PMA2020/Nigeria Household Questionnaire - Round 1
IDENTIFICATION
Please record the following identifying information prior to beginning the interview.
A. How many times have you visited this household?
[] 2nd time
[] 3rd time
B. Interviewer's name: Is this your name?
[ODK will display the name associated with the phone's serial number.]
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).
[] No
Please record your name
C. Current date and time.
[ODK will display on screen]
Is this date and time correct?
[] No
D. Record the correct date and time
Time____ Hour____ Minutes____ AM/PM____
E. Zone
[] North East
[] North West
[] South East
[] South South
[] South West
F. State
[] Kaduna
[] Kano
[] Lagos
[] Nasarawa
[] Rivers
[] Taraba
G. LGA
H. Enumeration area
.
I. Structure number
Please record the structure number from the household listing form
J. Household number
Please record the household number 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.
[] No
CHECK: Why are you resending this form?
Choose al that apply.
[] 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 is was not received
[] Other reason(s)
K. Is a member of the household and competent respondent present and available to be interviewed today?
[] No
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 Center for Population and Reproductive Health in collaboration with Center for Research, Evaluation Resources, and Development Population and Reproductive Health Program and Bayero University Kano. 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 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?
L. May I begin the interview now?
[] No
M. Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Check box: []
N. Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ B]."
O. Respondent's first name.
Please record the first name of the respondent.
[pg. 3]
SECTION 1 - Household Roster
I am now going to ask you a series of questions about each usual member of the household or anyone who slept in the house last night.
1. First name
2. Sex
[] Female
3. Age (years)
4. Marital Status
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Single
5. Relationship to head of household
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know
6. Family 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 did not sleep in the house last night
[] Visitor who slept in the house last night
8. Eligible female respondent
[] No
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?
[] No
Remember to include all children in the household.
[] No
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 the items 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.
[] No
A wall clock?
[] No
A radio?
[] No
A black/white television?
[] No
A color television?
[] No
A mobile phone?
[] No
A landline telephone?
[] No
A refrigerator?
[] No
A freezer?
[] No
Electric generator/invertor(s)?
[] No
A washing machine?
[] No
A computer?
[] No
A digital photo camera?
[] No
A non-digital photo camera?
[] No
A video deck?
[] No
A DVD/CD?
[] No
A sewing machine?
[] No
A bed? A table?
[] No
A cabinet/cupboard?
[] No
A bicycle?
[] No
A motorcycle or motor scooter?
[] No
A car or truck?
[] No
A boat with a motor?
[] No
A boat without a motor?
[] No
[] None of the above
11a. Does this household own any livestock, herds, other farm animals, or poultry?
These livestock can be kept anywhere, not necessarily on the homestead.
[] No
11b. How many of the following animals does this household own?
Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
The household can keep the livestock anywhere but must own the livestock recorded here.
Horses, donkeys, or mules? ____
Goats? Sheep? ____
Chickens/Ducks? ____
Pigs? ____
12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?
[] No
12b. How many of the following animals does this household keep ON THE HOMESTEAD? Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.
The household does not need to own the livestock recorded here.
Horses, donkeys, or mules? ____
Goats? Sheep? ____
Chickens/Ducks? ____
Pigs? ____
Section 3 - Household Observation
Please observe the floors, roof and exterior walls.
13. Main material of the floor
Observe.
[] DUNG
RUDIMENTARY FLOOR
[] PALM/BAMBOO
FINISHED FLOOR
[] VINYL OR ASPHALT STRIPS
[] CERAMIC TILES
[] CEMENT
[] CARPET/RUG
[] OTHER
14. Main material of the roof
Observe.
[] THATCH/PALM LEAF
RUDIMENTARY ROOFING
[] PALM/BAMBOO
[] WOOD PLANKS
[] CARDBOARD
FINISHED ROOFING
[] WOOD
[] CERAMIC TILES
[] CEMENT
[] ROOFING SHINGLES
[] OTHER
15. Main material of the exterior walls
Observe.
[] CANE/PALM/TRUNKS
[] DIRT MUD
RUDIMENTARY WALLS
[] STONE WITH MUD
[] PLYWOOD
[] CARDBOARD
[] REUSED WOOD
FINISHED WALLS
[] STONE WITH LIME/CEMENT
[] BRICKS
[] CEMENT BLOCKS
[] WOOD PLANKS/SHINGLES
[] OTHER
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?
[] No
[] Don't know
17. Can you show it to me?
[] No
18. At the place where the household washes their hands, observe if:
[] No
Water source is present: stored water
[] No
Water source is present: tap water
[] No
Handwashing area is near a sanitation facility
[] No
None of the above
[] No
19. 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 the bottom to see all choices.
Piped Water
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole
Dug Well
[] Unprotected Well
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
20. What is the main source of drinking water for members of your household?
Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole
Dug Well
[] Unprotected Well
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
21. What is the main source of water used by your household for other purposes such as cooking and hand washing? Selections from HQ19: [ODK will list water sources selected for HQ19]
Read out HQ19 selections only.
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole
Dug Well
[] Unprotected Well
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
Questions HQ 22 to HQ 25 will repeat x times, once for each water source selected in HQ 19. These sources include:
[ODK will display HQ19 selections.]
22. You mentioned you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:
[] No
Cooking
[] No
Livestock
[] No
Gardening / agriculture
[] No
Business venture
[] No
Washing
[] No
23. Is [WATER SOURCE] typically available:
Read all choices out loud.
[] Some of the year
[] Small part of the year
24. At a time when you expect to have water from [WATER SOURCE], is it usually available?
[] No, intermittent and predictable
[] No, intermittent and unpredictable
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 -88 for do not know, -99 for no response.
26. Does your household have a garden?
[] No
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.
[] Septic tank
[] Elsewhere
[] 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
28. What is the main toilet facility used by members of your household?
HQ27: [ODK will display HQ2 selections]
The main facility must be selected in HQ 27.
[] Septic tank
[] Elsewhere
[] 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
Question HQ 29 will repeat x times, once for each sanitation facility selected in HQ27. These facilities include:
HQ27: [ODK will display HQ2 selections]
29. How often does your household typically use: [TOILET FACILITY TYPE]?
Regular practices at the household only.
[] Most of the time
[] Occasionally
[] Rarely
29b. Do you share this toilet facility with other households or the public?
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public.
29c. Enter the number of households that share this facility including your own .
[TOILET FACILITY TYPE]
Must be between 2 and 9.
If 10 or greater, swipe back to HQ29b and choose "shared with ten or more households." If less than 2, swipe back to HQ29b and choose "not shared."
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.
31. For all children under age five: what methods, if any, does your household use to dispose of children's waste?
Do not read the possible answers out loud.
[] No
Leave waste where it is
[] No
Bury waste in field / yard
[] No
Dispose of waste in latrine / toilet
[] No
Dispose of waste with rubbish / garbage
[] No
Dispose of waste with waste water
[] No
Use it as manure
[] No
Burn it
[] No
[] Don't know
32. Ask permission to take a photo of the entrance of the house.
Did you get consent to take the photo?
[] No
Thank the respondent for her/his time.
The respondent is finished, but there are still three more questions for you to complete outside the house.
LOCATION AND QUESTIONNAIRE RESULT
P. Location
Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6m.
GPS coordinates can only be collected when outside.
Q. Ensure that no people are in the photo
CHOOSE IMAGE
[pg. 11]
R. Questionnaire result
Record the result of the Household Questionnaire
[] 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