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

001a. Your name: Is this your name?
[ODK will display the name associated with the phone's serial number.]

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

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

Record the correct date and time
Date: Month ___ Day ___ Year ___
Time: Hour ___ Minutes ___ AM/PM

003a. State

003b. LGA
ODK will populate a list of appropriate LGAs based on the state selected

003c. Locality
ODK will populate a list of appropriate Localities based on the LGA selected.

004. Enumeration area
ODK will populate a list of appropriate enumeration areas based on the LGA selected

005. Structure number
Please record the structure number from the household listing form.
Number ____

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

WARNING: Contact your supervisor before sending this form again.

008. CHECK: Why are you resending this form? Choose all that apply.

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

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

INFORMED CONSENT Find a competent member of the household. Read the greeting on the following screen.
010a. Hello. My name is ________________________________ and I am working for the Center for Research, Evaluation Resources, and Development in collaboration with the Centre for Advance Medical Research. 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?

010c. Interviewer's name Please record your name as a witness to the consent process. You previously entered "[NAME FROM 001a]."

011. 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.
101. Name of HH member/visitor Start with the head of the household.

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

103 Is [NAME] male or female?

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.

106 Does [NAME] usually live here?

107 Did [NAME] stay here last night?

1. What is the religion of [NAME]? Only recorded for the head of the household.

2. What is the ethnic group of [NAME]? Only recorded for the head of the household.

108. Are there any other usual members of your household or persons who slept in the house last night?

0. 109 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.

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 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.

202a. Does this household own any livestock, herds, other farm animals, or poultry? These livestock can be kept anywhere, not necessarily on the homestead.

202b. 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/bulls:
Horses, donkeys, or mules: ___
Goats: ___
Sheep: ___
Chickens/Ducks: ___
Pigs: ___

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.

203b. 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.
301. Main material of the floor
Observe.
Natural floor

Rudimentary floor

Finished floor

302. Main material of the roof
Observe.
Natural roofing

Rudimentary roofing

Finished roofing

303. Main material of the exterior walls
Observe.
Natural walls

Rudimentary walls

Finished walls

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?

401b. Can you show it to me?

401c. At the place where the household washes their hands, observe if:
Check all that apply.

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 the bottom to see all choices.
Piped Water

Dug Well

Water from Spring

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

Dug Well

Water from Spring

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 list water sources selected for 402]
Read out 402 selections only.
Piped Water

Dug Well

Water from Spring

Questions 405 to 408 will repeat X times, once for each water source selected in
402. These sources include: 402: [ODK will display 402 selections.]
405. You mentioned that you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:

99. 406 How many months out of the year is [WATER SOURCE] usually available? Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

99. 407 At a time of year when you expect to have water from [WATER SOURCE], is it usually available?

99. 408 How long does it take to go to [WATER SOURCE], get water, and come back? Zero is a possible answer Enter -88 for do not know Enter -99 for no response Convert answer to minutes. Answer includes waiting time in line.

409. 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:

410. What is the main toilet facility used by members of your household?
[ODK will display 409 selections] The main facility must have been selected in 409. Flush/pour flush toilets connected to:

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

411. How often does your household typically use: [TOILET FACILITY TYPE]? Regular practices at the household only.

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

412b 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 Q412a and choose "shared with ten or more households."
Enter -99 for no response.

413. 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.

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

Thank the respondent for her/his time. The respondent is finished, but there is still more for you to complete outside the home.
095b. Ensure that no people are in the photo
TAKE PICTURE CHOOSE IMAGE

096. Location Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6m. RECORD LOCATION

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 Household Questionnaire