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PMA2020 India/Rajasthan 2016 Household Questionnaire - Round 1

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

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

[] Yes 1
[] No 0

Enter your ID below.
Please record your ID

Interviewer's Name________

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

[] Yes 1
[] No 0

C. Record the correct date and time

Date____
Month____
Day____
Year____
Time____
Hour____
Minutes____
AM/PM____

D. District
ODK will populate a list of sampled Districts within the state.

D. Tehsil/Taluk
ODK will populate a list of appropriate Tehsil/Taluk based on the District selected.

D. City/Town/Village
ODK will populate a list of appropriate City/Town/Village based on the District selected.

D. Enumeration area
ODK will populate a list of appropriate enumeration areas based on the City/Town/Village selected for HQ H.

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

Number____

F. Household number
Please record the household number from the household listing form.

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 a competent member of the household. Read the greeting on the following screen.

Namaskar! My name is ____________________________________ and I am working for the IIHMR University Jaipur in collaboration with local Partners. I belong to this/nearby village. We are conducting a local survey that asks about your family and family members. Post to that we would also ask different questions from women aged between

1. 5-49 years. This survey is conducted across Rajasthan. From every enumeration area 35 households have been selected and in this extension your house is randomly selected. Though we would very much appreciate your participation in the survey, your refusal to take part in this survey will have no repercussions on you. Information provided by you would help us inform the government to better plan health services. As such there is no risk however; there may be a distress among participants to share information on personal topics. If you agree to take part in this study, it will not benefit you directly. However, we believe that information gathered in this study will help us and other groups like us to develop programs that will improve the lives of men and women in communities in Rajasthan and around India so we hope that you would take part in this survey. Whatever information you provide will be kept confidential and only our research team will have access to it. We will never use your name while analyzing the data. The tracking sheet and the database with your responses will be kept on password-protected computers and on a secure server. Participation in this study is entirely voluntary, if you do not wish to answer any question feel free to inform me and I would skip to the next question. You can choose not to participate at all or to end the interview at any point. The survey usually takes between 20 to 30 minutes to complete. If you have any questions about the study and your right as a research participant, you may ask me now or you may also contact Dr. Dhirendra Kumar at IIHMR University, in Jaipur, Rajasthan at +91-141-3924738.

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
Please ask the respondent to sign the paper copy of the consent form or give a thumb print on the paper copy of the consent form and do likewise in the ODK form in agreement of their participation.

Gather signature:________

Check box: []

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

Name________

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

Name________

SECTION 1 - Household Roster

I am now going to ask you a series of questions each usual member of the household or anyone who slept in the house last night.

1. First name

NAME________

2. Sex

[] Male 1
[] Female 2

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

AGE____

4. Marital Status

[] Married 1
[] Living with a partner 2
[] Married but gauna not performed 3
[] Divorced / separated 4
[] Widow / widower 5
[] Never Married 6
[] No response -99

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
[] No response -99

6. 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

7. Eligible female respondent
ODK will determine and display eligibility.

[] Yes 1
[] No 0

CHECK HQs: Is this person the Household Head?

[] Yes 1
[] No 0

8a. What is the religion of (NAME)?

[] Hindu 1
[] Muslim 2
[] Christian 3
[] Sikh 4
[] Buddhist/Neo-Buddhist 5
[] Jain 6
[] Jewish 7
[] Parsi/Zoroastrian 8
[] No Religion 9
[] Other 96
[] No Response -99

8b. What is the caste or tribe of (NAME)?

[] Scheduled Caste (SC) 1
[] Scheduled Tribe (ST) 2
[] Other Backward Caste (OBC) 3
[] General 4
[] Don't Know -88
[] No Response -99

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?

[] Yes 1
[] No 0

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.

[] Yes 1
[] No 0

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 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.

[] Electricity
[] Mattress
[] Pressure cooker
[] Chair
[] Cot/bed
[] Table
[] Electric fan
[] Radio/transistor
[] B and w television
[] Color television
[] Sewing machine
[] Mobile telephone
[] Landline telephone
[] Internet
[] Computer
[] Refrigerator
[] Air conditioner/cooler
[] Washing machine
[] Watch/clock
[] Bicycle
[] Motorcycle/scooter
[] Animal-drawn cart
[] Car
[] Water pump
[] Thresher
[] Tractor
[] None of the above -77
[] No response -99


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?
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.

COWS/ BULLS/BUFFALOES____
CAMELS____
HORSES/ DONKEYS/MULES____
GOATS____
SHEEP____
CHICKENS/DUCKS____

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.

[] Yes 1
[] No 0
[] No response -99

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.

COWS/ BULLS/BUFFALOES____
CAMELS____
HORSES/ DONKEYS/MULES____
GOATS____
SHEEP____
CHICKENS/DUCKS____

Section 3 - Household Observation

Please observe the floors, roof and exterior walls.

