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

A. How many times have you visited this household?

B. Interviewer's name: Is this your name?
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).
Enter your name below.
PLEASE RECORD YOUR NAME:
ODK will display the name associated with the phone's serial number.

Interviewer's Name

C. CURRENT DATE AND TIME DISPLAYED ON SCREEN Is this date and time correct?

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

E. Region PLEASE SELECT THE NAME OF THE REGION WHERE THE HOUSEHOLD IS LOCATED.

F. District
PLEASE SELECT THE NAME OF THE DISTRICT WHERE THE HOUSEHOLD IS LOCATED.
ODK will populate a list of appropriate districts based on the region selected for SQ E.

G. Subcounty
PLEASE SELECT THE NAME OF THE SUBCOUNTY WHERE THE HOUSEHOLD IS LOCATED ODK will populate a list of appropriate subcounties based on the district selected for SQ F.

H. Enumeration area
PLEASE CHOOSE THE NAME OF THE ENUMERATION AREA WHERE THE HOUSEHOLD IS LOCATED.
ODK will populate a list of appropriate Enumeration Areas based on the subcounty selected for SQ G.

I. Structure number PLEASE RECORD THE STRUCTURE NUMBER FROM THE HOUSEHOLD LISTING FORM.

J. Household number PLEASE RECORD THE NUMBER OF THE HOUSEHOLD 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.

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

No INFORMED CONSENT Find the competent member of the household. Read the greeting on the following screen:
Hello. My name is ________________________________ and I am working for the Makerere University, School of Public in collaboration with Ministry of Health, and Uganda Bureau of Statistics. 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. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask:
May I begin the interview now?

N. Interviewer's name PLEASE RECORD YOUR NAME AS A WITNESS TO THE CONSENT PROCESS.

O. Respondent's first name PLEASE RECORD THE FIRST NAME OF THE RESPONDENT.

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 No

1. First name

2. Sex

3. Age (years)

4. Marital Status

5. Relationship to head of household

6. Family ID

7. Is this person a usual member of the household or has he/she slept in the house last night?

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 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.

011a Does this household own any livestock, herds, other farm animals, or poultry? THESE LIVESTOCK CAN BE KEPT ANYWHERE, NOT NECESSARILY ON THE HOMESTEAD.

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

12a. Does this household keep any livestock, herds, other farm animals, or poultry ON THE HOMESTEAD, regardless of who owns these livestock?

12b. How many of the following animals does this household keep ON THE HOMESTEAD? The household does not need to own the livestock recorded here.

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.

Section 3 - Household Observation
Please observe the floors, roof and exterior walls

13. Main material of the floor
OBSERVE
Natural Floor

Finished Floor

14. Main material of the roof
OBSERVE
Natural Roofing

Finished Roofing

15. 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.

16. Do you have a place to wash your hands?

17. Can you show it to me?

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

Which of the following water sources does your household use on a regular basis for any part of the year for any purpose? Piped Water

Dug Well

Water from Spring

READ OUT ALL TYPES AND CHECK ALL THAT ARE USED. SCROLL TO THE BOTTOM TO SEE ALL CHOICES.

20. What is the main source of drinking water for members of your household? Piped Water

Dug Well

Water from Spring

21. What is the main source of water used by your household for other purposes such as cooking and hand washing? Piped Water

Dug Well

Water from Spring

22. QUESTIONS HQ 22 TO HQ 25 WILL REPEAT X TIMES, ONCE FOR EACH WATER SOURCE SELECTED IN HQ 19.
THESE SOURCES INCLUDE:
The ODK software will list all sources selected in HQ 19.
You mentioned you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:

23. Is [WATER SOURCE] typically available
(READ ALL CHOICES OUT LOUD):

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

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.
The same question will be generated by the ODK software for all water sources selected in HQ19.
Minutes ____

26. Does your household have a garden?

27. Do members of your household use any of the following toilet facilities? Flush/pour flush toilets connected to:

28. What is the main toilet facility used by members of your household? Flush/pour flush toilets connected to:

THE MAIN FACILITY MUST BE SELECTED IN HQ 27
QUESTIONS HQ 29 WILL REPEAT X TIMES, ONCE FOR EACH SANITATION FACILITY SELECTED IN HQ 27. THESE FACILITIES INCLUDE:
The ODK software will list all sources selected in HQ 27.

29. How often does your household typically use [TOILET FACILITY TYPE]? REGULAR PRACTICES AT THE HOUSEHOLD ONLY.

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

29c. Enter the number of households that share this facility (including your own).
Households ____
[TOILET FACILITY TYPE]
MUST BE BETWEEN 2 AND 10.
IF 10 OR GREATER, SWIPE BACK TO HQ29b AND CHOOSE ?SHARED WITH TEN OR MORE HOUSEHOLDS.?
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
Number of people ____

CHECK HQ 3: Are there any household members aged 5 years or under? Skip to HQ 32 if NO

31. For all children under age five: what methods, if any, does your household use to dispose of children's fecal waste?

DO NOT READ THE POSSIBLE ANSWERS OUT LOUD

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

Thank the respondent for his/her time.
THE RESPONDENT IS FINISHED, BUT THERE ARE STILL THREE MORE QUESTIONS FOR YOU TO COMPLETE OUTSIDE THE HOUSE.
LOCATION AND QUESTIONNAIRE RESULT

P. Take a GPS point outside near the entrance to the household.
Record location when the accuracy is smaller than 6m.
GPS COORDINATES CAN ONLY BE COLLECTED WHEN OUTSIDE.
Instructions are given directly by the ODK software
RECORD LOCATION

CHECK HQ 32: photo permission

Q. Ensure that no people are in the photo Instructions are given directly by the ODK software
TAKE PICTURE CHOOSE IMAGE

R. Record the result of the Household Questionnaire