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PMA2020 India/Rajasthan 2017 Household Questionnaire - Round 3

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

001a. 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

001. b Enter your ID below.
Please record your ID

Interviewer's Name _____

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

[] Yes 1
[] No 0

Record the correct date and time
Date
Month _____ Day___ Year ____
Time Hour _____ Minutes ____ AM/PM

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

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

003. c City/Town/VillageODK will populate a list of appropriate City/Town/Village based on the District selected.

004. Enumeration areaODK will populate a list of appropriate enumeration areas based on the City/Town/Village selected for HQ

005. 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.

[] Yes 1
[] No 0

WARNING: Contact your supervisor before sending this form again.

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

[] There are new household members on this form 1
[] I am correcting a mistake made on a previous form 2
[] The previous form disappeared from my phone without being sent 3
[] I submitted the previous form and my supervisor told me that it was not received 4
[] Other reason(s) 5


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

[] Yes 1
[] No 0

009. b Did this household participate in a previous PMA2020 survey?

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

INFORMED CONSENT Find a competent member of the household. Read the greeting on the following screen.
010. a 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 15-49 years, which would help to identify gaps in family planning and health services that affect regular availability and quality of information, services, and products. 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. Anoop Khanna at IIHMR University, in Jaipur, Rajasthan at +91-

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

010. b Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:

010. c Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM 001]."


011. 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.
Household Roster Screen #1
101. Name of HH member/visitor / Start with the head of the household.
Name ______

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

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
[] No response

103. Is [NAME] male or female?

[] Male
[] Female
[] No response

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

Screen #2

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.

Married
[] Living with a partner
[] Married, gauna not performed
[] Divorced / separated
[] Widow / widower
[] Never Married
[] No response

106. Does [NAME] usually live here?

[] Yes
[] No
[] No response

107. Did [NAME] stay here last night?
[NAME]

[] Yes
[] No
[] No response

Screen #3
101. What is the religion of [NAME]?
Only recorded for the head of the household.

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

Screen #4
102. 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

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

[] Yes
[] No


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 household members? (

[] Yes
[] No

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 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/
[] Colour television
[] Sewing machine
[] Mobile telephone
[] Land line telephone
[] Internet
[] Computer
[] Refrigerator
[] Airconditioner/cooler
[] Washing machine
[] Watch/clock
[] Bicycle/ Motorcycle/scooter
[] Animal-drawn cart/
[] Car/
[] Water pump/
[] Thresher/
[] Tractor/
[] None of the above
[] No response -99

202a. 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

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.

COWS/BULLS/ BUFFALOES ______
CAMELS ______
HORSES/DONKEYS/MULES ______
GOATS ______
SHEEP ______
CHICKENS/ DUCKS ______

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.

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

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.

COWS/BULLS/ BUFFALOES ______
CAMELS ______
HORSES/DONKEYS/MULES ______
GOATS ______
SHEEP ______
CHICKENS/ DUCKS ______

Section 3 - Household Observation
Please observe the floors, roof and exterior walls.
301. Main material of the floor
Observe.

[] MUD/CLAY/EARTH 11
[] SAND 12
[] DUNG 13
[] RAW WOOD PLANKS 21
[] PALM/BAMBOO 22
[] BRICK 23
[] STONE 24
[] PARQUET OR FINISHED WOOD 31
[] VINYL OR ASPHALT 32
[] CERAMIC TILES 33
[] CEMENT 34
[] CARPET 35
[] POLISHED STONE/MARBLE/GRANITE 36
[] OTHER. 96
[] NO-RESPONSE -99

302. Main material of the roof
Observe.

[] NO ROOF11
[] THATCH/PALM LEAF/REED/GRASS 12
[] MUD 13
[] SOD/MUD AND GRASS MIXTURE 14
[] PLASTIC/POLYTHENE SHEETING
[] RUSTIC MAT/ 21
[] PALM/BAMBOO// 22
[] RAW WOOD PLANKS/TIMBER 23
[] UNBURNT BRICK 24
[] LOOSELY PACKED STONE
[] FINISHED ROOFING METAL/GI 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 96
[] NO RESPONSE -99

303. Main material of the exterior walls
Observe.

[] NO WALLS 11
[] CANE/PALM/TRUNKS/BAMBOO 12
[] MUD 13
[]GRASS/REEDS/THATCH 14
[] BAMBOO WITH MUD 21
[] STONE WITH MUD 22
[] PLYWOOD 23
[] CARDBOARD 24
[] UNBURNT BRICK 25
[] RAW WOOD/REUSED WOOD 26
[] CEMENT/CONCRETE 31
[] STONE WITH LIME/CEMENT 32
[] BURNT BRICKS 33
[] CEMENT BLOCKS 34
[] WOOD PLANKS/SHINGLES 35
[] GI/METAL/ASBESTOS SHEETS 36
[] OTHER. 96
[] NO RESPONSE -99

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?

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

401b. Can you show it to me?

[] Yes 1
[] No 0


401c. At the place where the household washes their hands, observe if:
Check all that apply.

[] Soap is present
[] Stored water is present
[] Running water is present
[] Handwashing area is near a sanitation facility
[] None of the above -77

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
[] 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
[] No Response -99

403. What is the main source of drinking water for members of your household?
Selections from 402: [ODK will list water sources selected for 402]
Read out 402 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
[] No Response -99

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

Selections from 402: [ODK will list water sources selected for 402]

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
[] No Response -99

Questions 405 to 408 will repeat X times, once for each water source selected in 402. These sources include: 402: [ODK will display 402 selections.]
405. 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

406. 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

Number of months _____

407. 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

408. 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 answer to minutes. Answer includes waiting time in line.

Minutes: _____

409. 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
[] Septic tank
[] Pit latrine
[] Elsewhere
[] Unknown / Not sure / Don't know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] No facility / bush / field
[] Other_____________:
[] No Response -99

410. What is the main toilet facility used by members of your household
[ODK will display 409 selections]
The main facility must have been selected in 409.

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 7
[] Composting toilet 8
[] Bucket toilet 9
[] Hanging toilet /Hanging latrine 10
[] Other: 11
[] No facility / bush / field 12
[] No Response -99

More than one option selected for 409

Questions 411, 412a and 412b will repeat X times, once for each toilet facility selected in 409. These facilities include: 409: [ODK will display 409 selections]
411. 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
[] No response -99

412a. Do you share this toilet facility with other households or the public [TOILET FACILITY TYPE]?

[] 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

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

Number of Households: ______

413. 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: ______

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

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

RECORD LOCATION

097. How many times have you visited this household

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

098. In what language was this interview conducted?

[] English 1
[] Hindi 2
[] Other 96

099. 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