001a. Your name: ${your_name}

Is this your name?

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2019-07-01 and 2020-07-01.

003a. Region:

003b. Zone:

003c. District:

003d. Locality:

004. Enumeration area

005. Structure number

Please record the structure number from the household listing form.

Invalid response.

006. Household number

Please record the household number from the household listing form.

Invalid response.

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.

WARNING: Contact your supervisor before sending this form again.

008. CHECK: Why are you resending this form?

Choose all that apply.

WARNING: Each household should have ONLY ONE household roster with all household members listed on the same form.

Please contact your supervisor before sending this form.

009a. Is a member of the household and competent respondent present and available to be interviewed today?

INFORMED CONSENT

Find the competent female respondent. Administer the consent procedures.

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 using a smartphone. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. The survey usually takes only 15 minutes. Your data will not be linked to your identity when conducting analyses, presenting results, or sharing data.

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 information about this household. 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.

If you have any questions about the study and your right as a research participant, you may ask me now or you may also contact the principal investigators of the study, [name] at [phone number] or [name] at [phone number] at Addis Ababa University in Addis Ababa, Ethiopia.

At this time, do you want to ask me anything about the survey?

010a. Explain the consent form to the respondent. Then, ask: May I begin the interview now?

010c. Interviewer's name: ${your_name}

Mark your name as a witness to the consent process.

010c. Interviewer's name

Please record your name as a witness to the consent process. You previously entered "${name_typed}."

That is not what you entered for your name earlier in this survey.

010d. Is this household selected for the cross-section?

Section 1 Household Roster

I am now going to ask a series of questions about each usual member of the household or anyone who slept in the house last night.

Household member

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

If yes, check this box.

102. What is ${firstname}'s relationship to the head of household?

103. Is ${firstname} male or female?

104. How old was ${firstname} at their last birthday?

If less than one year old, record 0

Max: 130
Min: 15 if respondent
Min: 0 if not respondent

105. What is ${firstname}'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 ${firstname} usually live here?

107. Did ${firstname} 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 ${firstname}?

107b. Is this respondent enrolled in the panel?

This person IS NOT eligible for the female respondent questionnaire.

This person IS eligible for the female respondent questionnaire.

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 ${heads} household heads selected:
${head_name_joined}

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 ${num_HH_members} household members who are named ${names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

Section 2 Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

011. 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.
Cannot select 'no response' or 'none of the above' with other options.

Check here to acknowledge you considered all options.

012. What type of fuel does your household mainly use for cooking?

013. Where does your cooking take place?

014. Do you have an insecticide treated net in your household?

015a. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

015b.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?
Enter -88 for do not know.
Enter -99 for no response.
Error with MILK COWS/OXEN/BULL

Horses, Donkeys, Mules?
Enter -88 for do not know.
Enter -99 for no response.
Error with HORSES, DONKEYS, MULES

Camels?

Enter -88 for do not know.
Enter -99 for no response.
Error with CAMELS

Goats?
Enter -88 for do not know.
Enter -99 for no response.
Error with GOATS

Sheep?
Enter -88 for do not know.
Enter -99 for no response.
Error with SHEEP

Chickens?
Enter -88 for do not know.
Enter -99 for no response.
Error with CHICKENS

Beehives?
Enter -88 for do not know.
Enter -99 for no response.
Error with BEEHIVES

Section 3 Household Observation

Please observe the floors, roof and exterior walls.

016. Main material of the floor

Observe.

017. Main material of the roof

Observe.

018. 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.

019a. 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?

019b. At the place where the household washes their hands, observe if:

Check all that apply.

Cannot select 'none of the above' with other options.

020. What is the main source of drinking water for members of your household?

021. What is the main toilet facility used by members of your household?

IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE TOILET FACILITY.

022. Where is your toilet facility located?

${sanitation_main_lab}

023. How often does your household typically use:

${sanitation_main_lab}

Regular practices at the household only.

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

${sanitation_main_lab}

025. Enter the number of households that share this facility (including your own).

${sanitation_main_lab}

Must be between 2 and 9.

If 10 or greater, move back to 024 and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

026. 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.

Check all that apply.

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

027. Location

Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

028. Did you have to move away from the household to take the GPS reading?

029. How many times have you visited this household?

030. In what language was this interview conducted?

031. Was a translator used for this interview?

032. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.