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mADDS Ghana Household Questionnaire

IDENTIFICATION
Please record the following identifying information prior to beginning the interview.
A. 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
[] Yes 1
[] No 0

B. Is this date and time correct?
[ODK will display the current date and time from the device's settings. Check that it is correct.]

[] Yes 1
[] No 0

C. Record the correct date and time

Day____ Month____ Year____
Hours____ Min____ AM/PM____

D. Region
Select the region
[] Ashanti 1
[] Brong-Ahafo 2
[] Central 3
[] Eastern 4
[] Greater Accra 5
[] Northern 6
[] Upper East 7
[] Upper West 8
[] Volta 9
[] Western 10

D. District
Select the district
ODK will populate a list of appropriate district based on the region selected for SQ D

D. Locality name
Select the locality

ODK will populate a list of appropriate localities based on the district selected for SQE

D. Enumeration area
Select the EA code
E. Structure number
Please record the number of this structure from the Household Listing Form.

Structure Number:

F. Household number
Please record the number of this household from the Household Listing Form.

Household Number:

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

[] Yes 1
[] No 0

INFORMED CONSENT
Find the competent member of the household. Read the following greeting:

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

[] Yes 1
[] No 0
Respondent's signature
Ask the respondent to sign their name or check the box to confirm that they consent to participate.

GATHER SIGNATURE:
Check box []

I. Interviewer's signature
Record your name as a witness to the consent process.
J. Interviewee's name
Record the first name of the respondent only.
[pg. 3]
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

NAME________

2. Sex

[] Male 1
[] Female 2

3. Age (years)

AGE____

4. Marital Status

[] Married 1
[] 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

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

8. Eligible female respondent

[] Yes 1
[] No 0
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?

[] Yes 1
[] No 0

[pg. 4]
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:
Read out all types and select all that apply.

[] Electricity?
[] A wall clock?
[] A radio?
[] A black/white television?
[] A color television?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] A freezer?
[] Electric generator/invertor(s)?
[] A washing machine?
[] A computer?
[] A digital photo camera?
[] A non digital photo camera?
[] A video deck?
[] A DVD/CD?
[] A sewing machine?
[] A bed?
[] A table?
[] A cabinet/cupboard?
[] A bicycle?
[] A motorcycle or motor scooter?
[] A car or truck?
[] A boat with a motor?
[] A boat without a motor?
[] None of the above -77

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

11b. 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.
Enter -88 for Do not know
Enter -99 for No response
[] Cattle____
[] Milk cows or bulls____
[] Horses/Donkeys/ Mules____
[] Goats____
[] Sheep____
[] Pigs____
[] Rabbits____
[] Grasscutter____
[] Chickens____
[] Other poultry____
[] Other____

12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?

[] Yes 1
[] No 0

[pg. 5]
12b. How many of the following animals does this household keep ON THE HOMESTEAD?
The household does not need to own the livestock recorded here.
Zero is a possible answer.
Enter -88 for Do not know
Enter -99 for No response
[] Cattle____
[] Milk cows or bulls____
[] Horses/Donkeys/ Mules____
[] Goats____
[] Sheep____
[] Pigs____
[] Rabbits____
[] Grasscutter____
[] Chickens____
[] Other poultry____
[] Other____

Section 3 - Household Observation
Please observe the floors, roof and exterior walls
13. Main material of the floor
OBSERVE
Natural Floor
[] Earth/Sand 11
[] Dung 12

Rudimentary Floor
[] Wood Planks 21
[] Palm/Bamboo 22

Finished Floor
[] Parquet or polished wood 31
[] Vinyl/Asphalt strips 32
[] Ceramic Tile/Terazzo 33
[] Cement 34
[] Woolen Carpet/Synthetic Carpet 35
[] Linoleum/rubber carpet 36
[] Other 96

14. Main material of the roof
OBSERVE
Natural Floor
[] No Roof 11
[] Thatch/Palm Leaf/ Sod 12

Rudimentary Roofing
[] Rustic Mat 21
[] Palm/Bamboo 22
[] Wood Planks 23
[] Cardboard 24

Finished Roofing
[] Metal 31
[] Wood 32
[] Calamine/Cement Fiber 33
[] Ceramic Tiles/Brick Tiles 34
[] Cement 35
[] Roof Shingles 36
[] Asbestos/Slate Roofing Sheets 37
[] Other 96

15. Main material of the exterior walls
OBSERVE
Natural Walls
[] No Walls 11
[] Cane/Palm/Trunks 12
[] Dirt 13

Rudimentary Walls
[] Bamboo with Mud 21
[] Stone with Mud 22
[] Uncovered Adobe 23
[] Plywood 24
[] Cardboard 25
[] Reused Wood 26

Finished Walls
[] Cement 31
[] Stone with Lime/Cement 32
[] Bricks 33
[] Cement Blocks 34
[] Covered Adobe 35
[] Wood Planks/Shingles 36

[] Other 96

[pg. 6]
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, or do you have a movable container that is not kept in a fixed location, such as a bowl or kettle, that is commonly used for hand washing?
If the container is always in the same location, then count it as a fixed place.
[] Yes, fixed place 2
[] Yes, movable container 1
[] No 0
[] Don't know -88

17a. Can you show it to me?

