IDENTIFICATION
Please record the following identifying information prior to beginning the interview.

A. How many times have you visited this household?

B. Interviewer?s name: Is this your name?
If not, please record your name:
ODK will display the name associated with the phone?s serial number
C. CURRENT DATE AND TIME DISPLAYED ON SCREEN.
Is this date and time correct?

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.
F. District
PLEASE SELECT THE NAME OF THE DISTRICT WHERE THE HOUSEHOLD IS LOCATED.
ODK will populate a list of appropriate district based on the region selected for HQ E

G. Locality name
PLEASE SELECT THE NAME OF THE LOCALITY WHERE THE HOUSEHOLD IS LOCATED.
ODK will populate a list of appropriate localities based on the district selected for HQ F

H. Enumeration area
PLEASE SELECT THE NUMBER OF THE ENUMERATION AREA WHERE THE HOUSEHOLD IS LOCATED.
ODK will populate a list of appropriate EA numbers based on the locality selected for HQ G

I. Structure number
PLEASE RECORD THE NUMBER OF THE STRUCTURE OF WHICH THIS HOUSEHOLD IS A PART FROM THE HOUSEHOLD LISTING FORM.

J. Household number
PLEASE RECORD THE NUMBER OF THE HOUSEHOLD FROM THE HOUSEHOLD LISTING FORM.

[pg. 1]
K. Is a member of the household and competent respondent present and available to be interviewed today?

INFORMED CONSENT Find the competent member of the household. Read the following greeting:
Hello. My name is _________________________ and I am working for Kwame Nkrumah University of Science and Technology, and the Ghana Health Service. 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?

L. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask:
May I begin the interview now?

M. Respondent?s signature
PLEASE ASK THE RESPONDENT TO SIGN OR CHECK THE BOX IN AGREEMENT OF THEIR PARTICIPATION.
N. Interviewer?s signature
PLEASE RECORD YOUR NAME AS A WITNESS TO THE CONSENT PROCESS.

O. Interviewee?s 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

2. Sex

3. Age (years)

4. Marital Status

5. Relationship to head of household

6. Family ID

7. Is this person a usual member of the household or has he/she slept in the house last night?

8. Eligible female respondent

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?

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:

11. Are livestock kept on the homestead?

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

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

[pg. 4]
14. Main material of the roof
OBSERVE

15. 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.

16. Do you have a place to wash your hands?

17. Can you show it to me?

18. AT THE PLACE WHERE THE HOUSEHOLD WASHES THEIR HANDS, OBSERVE IF:

[pg. 5]
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?

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

[pg. 6]
21. What is the main source of water used by your household for other purposes such as cooking and handwashing?

READ OUT ALL TYPES AND CHECK THE MAIN SOURCEMUSTBE A SELECTION IN HQ 19.

22. QUESTIONS HQ 22 TO HQ 24 WILL REPEAT X TIMES, ONCE FOR EACH WATER SOURCE SELECTED IN HQ 17. THESE SOURCES INCLUDE:
The ODK software will list all sources selected in HQ 19.
You mentioned you used [WATER SOURCE]. At any time of the year, does your family use water from this source for:

The same question will be generated by the ODK software for all water sources selected in HQ19.

23. Is [WATER SOURCE] typically available:

The same question will be generated by the ODK software for all water sources selected in HQ19.

[pg. 7]
24. At a time when you expect to have water from [WATER SOURCE], is it usually available?
The same question will be generated by the ODK software for all water sources selected in HQ19
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
26. Does your family have a garden?

27. Do members of your household use any of the following toilet facilities?

READ OUT ALL TYPES AND CHECK ALL THAT ARE USED.

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 HQ 25.

29. QUESTION HQ 27 WILL REPEAT X TIMES, ONCE FOR EACH SANITATION FACILITY SELECTED IN HQ 25. THESE FACILITIES INCLUDE:
The ODK software will list all sources selected in HQ 27
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.
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.

[pg. 9]
31. For all children under age five: what methods, if any, does your household use to dispose of children's waste?

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 HOUSE.

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.

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

Qb. Ensure that no people are in the photo.

R. Record the result of the Household Roster.

[pg. 10]