13. Main material of the floor HQ13.
Observe.

NATURAL FLOOR
[] MUD/CLAY/EARTH 11
[] SAND 12
[] DUNG 13
RUDIMENTARY FLOOR
[] RAW WOOD PLANKS 21
[] PALM/BAMBOO 22
[] BRICK 23
[] STONE 24
FINISHED FLOOR
[] PARQUET OR POLISHED WOOD 31
[] VINYL OR ASPHALT 32
[] CERAMIC TILES 33
[] CEMENT 34
[] CARPET 35
[] POLISHED STONE/MARBLE/GRANITE 36
[] OTHER (SPECIFY) 96
[] NOT OBSERVED (NO-RESPONSE) -99

12. 14 Main material of the roof
Observe.

NATURAL ROOFING
[] NO ROOF 11
[] THATCH/PALM LEAF/REED/GRASS 12
[] MUD 13
[] SOD/MUD AND GRASS MIXTURE 14
[] PLASTIC/POLYTHENE SHEETING 15
RUDIMENTARY ROOFING
[] RUSTIC MAT 21
[] PALM/BAMBOO 22
[] RAW WOOD PLANKS/TIMBER 23
[] UNBURNT BRICK 24
[] LOOSELY PACKED STONE 25
FINISHED ROOFING
[] METAL 31
[] WOOD 32
[] CALAMINE/CEMENT FIBER 33
[] ASBESTOS SHEETS 34
[] RCC/RBC/CEMENT/CONCRETE 35
[] ROOFING SHINGLES 36
[] TILES 37
[] SLATE 38
[] BURNT BRICK 39
[] OTHER (SPECIFY) 96
[] NOT OBSERVED (NO-RESPONSE) -99

15. Main material of the exterior walls
Observe.

NATURAL WALLS
[] NO WALLS 11
[] CANE/PALM/TRUNKS/BAMBOO 12
[] MUD 13
[] GRASS/REEDS/THATCH 14
RUDIMENTARY WALLS
[] BAMBOO WITH MUD 21
[] STONE WITH MUD 22
[] PLYWOOD / 23
[] CARDBOARD 24
[] UNBURNT BRICK / 25
[] RAW WOOD/REUSED WOOD 26
FINISHED WALLS
[] CEMENT/CONCRETE 31
[] STONE WITH LIME/CEMENT 32
[] BURNT BRICKS 33
[] CEMENT BLOCKS 34
[] WOOD PLANKS/SHINGLES 35
[] GI/METAL/ASBESTOS SHEETS 36
[] OTHER (SPECIFY) 96
[] NOT OBSERVED (NO-RESPONSE) -99

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?

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

17. Can you show it to me?

[] Yes 1
[] No 0

18. 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 -77

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 of all types and check all that are used. Scroll to the bottom to see all choices.

[] Piped Water / Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole
[] Dug Well
[] Protected Well
[] Unprotected Well
[] Water from Spring
[] Protected Spring
[] Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream /Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No Response -99

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.

[] 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
[] No Response -99

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.

[] 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
[] No Response -99

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:

[] Drinking
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing
[] No response -99

23. Is [WATER SOURCE] typically available:
Read all choices out loud.

[] All of the year 1
[] Some of the year 2
[] Small part of the year 3
[] No response -99

24. At a time of year 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
[] No response -99

25. How long does it take to go to [WATER SOURCE], get water, and come back?
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____

26. Does your household have a garden?
A garden is a place to grow vegetables.

[] Yes 1
[] No 0
[] No response -99

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.

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Don't know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab/open pit
[] Bucket toilet
[] Composting toilet
[] Hanging toilet /Hanging latrine
[] No facility / bush / field
[] Other 96
[] No Response -99

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.

[] Flush/pour flush toilets connected to: Piped sewer system 1
[] Flush/pour flush toilets connected to: Septic tank 2
[] Flush/pour flush toilets connected to: Elsewhere 3
[] Flush/pour flush toilets connected to: Unknown / Not sure / Don't know 4
[] Ventilated improved pit latrine 5
[] Pit latrine with slab 6
[] Pit latrine without slab/open pit 7
[] Composting toilet 8
[] Bucket toilet 9
[] Hanging toilet /Hanging latrine 10
[] Other 11
[] No facility / bush / field 12
[] No Response -99

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.

[] 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?

[] 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:____

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, -99 for no response.

Number of People:____

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

[] Children use a latrine / toilet
[] Leave waste where it is
[] Bury waste in field / yard
[] Dispose of waste in latrine / toilet
[] Dispose of waste with rubbish / garbage
[] Dispose of waste with waste water
[] Use it as manure
[] Burn it
[] Don't know -88
[] No response -99

32. 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 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.

RECORD LOCATION________

CHECK 32: Permission to take photo?

L. Ensure that no people are in the photo

TAKE PICTURE

CHOOSE IMAGE

M. How many times have you visited this household?

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

N. Questionnaire result
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
[] Entire household absent for extended period of time 9