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

A. Your name: Is this your name?
[ODK will display the name associated with the phone's serial number.]
Check the button next to the name if that is your name and select 'yes' here. Do not check the button if that is not your name and select 'no' here (long press to remove response next to the name if needed).

Enter your name below.
Please record your name

B. Current date and time.
[ODK will display on screen]
Is this date and time correct?

C. Record the correct date and time

D. PROVINCE

D. District

D. SUB-DISTRICT

D. VILLAGE

D. BLOK SENSUS

E. Structure number
Please record the structure number from the household listing form.

F. Household number
Please record the household number from the household listing form.
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.
CHECK: Why are you resending this form?
Choose all that apply.
G. Is a member of the household and competent respondent present and available to be interviewed today?

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 BKKBN, University of North Sumatra, Universitas Gadjah Mada, and Hasanuddin University in collaboration with The Central Bureau of Statistics. 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 years.
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?

Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.

I. Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ B]."

J. Respondent's first name.
Please record the first name of the respondent.

[pg. 3]
SECTION 1 - Household Roster
I am now going to ask you a series of questions about each usual member of the household or anyone who slept in the house last night.

1. First name

2. Sex

3. Age (years) If less than one year old record 0.

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.

HQ_Ins1. Is [NAME] covered by any of the following insurance programs?

After recording information for one household member, the following prompt is asked to activate a looping script to record information for another member
9. Are there any other usual members of your household or persons who slept in the house last night?

READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named [NAMES OF ENTERED HOUSEHOLD MEMBERS]. Is this a complete list of the household members?
Remember to include all children in the household.
Section 2 - Household Characteristics
Now I would like to ask you a few questions about the characteristics of your household.

10. Please tell me about the items you're 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.
11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
11b. How many of the following animals does this household own?
Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
The household can keep the livestock anywhere but must own the livestock recorded here.
12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?
Homestead includes the structure and yard that is close to the structure.
12b. How many of the following animals does this household keep ON THE HOMESTEAD?
Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
The household does not need to own the livestock recorded here.
[pg. 5]
Section 3 - Household Observation
Please observe the floors, roof and exterior walls.

13. Main material of the floor
Observe.
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:

19. 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 the bottom to see all choices.
Piped Water

Dug Well

Water from Spring

[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River/Dam/Lake/Pond/Stream/Canal/Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] Refill Water
[] No response

20. What is the main source of drinking water for members of your household?
Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.

21. What is the main source of water used by your household for other purposes such as cooking and hand washing?
Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.
Questions HQ 22 to HQ 25 will repeat x times, once for each water source selected in HQ19. These sources include:
[ODK will display HQ19 selections.]
22. You mentioned that you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:

23. Is [WATER SOURCE] typically available:
Read all choices out loud.
24. At a time of year when you expect to have water from [WATER SOURCE], is it usually available?

25. How long does it take to go to [WATER SOURCE], get water, and come back?
Zero is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.
26. Does your household have a garden?
A garden is a place to grow vegetables.
27. Do members of your household use any of the following toilet facilities?
Read out all types and check all that are used. Scroll to the bottom to see all choices.
28. What is the main toilet facility used by members of your household?
HQ27: [ODK will display HQ27 selections]
The main facility must be selected in HQ 27.
Question HQ 29 will repeat x times, once for each sanitation facility selected in HQ27. These facilities include:
HQ27: [ODK will display HQ27 selections]
29. How often does your household typically use: [TOILET FACILITY TYPE]?
Regular practices at the household only.
29b. Do you share this toilet facility with other households or the public?

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.
30. How many people within your household regularly use the bush / field / river / stream / creek at home or at work?
There are x people in this household. Enter -88 for do not know, -99 for no response.

CHECK HQ 3: Are there any household members aged 5 years or under?

31. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?
PROBE: Anything else?
Do not read the possible answers out loud.
32. Ask permission to take a photo of the entrance of the house.
Did you get consent to take the photo?

Thank the respondent for her/his time.
The respondent is finished, but there is still more for you to complete outside the home.

LOCATION AND QUESTIONNAIRE RESULT
K. Location
Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6m.

CHECK 32: Permission to take photo?

L. Ensure that no people are in the photo

M. How many times have you visited this household?

N. Questionnaire result
Record the result of the Household Questionnaire