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India 2021 Phase 2 Household Questionnaire

001a. Your ID:

001b. Enter your ID below.

Please record your ID

Must start with "N10" followed by 3 numbers

002a. Is this date and time correct?


[] Yes
[] No

002b. Record the correct date and time.

The date must be between 2021-07-01 and 2021-12-31.

003a. District

003b. Tehsil / Taluk

003c. City / Town / Village

004. Enumeration Area

004a. Phase 1 Household list

005. Structure number

Please record the structure number from the household listing form.

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.

007a. Are you at the same dwelling unit location from Phase 1?

[] Yes
[] No

007b. Do people live in this dwelling unit?

[] Yes
[] No

007c. Is at least one of the original P1 members still living in the dwelling unit?

[] Yes
[] No

007d. Why are people not living in this dwelling unit?


[] P1 dwelling unit vacant or address not a dwelling unit
[] P1 dwelling unit destroyed
[] P1 dwelling unit not found

007e. What is the status of the original P1 household?

Confirm with the neighbors to know the status

[] Household moved out of the study area
[] Household moved within the study area
[] Household split with some members in the study area and some out of the study area
[] No information

008. Which woman from Phase 1 are you following up?

If you do not see any women in this list, double-check your answers to 004a and 007a

[] FQ_ODK_display_name

010. CHECK: Why are you resending this form?

Choose all that apply.

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

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

[] Yes
[] No

013. Does at least one girl aged 14-20 live in your household?

If there are no adolescents in this household, the household roster will be skipped. Please complete and save this form, and then move on to the next household.

[] Yes
[] No

013a. How many girls aged 14-20 currently live in the household?

Invalid response.


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

Namaskar! My name is ............................ and I am working for the Indian Institute of Health Management Research University Jaipur in collaboration. I belong to this/nearby village.

The Indian Institute of Health Management Research in collaboration with the School of Public Health at Johns Hopkins University in the United States are conducting a study named PMA (Performance Monitoring for Action). We are conducting a local survey that asks about your family and family members. After that we would also ask different questions of girls aged 15-19 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 35-105 households have been selected and your house is one that has been 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 some discomfort 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.

011a. Provide a paper copy of the Consent Form to the respondent and read it.

Then, ask:
May I begin the interview now?

[] Yes
[] No

011b. Respondent's signature

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

012. Interviewer's ID: {your_name}

Mark your ID as a witness to the consent process.

[] NA

Household Roster Updating

ODK will display the summary of all household members listed in Phase 1. You will then update their information to indicate any changes including births and deaths

Section 1 - Household Roster

PL102. P1 Household Member

Below are the Phase 1 details for member {P_pos}:

First name: {hq_firstname_auto}
Relationship to HH head: {hq_relationship_lab}
Gender: {hq_gender_lab}
Age: {hq_age_auto}
Marital Status: {hq_marital_status_lab}

Is this person the respondent?

If yes, check this box.

[] NA

PL103. What is the status of this member in the household?

[] Resident
[] Moved elsewhere in the study area
[] Moved out of the study area
[] Moved out of the study area to attend school
[] Deceased
[] Unknown

PL104. Household Member

First name: {hq_firstname_auto}
Relationship to HH head: {hq_relationship_lab}
Gender: {hq_gender_lab}
Age: {hq_age_auto}
Marital Status: {hq_marital_status_lab}

Do you wish to update any of this information?

[] Yes
[] No

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.

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

If yes, check this box.

[] NA

102. What is {firstname}'s relationship to the head of household?

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Other
[] Do not know
[] No response

103. Is {firstname} male or female?

[] Male
[] 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 0.

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.

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

106. Does {firstname} usually live here?

[] Yes
[] No
[] No response

107. Did {firstname} stay here last night?

[] Yes
[] No
[] No response

LCL_101. What is the religion of {firstname}?

Only recorded for the head of the household.

[] Hindu
[] Muslim
[] Christian
[] Sikh
[] Buddhist/Neo-Buddhist
[] Jain
[] Jewish
[] Parsi/Zoroastrian
[] No religion
[] Other
[] No response

LCL_102. What is the caste of {firstname}?

Only recorded for the head of the household.

[] Scheduled Caste (SC)
[] Scheduled Tribe (ST)
[] Other Backward Caste (OBC)
[] General
[] Do not know
[] No response

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.

[] Yes
[] No

Section 2 - Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

201. Is this structure/house newly built in the last 12 months?

[] Yes
[] No
[] No response

202. 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.

[] Electricity
[] Mattress
[] Pressure cooker
[] Chair
[] Cot / bed
[] Table
[] Electric fan
[] Radio / transistor
[] BandW television
[] Colour television
[] Sewing machine
[] Mobile telephone
[] Land line 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
[] No response

203. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

[] Yes
[] No
[] No response

203. How many of the following animals does this household own?

The household can keep the livestock anywhere, but must own the livestock recorded here.

Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.

Cows / bulls / buffaloes ___
Camels ___
Horses / donkeys / mules ___
Goats ___
Sheep ___
Chickens / ducks ___
Other ___

Section 3 - Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor


[] Mud / clay / earth
[] Sand
[] Dung
[] Raw wood planks
[] Palm / bamboo
[] Brick
[] Stone
[] Parquet / finished wood
[] Vinyl / asphalt
[] Ceramic tile
[] Cement
[] Carpet
[] Polished stone / marble / granite
[] Other
[] No response

302. Main material of the roof


[] No roof
[] Thatch / palm leaf / reed / grass
[] Mud
[] Sod / mud and grass mixture
[] Plastic / polythene sheeting
[] Rustic mat
[] Palm / bamboo
[] Raw wood planks / timber
[] Unburnt brick
[] Loosely packed stone
[] Finished roofing/metal
[] Wood
[] Calamine / cement fiber
[] Asbestos sheets
[] RCC / RBC / Cement / Concrete
[] Roofing shingles
[] Tiles
[] Slate
[] Burnt brick
[] Other
[] No response

303. Main material of the exterior walls


[] No walls
[] Cane / palm / trunks / bamboo
[] Mud
[] Grass / reeds / thatch
[] Bamboo with mud
[] Stone with mud
[] Plywood
[] Cardboard
[] Unburnt brick
[] Raw wood / reused wood
[] Cement / concrete
[] Stone with lime / cement
[] Burnt brick
[] Cement blocks
[] Wood planks / shingles
[] GI / metal / asbestos sheets
[] Other
[] No response

Section 4 - Water Sanitation and Hygiene

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

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

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from 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

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

[] 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 / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

501. Thank you for the time you have kindly granted us.

Are you willing to provide a phone number for this household where we may reach you in the future to follow up for future research?

[] Yes
[] No
[] No response

502. What is the phone number?

Enter a 10-digit number without the country code. Do not include spaces or dashes.

Invalid number of digits.

503. Can you repeat the number again?

Enter a 10-digit number without the country code. Do not include spaces or dashes.

Number entered must match previously entered number.

504. What is the name of the person who normally answers this phone?

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?

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

098. In what language was this interview conducted?

[] English
[] Hindi
[] Other

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant
[] Address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period