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PMA2020 / Kenya Household Questionnaire - Round 1

Please record the following identifying information prior to beginning the interview.
A. How many times have you visited this household?

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

B. Your name: Is this your name?
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:
ODK will display the name associated with the phone's serial number.
Interviewer's Name_____________________

C. CURRENT DATE AND TIME DISPLAYED ON SCREEN
Is this date and time correct?

[] Yes 1
[] No 0

D. Record the correct date and time

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

E. COUNTY

[] Bungoma 1
[] Kericho 2
[] Kiambu 3
[] Kilifi 4
[] Kitui 5
[] Nairobi 6
[] Nandi 7
[] Nyamira 8
[] Siaya 9

F. DISTRICT SUB\COUNTY)
PLEASE RECORD THE NAME OF THE
ODK will populate a list of appropriate districts based on the County selected for HQ E.

G. DIVISION

ODK will populate a list of appropriate divisions based on the district sub-county) selected for HQ F.

H. LOCATION

ODK will populate a list of appropriate locations based on the division selected for HQ G.

I. ENUMERATION AREA

ODK will populate a list of appropriate enumeration areas based on the location selected for HQ H.

J. STRUCTURE NUMBER
PLEASE RECORD THE NUMBER OF THE STRUCTURE FROM THE HOUSEHOLD LISTING FORM.
K. HOUSEHOLD NUMBER
PLEASE RECORD THE NUMBER OF THE HOUSEHOLD 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.
[] Yes 1
[] No 0

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

[] Yes 1
[] No 0

INFORMED CONSENT Find the competent member of the household. Read the following greeting:
Hello. My name is ________________________________ and I am working for the International Center for Reproductive Health in Kenya, in collaboration with the Ministry of Health and the Kenya National 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 questioni 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?
M. 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 OR CHECK THE BOX IN AGREEMENT OF THEIR PARTICIPATION.

GATHER SIGNATURE:
Check box: ???

O. Interviewer's name
PLEASE RECORD YOUR NAME AS A WITNESS TO THE CONSENT PROCESS.
P. Respondent's first name
PLEASE RECORD THE FIRST NAME OF THE RESPONDENT.
SECTION1- Household Roster
I am now going to ask you questions about each usual members 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)

AGE____

4. Marital Status

[] Married 1
[] Living with a partner 2
[] Divorced / separated 3
[] Widow / widower 4
[] Single 5

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

6. Family ID

ID____

7. 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

8. Eligible female respondent

[] Yes 1
[] No 0
ODK will determine and display eligibility based on age and sex.
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

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 items that your household owns. Does your household have:

Electricity?
[] Yes 1
[] No 0

A wall clock?
[] Yes 1
[] No 0

A radio?
[] Yes 1
[] No 0

A black/white television?
[] Yes 1
[] No 0

A color television?
[] Yes 1
[] No 0

A mobile phone?
[] Yes 1
[] No 0

A landline telephone?
[] Yes 1
[] No 0

A refrigerator?
[] Yes 1
[] No 0

A freezer?
[] Yes 1
[] No 0

Electric generator/invertor(s)?
[] Yes 1
[] No 0

A washing machine?
[] Yes 1
[] No 0

A computer?
[] Yes 1
[] No 0

A digital photo camera?
[] Yes 1
[] No 0

A non digital photo camera?
[] Yes 1
[] No 0

A video deck?
[] Yes 1
[] No 0

A DVD/CD?
[] Yes 1
[] No 0

A sewing machine?
[] Yes 1
[] No 0

A bed?
[] Yes 1
[] No 0

A table?
[] Yes 1
[] No 0

A cabinet/cupboard?
[] Yes 1
[] No 0

A bicycle?
[] Yes 1
[] No 0

A motorcycle or motor scooter?
[] Yes 1
[] No 0

A car or truck?
[] Yes 1
[] No 0

A boat with a motor?
[] Yes 1
[] No 0

A boat without a motor?
[] Yes 1
[] No 0

[] None of the above -77
[] No response -99
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.
[] Yes 1
[] No. 0

[pg. 4]
11b. How many of the following animals does this household own?

