001a. 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).

001b. Enter your name below. Please record your name
Interviewer's Name _____________

002a. Current date and time.
[ODK will display on screen]
Is this date and time correct?

002b. Record the correct date and time Date Month Day Year

Time Hour _____ Minutes ________

003a. PROVINCE ODK will populate a list of all provinces in the survey sample.

003b. District ODK will populate a list of appropriate DISTRICTS based on the PROVINCE selected. Always
003c. SUB-DISTRICT ODK will populate a list of appropriate SUBDISTRICT based on the DISTRICT selected.

003d. VILLAGE ODK will populate a list of appropriate VILLAGE based on the SUB-DISTRICT selected.

004. BLOK SENSUS ODK will populate a list of appropriate enumeration areas based on the Village selected

O05 Structure number Please record the structure number from the household listing form.
Number _____

006. Household number Please record the household number from the household listing form.
Number ________

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.

008. CHECK: Why are you resending this form? Choose all that apply.

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

010. Did this household participate in a previous PMA2020 survey?

00. 9=1 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, UniversitasGadjahMada, 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 aska 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?

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.
Gather signature: __________
Check box: ?

011c. Interviewer's name Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ B]."

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

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.

101. Name of HH member/visitor
Start with the head of the household.

102. What is [NAME]'s relationship to the head of the household?

103. Is [NAME] Male or Female?

104. How old was [NAME] at their last birthday? If less than one year old, enter 0

105. What is [NAME]'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 [NAME] usually live here?

107. Did [NAME] stay here last night?

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

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 [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.

201. Please tell me about the 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.

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? 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.
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? 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.

Section 3 - Household Observation
Please observe the floors, roof and exterior walls.

301. Main material of the floor
Observe.
Natural Floor

Rudimentary Floor

Finished Floor

Main material of the roof
Observe.
Natural Roofing

Rudimentary Roofing

Finished Roofing

Main material of the exterior walls
Observe.
Natural Walls

Finished Walls

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

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 the bottom to see all choices.
Piped Water

Dug Well

Water from Spring

What is the main source of drinking water for members of your household? Selections from HQ402: [ODK will list water sources selected for HQ402]
Read out HQ402 selections only. Piped Water

Dug Well

Water from Spring

404. What is the main source of water used by your household for other purposes such as cooking and hand washing? Selections from HQ402: [ODK will list water sources selected for HQ402]
Read out HQ402 selections only.
Piped Water

Dug Well

Water from Spring

402. Questions HQ405 to HQ408 will repeat X times, once for each water source selected in HQ402. These sources include:
[ODK will display HQ402 selections.]

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

How many months out of the year is [WATER SOURCE] usually available? Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

At a time of year when you expect to have water from [WATER SOURCE], is it usually available?

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.

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.

410. What is the main toilet facility used by members of your household? HQ409: [ODK will display HQ409 selections]
The main facility must be selected in HQ409

409. Question HQ411 will repeat X times, once for each sanitation facility selected in HQ409. These facilities include:
HQ409: [ODK will display HQ409 selections]

How often does your household typically use: [TOILET FACILITY TYPE]? Regular practices at the household only.

99. 412a Do you share this toilet facility with other households or the public?

412b. 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 HQ412a and choose "shared with ten or more households."
Enter -99 for no response.

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, -99 for no response.

414. For all children under age five: what methods, if any, does your household use to dispose of children's waste? PROBE: Anything else? Do not read the possible answers out loud.

401. Do you have a garbage bin inside the house?

402. Do you have a garbage receptacle outside the house?

403. Do you burn your garbage at home?

404. Is there any manager or transporter for garbage in your neighborhood?

095a 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.
095b. Ensure that no people are in the photo
TAKE PICTURE CHOOSE IMAGE

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