ AM/PM____
D1. Region
[] 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
[] Afar 2
[] Amhara 3
[] Oromia 4
[] Ethiopia Somali 5
[] Benishangul Gumuz 6
[] SNNPR 7
[] Gambella 8
[] Harari 9
[] Addis Ababa 10
[] Dire Dawa 11
D2. Zone
ODK will populate a list of appropriate zones based on the selected region.
D3. District
ODK will populate a list of appropriate districts based on the selected zone.
D4. Locality Name
ODK will populate a list of appropriate localities based on the selected district. There may be only one choice.
D5. Enumeration area
ODK should populate the appropriate EA
E. Structure number
Please record the structure number from the household listing form.
F. Household number
Please record the household number 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
WARNING: Contact your supervisor before sending this form again.
[] No 0
CHECK: Why are you resending this form?
Choose al 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
[] 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
[pg. 2]
G. Is a member of the household and competent respondent present and available to be interviewed today?
[] Yes 1
[] No 0
[] No 0
G2. Did this household participate in a previous PMA2020 survey?
[] Yes 1
[] No 0
[] Do not know -88
[] No response -99
[] No 0
[] Do not know -88
[] No response -99
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 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?
H. Explain the consent form to the respondent. Then, ask: May I begin the interview now?
[] Yes 1
[] No 0
[] No 0
I. Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ B]."
J. Respondent's first name.
Please record the first name of the respondent.
[pg. 3]
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
[] Female 2
3. Age (years)
AGE____
4. Marital Status
[] Married 1
[] Living with a partner 2
[] Divorced / separated 3
[] Widow / widower 4
[] Single 5
[] 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
[] 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
[] 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.
[] No 0
After recording information for one household member, the following prompt is asked to activate a looping script to record information for another member
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?
[] No 0
Remember to include all children in the household.
[] Yes 1
[] No 0
[] 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 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.
Electricity?
A watch clock?
A radio?
A television?
A mobile phone?
A non-mobile telephone?
A refrigerator?
A table?
A chair?
A bed with cotton sponge spring mattress?
An electric mitad?
A kerosene lamp pressure lamp?
A bicycle?
A motorcycle or motor scooter?
An animal drawn cart?
A car or truck?
[] None of the above -77
[] No response -99
READ OUT ALL TYPES AND SELECT ALL THAT APPLY.
[] Yes 1
[] No 0
[] No 0
A watch clock?
[] Yes 1
[] No 0
[] No 0
A radio?
[] Yes 1
[] No 0
[] No 0
A television?
[] Yes 1
[] No 0
[] No 0
A mobile phone?
[] Yes 1
[] No 0
[] No 0
A non-mobile telephone?
[] Yes 1
[] No 0
[] No 0
A refrigerator?
[] Yes 1
[] No 0
[] No 0
A table?
[] Yes 1
[] No 0
[] No 0
A chair?
[] Yes 1
[] No 0
[] No 0
A bed with cotton sponge spring mattress?
[] Yes 1
[] No 0
[] No 0
An electric mitad?
[] Yes 1
[] No 0
[] No 0
A kerosene lamp pressure lamp?
[] Yes 1
[] No 0
[] No 0
A bicycle?
[] Yes 1
[] No 0
[] No 0
A motorcycle or motor scooter?
[] Yes 1
[] No 0
[] No 0
An animal drawn cart?
[] Yes 1
[] No 0
[] No 0
A car or truck?
[] Yes 1
[] No 0
[] No 0
[] None of the above -77
[] No response -99
11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
[] Yes 1
[] No 0
[] No response -99
[] 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.
Milk cows, oxen or bulls ____
Horses, donkeys, or mules ____
Camels ____
Goats ____
Sheep ____
Chickens ____
Beehives ____
Horses, donkeys, or mules ____
Camels ____
Goats ____
Sheep ____
Chickens ____
Beehives ____
[pg. 5]
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
[] 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.
The household does not need to own the livestock recorded here.
Milk cows, oxen or bulls ____
Horses, donkeys, or mules ____
Camels ____
Goats ____
Sheep ____
Chickens ____
Beehives ____
Horses, donkeys, or mules ____
Camels ____
Goats ____
Sheep ____
Chickens ____
Beehives ____
Section 3 - Household Observation
Please observe the floors, roof and exterior walls
13. Main material of the floor
Observe.
[] Earth Sand 11
[] Dung 12
[] Wood Planks 21
[] Palm Bamboo 22
[] Parquet or polished wood 31
[] Vinyl Asphalt strips 32
[] Ceramic Tiles 33
[] Cement 34
[] Carpet 35
[] Other 96
[] No response -99
[] Dung 12
[] Wood Planks 21
[] Palm Bamboo 22
[] Parquet or polished wood 31
[] Vinyl Asphalt strips 32
[] Ceramic Tiles 33
[] Cement 34
[] Carpet 35
[] Other 96
[] No response -99
14. Main material of the roof
Observe.
