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PMA Ethiopia Household Questionnaire 2019

001a. Your name: ${your_name}

Is this your name?

[] Yes
[] No

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

[] Yes
[] No

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?


[] Yes
[] No

WARNING: Contact your supervisor before sending this form again.

008. CHECK: Why are you resending this form?

Choose all that apply.

[] There are new household members on this form
[] I am correcting a mistake made on a previous form
[] The previous form disappeared from my phone without being sent
[] I submitted the previous form and my supervisor told me that it was not received
[] Other reason(s)

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?

[] Yes
[] No


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?

[] Yes
[] No

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

Mark your name as a witness to the consent process.

[] NA

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?

[] Yes
[] No

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.

[] NA

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

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Step child/adopted
[] Other
[] Do not know
[] No response

103. Is ${firstname} male or female?

[] Male
[] 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.

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

106. Does ${firstname} usually live here?

[] Yes
[] No
[] No response

107. Did ${firstname} stay here last night?

[] Yes
[] No
[] No response

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}?

[] Orthodox
[] Catholic
[] Protestant
[] Moslem
[] Wakefeta
[] Traditional
[] Other
[] No religion
[] No response

107b. Is this respondent enrolled in the panel?

[] Yes
[] No

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?

[] Yes
[] No

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:

Go back, select only one head.

For each member, check that the relationship to the household head is accurate.


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.


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.

[] Yes
[] No

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.

[] 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
[] No response

Check here to acknowledge you considered all options.

[] NA

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

[] No response

013. Where does your cooking take place?

[] Within house
[] In separate building
[] Outdoors
[] No response

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

[] Yes
[] No
[] No response

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

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

[] Yes
[] No
[] No response

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.


Horses, Donkeys, Mules?
Enter -88 for do not know.
Enter -99 for no response.



Enter -88 for do not know.
Enter -99 for no response.

Error with CAMELS

Enter -88 for do not know.
Enter -99 for no response.

Error with GOATS

Enter -88 for do not know.
Enter -99 for no response.

Error with SHEEP

Enter -88 for do not know.
Enter -99 for no response.

Error with CHICKENS

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


[] Earth/Sand
[] Dung
[] Wood Planks
[] Palm/Bamboo
[] Parquet or polished wood
[] Vinyl/Asphalt strips/Plastic tiles
[] Ceramic Tiles
[] Cement
[] Carpet
[] Other
[] No response

017. Main material of the roof


[] No Roof
[] Thatch/Leaf/Mud
[] Rustic Mat/Plastic Sheets
[] Reed/Bamboo
[] Wood Planks
[] Cardboard
[] Corrugated iron/metal
[] Asbestos/Cement Fiber
[] Cement/Concrete
[] Roof Shingles
[] Other
[] No response

018. Main material of the exterior walls


[] No Walls
[] Cane/Palm/Trunks/Bamboo/Reed
[] Dirt
[] Bamboo/Wood with Mud
[] Stone with Mud
[] Uncovered Adobe
[] Plywood
[] Cardboard
[] Reused Wood
[] Corrugated sheets
[] Cement
[] Stone with Lime/Cement
[] Bricks
[] Cement Blocks
[] Covered Adobe
[] Wood Planks/Shingles
[] Other
[] No response

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?

[] Observed, fixed place
[] Observed, mobile
[] Not observed, not in dwelling/yard/plot
[] Not observed, no permission to see
[] Not observed, other reason
[] No response

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.

[] Soap or detergent is present
[] Stored water is present
[] Running water is present
[] Handwashing area is near a sanitation facility
[] None of the above

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

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart or Bicycle with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

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


[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Bucket/pan
[] Composting toilet
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

022. Where is your toilet facility located?


[] In own dwelling
[] In own yard / plot
[] Elsewhere
[] No response

023. How often does your household typically use:


Regular practices at the household only.

[] Always
[] Most of the time
[] Occasionally
[] No response

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


[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public
[] No response

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


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.

[] Children use a latrine / toilet
[] Leave waste where it is
[] Dispose of 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
[] No response

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?

[] Yes
[] No

029. How many times have you visited this household?

[] 1st time
[] 2nd time
[] 3rd time

030. In what language was this interview conducted?

[] English
[] Amharic
[] Afan Oromo
[] Tigringna
[] Sidamigna
[] Wolayitigna
[] Afar
[] Somali
[] Kefigna
[] Other

031. Was a translator used for this interview?

[] Yes
[] No

032. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant or address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period