[] Cattle Indigenous ____
[] Cows/Bulls ____
[] Horses, Donkeys, Mules ____
[] Goats ____
[] Sheep ____
[] Chickens ____
ZERO IS A POSSIBLE ANSWER. ENTER O88 FOR DO NOT KNOW. ENTER O99 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?

[] Yes 1
[] No 0

12b. How many of the following animals does this household keep ON THE HOMESTEAD? The household does not need to own the livestock recorded here.

[] Cattle Indigenous ____
[] Cows/Bulls ____
[] Horses/Donkeys/Mules ____
[] Goats ____
[] Sheep ____
[] Chicken ____

THE HOUSEHOLD DOES NOT NEED TO OWN THE LIVESTOCK RECORDED HERE. ZERO IS A POSSIBLE ANSWER. ENTER O88 FOR DO NOT KNOW, O99 FOR NO RESPONSE.
Section 3 - Household Observation
Please observe the floors, roof and exterior walls
13. Main material of the floor
OBSERVE

Natural Floor
[] Earth/Sand 11
[] Dung 12

Rudimentary Floor
[] Wood Planks 21
[] Palm/Bamboo 22

Finished Floor
[] Parquet or polished wood 31
[] Vinyl or Asphalt strips 32
[] Ceramic Tiles 33
[] Cement 34
[] Carpet 35

[] Other 96
[] No response -99

14. Main material of the roof
OBSERVE
[] No Roof 10
Natural Roofing
[] Grass/Thatch/Makuti 11
[] Dung/Mud 12

Rudimentary Roofing
[] Corrugated Iron (Mabati) 21
[] Tin Cans 22

Finished Roofing
[] Asbestos Sheet 31
[] Cement 32
[] Tiles 33

[] Other 96
No response -99

15. Main material of the exterior walls
OBSERVE
[] No Walls 11
Natural Walls
[] Cane/Palm/Trunks 12
[] Dirt 13

Rudimentary Walls
[] Bamboo with Mud 21
[] Stone with Mud 22
[] Uncovered Adobe 23
[] Plywood 24
[] Cardboard 25
[] Reused Wood 26

Finished Walls
[] Cement 31
[] Stone with Lime/Cement 32
[] Bricks 33
[] Cement Blocks 34
[] Covered Adobe 35
[] Wood Planks/Shingles 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.
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
[] Yes 1
[] No 0

Water source is present: stored water
[] Yes 1
[] No 0

Water source is present: tap water
[] Yes 1
[] No 0

Handwashing area is near a sanitation facility
[] Yes 1
[] No 0

None of the above
[] Yes 1
[] No 0

19. Which of the following water sources does your family use on a regular basis for any part of the year for any household purpose?

Piped Water
Piped into dwelling/indoor
[] Yes 1
[] No 0

Pipe to yard/plot
[] Yes 1
[] No 0

Public tap/standpipe
[] Yes 1
[] No 0

Tube well or borehole
[] Yes 1
[] No 0

Dug Well
Protected Well
[] Yes 1
[] No 0

Unprotected Well
[] Yes 1
[] No 0

Water from Spring
Protected Spring
[] Yes 1
[] No 0

Unprotected Spring
[] Yes 1
[] No 0

Rainwater
[] Yes 1
[] No 0

Tanker Truck
[] Yes 1
[] No 0

Cart with Small Tank
[] Yes 1
[] No 0

Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Yes 1
[] No 0

Bottled Water
[] Yes 1
[] No 0

Sachet Water
[] Yes 1
[] No 0

[] No response -99

READ OUT ALL TYPES AND CHECK ALL THAT ARE USED. SCROLL TO THE BOTTOM TO SEE ALL CHOICES.
20. What is the main source of drinking water for members of your household?

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
READ OUT HQ19 SELECTIONS ONLY.
21. What is the main source of water used by your household for other purposes such as cooking and handwashing?

