Data Cart

Your data extract

0 variables
0 samples
View Cart

PMA Nigeria Household Questionnaire 2019 - Baseline Survey

001a. Your name: ${your_name}.

Is this your name?

[] Yes
[] No

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

[] Yes
[] No

002b. Record the correct date and time.

The date must be between 2019-10-01 and 2020-10-01.

003a. State
[] Kano
[] Lagos

003b. LGA

003c. Locality

004. Enumeration area

005. Structure number

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.

007. CHECK: Have you already sent a form for this structure and household?


[] Yes
[] No

WARNING: Contact your supervisor before sending this form again.

008. 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 it was not received
[] Other reason(s)

WARNING: Each household should have ONLY ONE household roster with all household members listed on the same form.

Please contact your supervisor before sending this form.

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

[] Yes
[] No


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. We are conducting a local survey about various health issues. Your household has been selected for this survey. 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?

May I begin the interview now?

If yes continue with interview, if no thank the respondent and end the interview.

Hello, my name is _____. I am one of the interviewers for the PMA/Lagos survey that is supported by the Centre for Research Evaluation Resources and Development. The survey will collect information from selected households about household characteristics, reproductive behaviour among women of child bearing age and water and sanitation. Your household is one of those selected to participate in the survey.

As part of the survey, I would like to ask you some questions about your household. There is little or no risk to either you or your family for participating in this survey. Some of the questions in the survey ask about access to water, toilet facilities and different household items. There are no consequences for not participating. There are no direct benefits to you for participating in this survey. You will not be paid for being in this survey and you are free to stop the interview at anytime. However, we will give your household a very small appreciation gift for your involvement in this survey.

I want to assure you that all of your answers will be kept strictly confidential. I will not keep a record of your name or address. You have the right to stop the interview at any time, or to skip any questions that you don't want to answer. There are no Right or Wrong answers.

Your participation is completely voluntary but your experiences could be very helpful to other people in Nigeria.

Would it be alright for me to ask you some questions? The questions should take only about 20 minutes to complete.

There are a few things you should know about this survey:
1. You get to decide if you want to be in the survey and whatever you decide is OK.
2. It is also OK to say 'Yes' and change your mind later. You can stop being in the survey at any time. If you want to stop, please tell me and I will not be upset.
3. You can say 'Yes' to the study and as I ask you questions, you can say 'No' to any question that you do not want to answer.
4. Your answers will be kept strictly confidential. That means that your answers will just be between you and me and will never be connected to your name or any other personal information.
5. Sometimes you might not know the answer to a question or might not want to answer a question. I would rather you say you don't know or that you don't want to answer a question than tell me a story that isn't true.
6. We will document your address so we can visit you at least one time a year for the 4 year duration of this study.

Do you have any questions?

For any further concerns about your rights in this survey or the procedures you may contact [name] who is prepared to address your concerns. Please feel free to write down this information for future reference.

010a. May I begin the interview now?

[] Yes
[] No

010b. Respondent's signature

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


[] NA

WARNING: The respondent has not signed or checked the box, despite agreeing to be interviewed in the previous question. To conduct the survey, the respondent must sign or touch the checkbox.

You may go back to obtain a signature or check the box or you should go back to the previous question to indicate the respondent does not want to be interviewed.

010c. Interviewer's name: ${your_name}

Mark your name as a witness to the consent process.

[] NA

010c. Interviewer's name

Please record your name as a witness to the consent process. You previously entered "${name_typed}."

That is not what you entered for your name earlier in this survey.

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.

Household member

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

If yes, check this box.

[] NA

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

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Other
[] Do not know
[] No response

103. Is ${firstname} male or female?

[] Male
[] 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.

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

106. Does ${firstname} usually live here?

[] Yes
[] No
[] No response

107. Did ${firstname} stay here last night?

[] Yes
[] No
[] No response

ERROR: Members on household roster must usually live here or must have stayed here last night.

Go back and remove this household member.

LCL_101. What is the religion of ${firstname}?

[] Catholic
[] Other Christian
[] Islam
[] Traditionalist
[] Other
[] No religion
[] No response

LCL_102. What is the ethnicity of ${firstname}?

[] Afo/Gwandara
[] Alago
[] Eggon
[] Fufulde
[] Hausa
[] Igbo
[] Izon/Ijaw
[] Katab/Tyap
[] Mada
[] Mambila
[] Mumuye
[] Ogoni
[] Rundawa
[] Wurkum
[] Yoruba
[] Other
[] No response

This person IS NOT eligible for the female respondent questionnaire.

This person IS eligible for the female respondent questionnaire.

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

[] Yes
[] No

There are other members of the household. Move forward and select "Add Group"

There are no other members of the household. Move forward and select "Do Not Add"

ERROR: There is no household head.

Go back, select a head.

For each member, check that the relationship to the household head is accurate.

ERROR: There are ${heads} household heads selected:

Go back, select only one head.

For each member, check that the relationship to the household head is accurate.


The checkbox for 101a (Is this person the respondent?) was never selected for any of the household members.

You entered the following household members: ${names}.

If the respondent was entered in the roster but never selected as the respondent in 101a: Please go back and select the checkbox in 101a for the correct respondent.

If the respondent is a household member but left out of the list of household members: Add the respondent to the list.

If the respondent is not a household member: Stop the interview. Find a household member and interview that person. Be sure to ask for consent.


The checkbox for 101a (Is this person the respondent?) was selected more than once.

Please go back and make sure that it is only selected once.

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.

[] Yes
[] No

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 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.

[] Electricity?
[] A radio?
[] A television?
[] A mobile telephone?
[] A non-mobile telephone?
[] A refrigerator?
[] A cable TV?
[] A small generating set?
[] A big generating set
[] An air conditioner?
[] A computer?
[] An electric iron?
[] A fan?
[] A watch?
[] A bicycle?
[] A motorcycle or motor scooter?
[] An animal-drawn cart?
[] A car or truck?
[] A canoe?
[] A boat with a motor?
[] A microwave oven?
[] A washing machine?
[] A grain grinder?
[] A food blender?
[] A mattress?
[] None of the above
[] No response

Check here to acknowledge you considered all options.

[] NA

202a. 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

202b. 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.

Milk cows/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


[] Earth/Sand
[] Dung
[] Wood Planks
[] Palm/Bamboo
[] Parquet or polished wood
[] Vinyl or Asphalt Strips
[] Ceramic Tiles
[] Cement
[] Carpet/Rug
[] Other
[] No response

302. Main material of the roof


[] No roof
[] Thatch/Palm Leaf
[] Rustic Mat
[] Palm/Bamboo
[] Wood planks
[] Cardboard
[] Metal/Zinc
[] Wood
[] Ceramic Tiles
[] Cement
[] Roofing Shingles
[] Other
[] No response

303. Main material of the exterior walls


[] No Walls
[] Cane/Palm Trunks
[] Dirt/Mud
[] Bamboo with Mud
[] Stone with Mud
[] Plywood
[] Cardboard
[] Reused Wood
[] 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.

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

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] 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
[] No response

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

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

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?

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

098. In what language was this interview conducted?

[] English
[] Hausa
[] Yoruba
[] Pidgin
[] Other

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.

[] Completed
[] 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
[] Entire household absent for extended period