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NER4 Household Questionnaire

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

001a. Your name: [ODK will display the first name linked with the telephone number]
Is this your name?

[] Yes
[] No

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

002a. Current date and time.
[ODK will display it on the screen]
Is this date and time correct?

[] Yes
[] No

002b. Record the correct date and time.

Date____ Month____ Day____ Year____
Time____ Hour____ Minutes____ AM/PM____

003a. Région

[] Niamey
[] Agadez
[] Diffa
[] Dosso
[] Maradi
[] Tahoua
[] Tillaberi
[] Zinder

003b. Commune
ODK will populate a list of communes based on the selected region.

003c. Locality
ODK will populate a list of localities based on the selected commune.

004. Enumeration Area
ODK will populate a list of enumeration areas based on the selected locality.

005. Structure number
Please record the structure number from the household listing form.
[] Structure number ________

006. Household number
Please record the household number from the household listing form.
[] Household 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
[] No

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
[] 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)

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

[] Yes
[] No

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

[] Yes
[] No
[] Do not know
[] No response

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

Hello. My name is ________________________________ and I am working for l'Institut National de la Statistique (INS). We are conducting a local survey about various health issues in Niger. Your household has been selected for this survey. 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 question; 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?

010a. Ask: May I begin the interview now?

[] Yes
[] No

010b. Respondent's signature
GATHER SIGNATURE:
Checkbox

[] NA

010c. 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.
[] Name ________

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.

Household member

101. Name of household member / visitor
Start with the head of the household

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

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
[] 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?

[] Yes
[] No
[] No response

HQ8. Eligible female respondent

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

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]. Is this a complete list of household members?
Remember to include all children in the household.
[] Yes
[] No

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 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?
[] A radio?
[] A television?
[] A DVD/CD player?
[] A mobile phone?
[] A landline telephone?
[] A refrigerator?
[] An air conditioner?
[] A stove
[] A satellite dish?
[] A computer?
[] An animal-drawn cart?
[] A plow?
[] A motorized water pump?
[] None of the above
[] No response

Check here to acknowledge you considered all options.

[] NA

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
[] No
[] No response

202b. 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.
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Camel: Number _______
[] Chickens, Guinea Fowl, Pigeons: Number _______
[] Ducks, Geese: Number _______
[] Other: Number _______

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
[] No
[] No response

203b. How many of the following animals does this household keep ON THE HOMESTEAD.
The household does not need to own the livestock recorded here. Zero is a possible answer.
[] Cows or bulls: Number _______
[] Horses, donkeys or mules: Number _______
[] Goats: Number ________
[] Sheep: Number ________
[] Camel: Number _______
[] Chickens, Guinea Fowl, Pigeons: Number _______
[] Ducks, Geese: Number _______
[] Other: Number _______

Section 3 -- Household Observation
Please observe the floors, roof and exterior walls.

301. Main material of the floor
Observe.
Natural Floor
[] Earth / sand
Rudimentary Floor
[] Wooden boards
[] Palm / bamboo
Finished Floor
[] Parquet or polished wood
[] Vinyl/Asphalt strips
[] Tiles
[] Cement
[] Carpet
[] Other
[] No answer

302. Main material of the roof
Observe.
Natural Roof
[] No roof
[] Thatch / leaves
[] Soil
Rudimentary Roofing
[] Mats
[] Palm / bamboo
[] Wooden boards
[] Cardboard
[] Animal hide
Finished Roofing
[] Sheet metal
[] Wood
[] Zinc / fiber cement
[] Tile
[] Cement
[] Other
[] No answer

303. Main material of the exterior walls
Observe.
Natural Walls
[] No wall
[] Bamboo / cane / palm / trunk
[] Earth
[] Straw
Rudimentary Walls
[] Stones with mud
[] Plywood
[] Cardboard
[] Recovered wood
Finished Walls
[] Cement
[] Stones with lime / cement
[] Bricks
[] Cement blocks
[] Wood board / shingles
[] Sheet metal
[] Other
[] No answer

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
[] No
[] Do not know
[] No response

401b. Can you show it to me?