[] No Roof 11
[] Thatch Palm Leaf Mud 12
[] Rustic Mat Plastic Sheets 21
[] Reed Bamboo 22
[] Wood Planks 23
[] Cardboard 24
[] Corrugated Iron Metal 31
[] Wood 32
[] Asbestos Cement Fiber 33
[] Cement Concrete 34
[] Roof Shingles 35
[] Other 96
[] No response 99
[] Thatch Palm Leaf Mud 12
[] Rustic Mat Plastic Sheets 21
[] Reed Bamboo 22
[] Wood Planks 23
[] Cardboard 24
[] Corrugated Iron Metal 31
[] Wood 32
[] Asbestos Cement Fiber 33
[] Cement Concrete 34
[] Roof Shingles 35
[] Other 96
[] No response 99
[pg. 6]
15. Main material of the exterior walls
Observe.
[] No Walls 11
[] Cane Trunks Bamboo Reed 12
[] Dirt 13
[] Bamboo with Mud 21
[] Stone with Mud 22
[] Uncovered Adobe 23
[] Plywood 24
[] Cardboard 25
[] Reused Wood 26
[] Corrugated sheets 27
[] Cement 31
[] Stone with Lime Cement 32
[] Bricks 33
[] Cement Blocks 34
[] Covered Adobe 35
[] Wood Planks Shingles 36
[] Other 96
[] No response -99
[] Cane Trunks Bamboo Reed 12
[] Dirt 13
[] Bamboo with Mud 21
[] Stone with Mud 22
[] Uncovered Adobe 23
[] Plywood 24
[] Cardboard 25
[] Reused Wood 26
[] Corrugated sheets 27
[] 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
[] No 0
[] Don't know -88
[] No response -99
17a. Can you show it to me?
[] Yes 1
[] No 0
[] No 0
18a. 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 -77
[] Water source is present: stored water
[] Water source is present: running water
[] Handwashing area is near a sanitation facility
[] None of the above -77
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
[] Pipe to yard plot
[] Public tap standpipe
[] Tube well or borehole
Dug Well
Dug Well
[] Protected Well
[] Unprotected Well
[] Unprotected Well
Water from Spring
[] Protected Spring
[] Unprotected 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
[] 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?
Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.
Piped Water
[] Tube well or borehole 4
Dug Well
Water from Spring
[] 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
[] Piped into dwelling indoor 1
[] Pipe to yard plot 2
[] Public tap standpipe 3
[] Pipe to yard plot 2
[] Public tap standpipe 3
[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6
[] Unprotected Well 6
Water from Spring
[] Protected Spring 7
[] Unprotected Spring 8
[] 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
21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.
Piped Water
[] Tube well or borehole 4
Dug Well
Water from Spring
[] 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
Questions HQ 22 to HQ 25 will repeat x times, once for each water source selected in HQ 19. These sources include:[] Piped into dwelling indoor 1
[] Pipe to yard plot 2
[] Public tap standpipe 3
[] Pipe to yard plot 2
[] Public tap standpipe 3
[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6
[] Unprotected Well 6
Water from Spring
[] Protected Spring 7
[] Unprotected Spring 8
[] 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
[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
[] 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
[] Some of the year 2
[] Small part of the year 3
[] No response -99
[pg. 9]
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
[] 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.
Minutes _________
26. Does your household have a garden?
A garden is a place to grow vegetables.
[] Yes 1
[] No 0
[] No response -99
[] 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
[] 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
[] No facility / bush / field
[] No response -99
[] 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
[] No facility / bush / field
[] No response -99
28. What is the main toilet facility used by members of your household?
HQ27: [ODK will display HQ2 selections]
The main facility must be selected in HQ 27.
Flush pour flush toilets connected to:
[] 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:[] Piped sewer system 1
[] Septic tank 2
[] Elsewhere 3
[] Unknown / Not sure / Don't know 4
[] 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
HQ27: [ODK will display HQ2 selections]
[pg. 10]
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
[] 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
[] 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
[] Yes 1
[] No 0
[] No 0
Leave waste where it is
[] Yes 1
[] No 0
[] No 0
Bury waste in field / yard
[] Yes 1
[] No 0
[] No 0
Dispose of waste in latrine / toilet
[] Yes 1
[] No 0
[] No 0
Dispose of waste with rubbish / garbage
[] Yes 1
[] No 0
[] No 0
Dispose of waste with waste water
[] Yes 1
[] No 0
[] No 0
Use it as manure
[] Yes 1
[] No 0
[] No 0
Burn it
[] Yes 1
[] No 0
[] No 0
[] 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
[] 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.
[pg. 11]
LOCATION AND QUESTIONNAIRE RESULT
K. 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?
L. Ensure that no people are in the photo
TAKE PICTURE
CHOOSE IMAGE
CHOOSE IMAGE
M. How many times have you visited this household?
[] 1st time 1
[] 2nd time 2
[] 3rd time 3
[] 2nd time 2
[] 3rd time 3
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
[] 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