001a. Your name:

001b. Enter staff name below:

Please record your name

002a. Is this date and time correct?

{today_formatted}

002b. Record the correct date and time.

The date must be between 2021-12-01 and 2022-12-31.

003a. Region

003b. Commune / Departement

003c. Locality / Commune

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?

007b. Do people live in this dwelling unit?

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

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

GO TO 099, ENTER THE RESULT CODE AND SUBMIT THE FORM

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

Confirm with the neighbors to know the status

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

010. CHECK: Why are you resending this form?

Choose all that apply.

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

INFORMED CONSENT

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

My name is ........................ and I work for the National Institute of Statistics (INS) in collaboration with the Ministry of Public Health, Population and Social Affairs. We are currently conducting a national survey on several topics related to women's reproductive health. We very much appreciate your being part of this survey. The information we collect will help inform the government to better plan health services. The survey usually takes about 15-20 minutes to complete. Any information you share will be strictly confidential and will not be shared with anyone outside the research team.
Your household has been selected for this survey. Participation in this survey is voluntary, and if there is a question you do not wish to answer, please let me know and I will move on to the next question; or you may stop the interview at any time. However, we hope that you will agree to participate in this survey as your opinion is important.
Before I start, do you have any questions on this survey?

010a. Read the verbal consent text.

Then, ask:
May I begin the interview now?

010b. Respondent's signature

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

011. Interviewer's name: {your_name}

Mark your name as a witness to the consent process.

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.

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

Respondent cannot be deceased

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?

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.

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

103. Is {firstname} male or 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.

106. Does {firstname} usually live here?

107. Did {firstname} stay here last night?

LCL_101. What is the religion of {firstname}?

Only recorded for the head of the household.

LCL_102. What is the ethnicity of {firstname}?

Only recorded for the head of the household.

Are there any other usual members of your household or persons who slept in the house last night that I have not listed here?

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.

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?

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.

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

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

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 or bulls ___
Horses, donkeys or mules ___
Goats ___
Sheep ___
Camels ___
Chickens ___
Geese ___
Other ___

Section 3 - Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor

Observe.

302. Main material of the roof

Observe.

303. 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.

401. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

402. At the place where the household washes their hands, observe availability of water

403. At the place where the household washes their hands, observe availability of soap or detergent:

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

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

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?

502. What is the phone number?

Enter an 8-digit number without the country code. Do not include spaces or dashes.

Invalid number of digits.

503. Can you repeat the number again?

Enter an 8-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?

098. In what language was this interview conducted?

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.