[] Yes
[] No

401c. At the place where the household washes their hands, observe if:
Cannot select 'none of the above' with other options.
[] Soap is present
[] Yes
[] No
[] Water source is present: stored water
[] Yes
[] No
[] Water source is present: running water
[] Yes
[] No
[] Handwashing area is near a sanitation facility
[] Yes
[] No
[] None of the above
[] Yes

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 bottom to see all choices.
Cannot select 'no response' with other options.
[] Piped Water: Piped into dwelling/indoor
[] Yes
[] No
[] Piped Water: Pipe to yard/plot
[] Yes
[] No
[] Piped Water: Public tap/standpipe
[] Yes
[] No
[] Tube well or borehole
[] Yes
[] No
[] Dug Well: Protected Well
[] Yes
[] No
[] Dug Well: Unprotected Well
[] Yes
[] No
[] Water from Spring: Protected Spring
[] Yes
[] No
[] Water from Spring: Unprotected Spring
[] Yes
[] No
[] Rainwater
[] Yes
[] No
[] Tanker Truck
[] Yes
[] No
[] Cart with Small Tank
[] Yes
[] No
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Yes
[] No
[] Bottled Water
[] Yes
[] No
[] Sachet Water
[] Yes
[] No
[] No response
[] Yes

Check here to acknowledge you considered all options.

[] NA

403. What is the main source of drinking water for members of your household?
Selections from 402: [ODK will display sources selected in 402]
Read out 402 selections only.
[] 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

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 display sources selected in 402]
Read out 402 selections only.
[] 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

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

405. You mentioned that you use [WATER SOURCE]. At any time of the year does your household use water from this source for:
Cannot select 'no response' with other options.
[] Drinking
[] Yes
[] No
[] Cooking
[] Yes
[] No
[] Livestock
[] Yes
[] No
[] Gardening / agriculture
[] Yes
[] No
[] Business venture
[] Yes
[] No
[] Washing
[] Yes
[] No
[] No response
[] Yes

406. How many months out of the year is piped water to your indoor usually available:
Zero is a possible answer. Please record the number of completed months.
[] Number of months ________

407. At a time of year when you expect to have water from [WATER SOURCE], is it usually available?

[] Yes, always
[] No, intermittent and predictable
[] No, intermittent and unpredictable
[] No response

408. How long does it take to go to the [WATER SOURCE], get water, and come back?
0 is a possible answer. Convert answer to minutes. Includes waiting time in line.
[] Number of months ________

409. Do members of your household use any of the following toilet facilities?
Read out all types. Check all that are used. Scroll to bottom to see all choices.
[] Flush/pour flush toilets connected to: Piped sewer system
[] Yes
[] No
[] Flush/pour flush toilets connected to: Septic tank
[] Yes
[] No
[] Flush/pour flush toilets connected to: Pit Latrine
[] Yes
[] No
[] Flush/pour flush toilets connected to: Elsewhere
[] Yes
[] No
[] Flush/pour flush toilets connected to: Unknown / Not sure / Don't know
[] Yes
[] No
[] Ventilated improved pit latrine
[] Yes
[] No
[] Pit latrine with slab
[] Yes
[] No
[] Pit latrine without slab
[] Yes
[] No
[] Composting toilet
[] Yes
[] No
[] Bucket toilet
[] Yes
[] No
[] Hanging toilet /Hanging latrine
[] Yes
[] No
[] Other
[] Yes
[] No
[] No facility / bush / field
[] Yes
[] No
[] No response
[] Yes

Check here to acknowledge you considered all options.

[] NA

410. What is the main toilet facility used by members of your household?
Selections from 409: [ODK will display facilities selected in 409]
The main facility must be selected in 409.
[] 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
[] Composting toilet
[] Bucket toilet
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

Question 411, 412a, 412b will repeat X times, once for each sanitation facility selected in 409. These facilities include:
409: [ODK will display facilities selected in 409]

411. How often does your household typically use:
[TYPE OF SANITATION FACILITY]?
Regular practices at the household only.
[] Always
[] Most of the time
[] Occasionally
[] No response

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

[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public.
[] No response

412b. Enter the number of households that share this facility (including your own).
[TYPE OF SANITATION FACILITY]
Must be between 2 and 9.
__________Number of households

413. How many people within your household regularly use the bush / field at home or at work?
There are [X NUMBER] people in this household.
Must be between zero and the number of household members.
__________Number of people

095a. Ask permission to take a photo to the entrance of the household.
Did you get consent to take the photo?

[] Yes
[] No

095b. Ensure that no people are in the photo.
[] TAKE A PHOTO
[] SELECT IMAGE

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.

[ENTER GPS COORDINATES]
097. How many times have you visited this household?

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

098. In what language was this interview conducted?

[] English
[] French
[] Djerma/Sonraï
[] Haussa
[] Fulfulde
[] Kanouri
[] Gourmantchema
[] Tamacheq
[] Toubou
[] Arabic
[] Other

099. Questionnaire result
Record the result of the household questionnaire.
[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant or address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period