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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?

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

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).

[] Yes 1
[] No 0
Enter your name below.
Please record your name

Interviewer's Name

C. Current date and time.
[ODK will display 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. Zone

[] North Central 1
[] North East 2
[] North West 3
[] South East 4
[] South South 5
[] South West 6

F. State
[] Anambra 1[] Kaduna 2[] Kano 3[] Lagos 4[] Nasarawa 5[] Rivers 6[] Taraba 7
G. LGA

ODK will populate a list of appropriate LOCATION INFORMATION 3 based on the LOCATION INFORMATION 2 selected for HQ F

H. Enumeration area

ODK will populate a list of appropriate enumeration areas based on the LOCATION INFORMATION 4 selected for HQ H

.
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.

[] Yes 1
[] No 0
WARNING: Contact your supervisor before sending this form again.
CHECK: Why are you resending this form?
Choose al that apply.
[] There are new household members on this form 1
[] I am correcting a mistake made on a previous form 2
[] The previous form disappeared from my phone without being sent 3
[] I submitted the previous form and my supervisor told me that is was not received 4
[] Other reason(s) 5

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

[] Yes 1
[] No 0

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?

[] Yes 1
[] No 0

M. Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.

Gather signature:
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

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
READ THIS CHECK OUT LOUD: There are [NUMBER OF HOUSEHOLD MEMBERS ENTERED] household members who are named [NAMES OF ENTERED HOUSEHOLD MEMBERS]. Is this a complete list of the household members?
Remember to include all children in the household.
[] 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 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.

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? 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 -88

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

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.

Milk cows or bulls? ____
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?

[] Yes 1
[] No 0

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.

Milk cows or bulls? ____
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.
NATURAL FLOOR
[] EARTH/SAND 1
[] DUNG 2

RUDIMENTARY FLOOR
[] WOOD PLANKS 3
[] PALM/BAMBOO 4

FINISHED FLOOR
[] PARQUET OR POLISHED WOOD 5
[] VINYL OR ASPHALT STRIPS 6
[] CERAMIC TILES 7
[] CEMENT 8
[] CARPET/RUG 9
[] OTHER 10

14. Main material of the roof
Observe.
NATURAL ROOFING
[] NO ROOF 1
[] THATCH/PALM LEAF 2

RUDIMENTARY ROOFING
[] RUSTIC MAT 3
[] PALM/BAMBOO 4
[] WOOD PLANKS 5
[] CARDBOARD 6

FINISHED ROOFING
[] METAL/ZINC 7
[] WOOD 8
[] CERAMIC TILES 9
[] CEMENT 10
[] ROOFING SHINGLES 11
[] OTHER 14

15. Main material of the exterior walls
Observe.
NATURAL WALLS
[] NO WALLS 1
[] CANE/PALM/TRUNKS 2
[] DIRT MUD 3

RUDIMENTARY WALLS
[] BAMBOO WITH MUD 4
[] STONE WITH MUD 5
[] PLYWOOD 6
[] CARDBOARD 7
[] REUSED WOOD 8

FINISHED WALLS
[] CEMENT 9
[] STONE WITH LIME/CEMENT 10
[] BRICKS 11
[] CEMENT BLOCKS . 12
[] WOOD PLANKS/SHINGLES 13
[] OTHER 14

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

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 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

[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole

Dug Well

[] Protected Well
[] Unprotected Well

Water from Spring

[] Protected 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.

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

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.

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

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:

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

23. Is [WATER SOURCE] typically available:
Read all choices out loud.
[] All of the year 1
[] Some of the year 2
[] Small part of the year 3

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

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.

Minutes _________

26. Does your household have a garden?

[] Yes 1
[] No 0

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.

Flush/pour flush toilets connected to:
[] Piped sewer system
[] 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.

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

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.
[] Always 1
[] Most of the time 2
[] Occasionally 3
[] Rarely 4

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

[] Not shared 1
[] Shared with less than ten households 2
[] Shared with ten or more households 3
[] Shared with the public. 4

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.
Number of people _________

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 waste?
Do not read the possible answers out loud.
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

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 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.

RECORD LOCATION

Q. Ensure that no people are in the photo

TAKE PICTURE
CHOOSE IMAGE

[pg. 11]
R. Questionnaire result
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