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PMA2020 Nigeria Household Questionnaire - Round 3

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

A. Your 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
[] No
Enter your name below.
Please record your name
Interviewer's Name

B. Current date and time.
[ODK will display on screen]
Is this date and time correct?

[] Yes
[] No

C. Record the correct date and time

Date: Month____ Day____ Year____
Time: Hour____ Minutes____ AM/PM____

D1. State

[] Kaduna
[] Lagos
[] Taraba
[] Kano
[] Rivers
[] Nasarawa
[] Anambra

D2. LGA

ODK will generate a list of LGA within the selected State.

D5. Enumeration area

ODK will generate a list of enumeration areas within the selected LGA.

E. Structure number
Please record the structure number from the household listing form.

Number ____

F. Household number
Please record the household number from the household listing form.

Number____
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.
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 is was not received
[] Other reason(s)

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

[] Yes
[] No

G2 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 the Center for Research, Evaluation Resources, and Development in collaboration with 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?

H. May I begin the interview now?

[] Yes
[] No

I. Interviewer's name
Please record your name as a witness to the consent process. You previously entered "[NAME FROM HQ B]."

J. Respondent's first name.
Please record the first name of the respondent.

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
[] Female

3. Age (years)

AGE____

4. Marital Status

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Single

5. Relationship to head of household

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] Other
[] Don't know

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
[] 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

[] Yes
[] No
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
[] No
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
[] 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 you're 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?
[] A wall clock?
[] A radio?
[] A black/white television?
[] A color television?
[] A mobile telephone?
[] A non-mobile telephone?
[] A refrigerator?
[] A cable TV?
[] A generating set?
[] Air conditioner?
[] A computer?
[] Electric iron?
[] A fan?
[] A watch?
[] A bicycle?
[] A motorcycle or motor scooter?
[] An animal-drawn cart?
[] A car or truck?
[] A boat without a motor?
[] A canoe?
[] None of the above
[] No response

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
[] No
[] No response

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?
Homestead includes the structure and yard that is close to the structure.
[] Yes
[] No
[] No response

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
[] DUNG

RUDIMENTARY FLOOR
[] WOOD PLANKS
[] PALM/BAMBOO

FINISHED FLOOR
[] PARQUET OR POLISHED WOOD
[] VINYL OR ASPHALT STRIPS
[] CERAMIC TILES
[] CEMENT
[] CARPET/RUG

[] OTHER
[] NO RESPONSE

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

RUDIMENTARY ROOFING
[] RUSTIC MAT
[] PALM/BAMBOO
[] WOOD PLANKS
[] CARDBOARD

FINISHED ROOFING
[] METAL/ZINC
[] WOOD
[] CERAMIC TILES
[] CEMENT
[] ROOFING SHINGLES

[] OTHER
[] NO RESPONSE

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

RUDIMENTARY WALLS
[] BAMBOO WITH MUD
[] STONE WITH MUD
[] PLYWOOD
[] CARDBOARD
[] REUSED WOOD

FINISHED WALLS
[] CEMENT
[] STONE WITH LIME/CEMENT
[] BRICKS
[] CEMENT BLOCKS .
[] WOOD PLANKS/SHINGLES

[] OTHER
[] NO RESPONSE

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, or do you have a movable container that is not kept in a fixed location, such as a bowl or kettle, that is commonly used for hand washing?
If the container is always in the same location, then count it as a fixed place
[] Yes, fixed place
[] Yes, movable container
[] No
[] Don't know
[] No response

17a. Can you show it to me?

[] Yes
[] No

17b. Can you show me any soap, water, and movable container available in the household used for hand washing?

[] Yes
[] No

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

Soap is present
[] Yes
[] No

Water source is present: stored water
[] Yes
[] No

Water source is present: running water
[] Yes
[] No

Hand washing area is near a sanitation facility
[] Yes
[] No

[] None of the above

18b. ANYWHERE WITHIN THE HOUSEHOLD,

[] Soap is present
[] Water source is present: stored water
[] Water source is present: running water
[] Hand washing container Is observed
[] None of the above

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
[] No Response

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
[] 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
[] No Response