[] Yes 1
[] 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

17b. Can you show me any soap, water, and movable container available in the household used for hand washing?

[] Yes 1
[] No 0

18b. Anywhere within the household, OBSERVE if:

[] Soap is present
[] Water source is present: stored water
[] Water source is present: running water
[] Hand washing container is observed
[] None of the above

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?
READ OUT ALL TYPES AND CHECK ALL THAT ARE USED.
Piped Water
Piped into dwelling/indoor
[] Yes 1
[] No 0

Pipe to yard/plot
[] Yes 1
[] No 0

Public tap/standpipe
[] Yes 1
[] No 0

Tube well or borehole
[] Yes 1
[] No 0

Dug Well
Protected Well
[] Yes 1
[] No 0

Unprotected Well
[] Yes 1
[] No 0

Water from Spring
Protected Spring
[] Yes 1
[] No 0

Unprotected Spring
[] Yes 1
[] No 0

Rainwater
[] Yes 1
[] No 0

Tanker Truck
[] Yes 1
[] No 0

Cart with Small Tank
[] Yes 1
[] No 0

Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Yes 1
[] No 0

Bottled Water
[] Yes 1
[] No 0

Sachet Water
[] Yes 1
[] No 0

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 in HQ19
Piped Water
[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Public tap/standpipe 3

[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6

Water from Spring
[] Protected Spring 7
[] 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

[pg. 7]
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 source. Must be a selection in HQ19.
Piped Water
[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Public tap/standpipe 3

[] Tube well or borehole 4
Dug Well
[] Protected Well 5
[] Unprotected Well 6

Water from Spring
[] Protected Spring 7
[] 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

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.
22. You mentioned you used [WATER SOURCE]. At any time of the year, does your family use water from this source for:

Drinking
[] Yes 1
[] No 0

Cooking
[] Yes 1
[] No 0

Livestock
[] Yes 1
[] No 0

Gardening / agriculture
[] Yes 1
[] No 0

Business venture
[] Yes 1
[] No 0

23 Is [WATER SOURCE] typically available:

[] All of the year 1
[] Some of the year 2
[] Small part of the year 3

24. At a time 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

25. How long does it take to go there, get water, and come back? [WATER SOURCE]?
Zero is a possible answer
Enter -88 for do not know
Enter -99 for no response
Convert time into minutes.
Answer includes waiting time in line.

Minutes____

[pg. 8]
26. Does your family have a garden?
A garden is a place to grow vegetables
[] Yes 1
[] No 0

27. Do members of your household use any of the following toilet facilities?
READ OUT ALL TYPES AND CHECK ALL THAT ARE USED.
Flush/pour flush toilets connected to:
Piped sewer system
[] Yes 1
[] No 0

Septic tank
[] Yes 1
[] No 0

Pit Latrine
[] Yes 1
[] No 0

Elsewhere
[] Yes 1
[] No 0

Not sure / Don't know
[] Yes 1
[] No 0

Ventilated improved pit latrine
[] Yes 1
[] No 0

Pit latrine with slab
[] Yes 1
[] No 0

Pit latrine without slab/open pit
[] Yes 1
[] No 0

Bucket/pan
[] Yes 1
[] No 0

Composting toilet
[] Yes 1
[] No 0

Hanging toilet /Hanging latrine
[] Yes 1
[] No 0

Other:
[] Yes 1
[] No 0

No response -99

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 HQ25.
Flush/pour flush toilets connected to:
[] Piped sewer system 1
[] Septic tank 2
[] Pit Latrine 13
[] Elsewhere 3
[] Unknown / Not sure / Don't know 4

[] Ventilated improved pit latrine 5
[] Pit latrine with slab 6
[] Pit latrine without slab/open pit 7
[] Bucket/pan 9
[] Composting toilet 8
[] Hanging toilet /Hanging latrine 10
[] Other: 11
[] No facility / bush / field 12
[] No Response -99

QUESTIONS HQ 29-29b 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 25.
29a. How often does your family 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

29b. Do you share this toilet facility with other households or the public? [Select one]

[] 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

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 Households____

[pg. 9]
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.
Number of People____

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

[] Yes 1
[] No 0

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
K. PHOTO
Ensure that no people are in the photo

Instructions are given directly by the ODK software
TAKE PICTURE
CHOOSE IMAGE

L. GPS: 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.

Instructions are given directly by the ODK software
RECORD LOCATION

M. How many times have you visited this household?

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

N. 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