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
READ OUT HQ19 SELECTIONS ONLY.
22. QUESTIONS HQ 22 TO HQ 25 WILL REPEAT X TIMES, ONCE FOR EACH WATER SOURCE SELECTED IN HQ 19. THESE SOURCES INCLUDE:
The ODK software will list all sources selected in HQ 19.
You mentioned that you use [WATER SOURCE]. At any time of the year, does your family use water from this source for:

Drinking
[] Yes 1
[] No 0

Cooking
[] Yes 1
[] No 0

Livestock
[] Yes 1
[] No 0

Gardening / agriculture
[] Yes 1
[] No 0

Business venture
[] Yes 1
[] No 0

Washing
[] Yes 1
[] No 0

[] No response -99
The same question will be generated by the ODK software for all water sources selected in HQ19
23. Is [WATER SOURCE] typically available:

[] All of the year 1
[] Some of the year 2
[] Small part of the year 3
READ ALL CHOICES OUT LOUD.
The same question will be generated by the ODK software for all water sources selected in HQ19
24. At a time 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
The same question will be generated by the ODK software for all water sources selected in HQ19
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 O88 FOR DO NOT KNOW, O99 FOR NO RESPONSE.
The same question will be generated by the ODK software for all water sources selected in HQ19
Minutes____

26. Does your household have a garden?

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

27. Do members of your household use any of the following toilet facilities?

Flush/pour flush toilets connected to:
Piped sewer system
[] Yes 1
[] No 0

Septic tank
[] Yes 1
[] No 0

Elsewhere
[] Yes 1
[] No 0

Unknown / Not sure / Don't know
[] Yes 1
[] No 0

Ventilated improved pit latrine
[] Yes 1
[] No 0

Pit latrine with slab
[] Yes 1
[] No 0

Pit latrine without slab
[] Yes 1
[] No 0

Composting toilet
[] Yes 1
[] No 0

Bucket toilet
[] Yes 1
[] No 0

Hanging toilet /Hanging latrine
[] Yes 1
[] No 0

Other (please explain):
[] Yes 1
[] No 0

No facility / bush / field
[] Yes 1
[] No 0

[] No response -99
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?

Flush/pour flush toilets connected to:
[] Piped sewer system 1
[] Septic tank 2
[] 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
THE MAIN FACILITY MUST BE SELECTED IN HQ 27
QUESTIONS HQ 29-29b WILL REPEAT X TIMES, ONCE FOR EACH SANITATION FACILITY SELECTED IN HQ 27. THESE FACILITIES INCLUDE:
The ODK software will list all sources selected in HQ 27.
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? [Select one]

[] 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 10.
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 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____
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?

Children use a latrine / toilet
[] Yes 1
[] No 0

Leave waste where it is
[] Yes 1
[] No 0

Bury waste in field / yard
[] Yes 1
[] No 0

Dispose of waste in latrine / toilet
[] Yes 1
[] No 0

Dispose of waste with rubbish / garbage
[] Yes 1
[] No 0

Dispose of waste with waste water
[] Yes 1
[] No 0

Use it as manure
[] Yes 1
[] No 0

Burn it
[] Yes 1
[] No 0

[] Don't know -88
[] No response -99
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?

[] Yes 1
[] No 0

Thank the respondent for his/her time.
THE RESPONDENT IS FINISHED, BUT THERE ARE STILL TWO MORE QUESTIONS FOR YOU TO COMPLETE OUTSIDE THE HOUSE.
LOCATION AND QUESTIONNAIRE RESULT
Q. Take a GPS point outside near the entrance to the household.
Record location when the accuracy is smaller than 6m.
GPS COORDINATES CAN ONLY BE COLLECTED WHEN OUTSIDE.
Instructions are given directly by the ODK software
TAKE PICTURE
RECORD LOCATION

R. Ensure that no people are in the photo

Instructions are given directly by the ODK software
TAKE PICTURE
CHOOSE IMAGE

S. 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 9