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.

003a. Region

Please select the name of the region where the facility is located.

[] Ashanti
[] Brong-Ahafo
[] Central
[] Eastern
[] Greater Accra
[] Northern
[] Upper East
[] Upper West
[] Volta
[] Western

003b. Locality

Please select the name of the locality where the facility is located.

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?

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 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?

011a. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

011b. Respondent's signature

Please ask the respondent to sign or check the box in agreement of their participation.

Checkbox

WARNING: the respondent has not signed or checked the box, despite agreeing to be interviewed in the previous question. To conduct the survey, the respondent must sign or touch the checkbox.

You may go back to obtain a signature or check the box or you should go back to the previous question to indicate the respondent does not want to be interviewed.

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.

011. Respondent's first name.

Please record the first name of the respondent.

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

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

Age must be less than 130 and greater than zero.

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.

LCL101. What is the religion of {firstname}?

Only recorded for the head of the household.

LCL102. What is the ethnicity of {firstname}?

Only asked of the head of the household.

108. Are there any other usual members of your household or persons who slept in the house last night?

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.

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.

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

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

Zero is a possible answer.

203a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these animals?

Homestead includes the structure and yard that is close to the structure.

203b. 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.

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

Now I would like to ask you a few questions about water, sanitation and hygiene.

401a. Do you have a place to wash your hands?

401b. Can you show it to me?

401c. At the place where the household washes their hands, observe if:

Check all that apply.

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

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.

Cannot select 'no response' with other options.

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

Selections from 402:  {source_labels}

Read out 402 selections only.

You did not select that choice in 402.

404. What is the main source of water used by your household for other purposes such as cooking and hand washing?

Selections from 402: {source_labels}

Read out 402 selections only.

You did not select that choice in 402.

Questions 405 to 408 will repeat {number_of_sources} times, once for each water source selected in 402. These sources include:

{source_labels}

405. You mentioned that you use piped water in your dwelling/indoor. At any time of the year, does your household use water from this source for:

Cannot select 'no response' with other options.

406. How many months out of the year is piped water to your indoor usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the piped source in your dwelling, is it usually available?

405. You mentioned that you use piped water to yard/plot. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is piped water to the yard/plot usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the piped supply in your yard/plot, is it usually available?

408. How long does it take to go to the yard/plot, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use piped water to public tap/standpipe. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is piped water to public tap/standpipe usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from piped water to public tap/standpipe , is it usually available?

408. How long does it take to go to the public tap/standpipe, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use a tube well or borehole. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is the tube well or borehole usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from a tube well or borehole , is it usually available?

408. How long does it take to go to the tube well or borehole, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use a protected dug well. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is the protected dug well usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the protected dug well, is it usually available?

408. How long does it take to go to the protected dug well, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use unprotected dug well. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is the unprotected dug well usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the unprotected dug well, is it usually available?

408. How long does it take to go to the unprotected dug well, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use protected water from a spring. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is water from the protected spring usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the protected spring, is it usually available?

408. How long does it take to go to the protected spring, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use water from an unprotected spring. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is the unprotected spring usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the unproteced spring, is it usually available?

408. How long does it take to go to the unprotected spring, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use rainwater. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is rainwater usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have Rainwater, is it usually available?

408. How long does it take to go to your collected rainwater, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use a Tanker Truck. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is the Tanker Truck usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from the Tanker Truck, is it usually available?

408. How long does it take to go to the Tanker Truck, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use a cart with a small tank. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is Cart with Small Tank usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have Cart with Small Tank , is it usually available?

408. How long does it take to go the cart or bicycle with a small tank, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use surface water. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is surface water usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from a surface water source, is it usually available?

408. How long does it take to go to the surface water source, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use water from the bottled water source. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is bottled water usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have water from bottled water source, is it usually available?

408. How long does it take to go to the bottled water source, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

405. You mentioned that you use sachet water. At any time of the year, does your household use water from this source for:

Invalid response.

406. How many months out of the year is sachet water usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have sachet water, is it usually available?

408. How long does it take to go to the sachet water source, get water, and come back?

0 is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

Invalid response.

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.

Cannot select 'no response' with other options.

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

The main facility must be selected in 409.

Question 411, 412a, 412b will repeat {number_of_sanitation} times, once for each sanitation facility selected in 409. These facilities include:

{sanitation_labels}

411. How often does your household typically use:

{san_label_1}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_1}

412b. Enter the number of households that share this facility (including your own).

{san_label_1}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_2}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_2}

412b. Enter the number of households that share this facility (including your own).

{san_label_2}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_flushpit}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_flushpit}

412b. Enter the number of households that share this facility (including your own).

{san_label_flushpit}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

411. How often does your household typically use:

{san_label_3}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_3}

412b. Enter the number of households that share this facility (including your own).

{san_label_3}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_4}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_4}

412b. Enter the number of households that share this facility (including your own).

{san_label_4}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_5}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_5}

412b. Enter the number of households that share this facility (including your own).

{san_label_5}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_6}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_6}

412b. Enter the number of households that share this facility (including your own).

{san_label_6}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_7}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_7}

412b. Enter the number of households that share this facility (including your own).

{san_label_7}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_8}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_8}

412b. Enter the number of households that share this facility (including your own).

{san_label_8}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_9}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_9}

412b. Enter the number of households that share this facility (including your own).

{san_label_9}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

{san_label_10}

Regular practices at the household only.

412a. Do you share this toilet facility with other households or the public?

{san_label_10}

412b. Enter the number of households that share this facility (including your own).

{san_label_10}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with ten or more households."

Enter -99 for no response.

Invalid response.

411. How often does your household typically use:

Other: {sanitation_all_other}

Regular practices at the household only.

411: How often does your household typically use:

No facility / bush / field

Regular practices at the household only.

413. How many people within your household regularly use the bush / field at home or at work?

There are {num_HH_members} people in this household.

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

Must be between zero and the number of household members.

WARNING: The respondent entered zero for the previous question, 413, but listed open defecation as a household sanitation facility in 409.

414. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?

Do not read the possible responses out loud.

PROBE: anything else?

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 household questionnaire.

Check answer to 009 and the consent.