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

A. How many times have you visited this household?

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

D. Record the correct date and time

E. COUNTY

F. DISTRICT SUB\COUNTY)
PLEASE RECORD THE NAME OF THE
G. DIVISION

H. LOCATION

I. ENUMERATION AREA

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

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?

Respondent's signature
PLEASE ASK THE RESPONDENT TO SIGN OR CHECK THE BOX IN AGREEMENT OF THEIR PARTICIPATION.

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

2. Sex

3. Age (years)

4. Marital Status

5. Relationship to head of household

6. Family ID

7. Is this person a usual member of the household or has he/she slept in the house last night?

8. Eligible female respondent

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?

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:

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

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?

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.

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

14. Main material of the roof
OBSERVE
15. Main material of the exterior walls
OBSERVE
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?

17. Can you show it to me?

18. AT THE PLACE WHERE THE HOUSEHOLD WASHES THEIR HANDS, OBSERVE IF:
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?

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?

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?

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:

The same question will be generated by the ODK software for all water sources selected in HQ19

23. Is [WATER SOURCE] typically available:

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?

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
26. Does your household have a garden?

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.

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

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.
29b. Do you share this toilet facility with other households or the public? [Select one]

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.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?

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?

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.
R. Ensure that no people are in the photo

S. Record the result of the Household Questionnaire