001b. Enter your name below.

Please record your name

002b. Record the correct date and time.

Day: Month: Year:

003a. Region

003b. Zone

003c. District

003d. Locality name

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.

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?

010a. Ask: May I begin the interview now?

Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask.

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

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] ?

CRVS_101. Does {firstname} have a birth certificate?

Note: Please observe and verify the birth certificate.

CRVS_102a. Has {firstname}'s birth ever been registered with the woreda or kebele?

CRVS_102b. PROBE: Does {firstname} have a birth notification or a document stating {firstname} date of birth? Check all that apply.

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

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. Zero is a possible answer.

Milk Cow, Oxen or Bulls?

Horses, Donkeys, Mules?

Camels?

Goats?

Sheep?

Chickens?

Beehives?

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 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?

Selections from 409: [SELECTIONS] The main facility must be selected in 409.

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.