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PMA2020 - Uganda 2015 Household Questionnaire Round 2

IDENTIFICATION
Please record the following identifying information prior to beginning the interview.
How many times have you visited this household?

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

A. Interviewer's name: Is this your name?
If not, please record your name:
ODK will display the name associated with the phone's serial number
[] Yes 1
[] No 0

B. Is this date and time correct?
[ODK will display the current date and time from the device's settings. Check that it is correct.]

[] Yes 1
[] No 0

D. Record the correct date and time

Day____ Month____ Year____
Hours____ Min____ AM/PM____

E. Region
Select the region
PLEASE SELECT THE NAME OF THE REGION WHERE THE HOUSEHOLD IS LOCATED
[] Central 1
[] Eastern 2
[] Northern 3
[] Western 4

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

E. Subcounty name
Select the 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

E. Enumeration area
ODK will populate a list of appropriate Enumeration Areas based on the district selected for SQ g
PLEASE SELECT THE NAME OF THE ENUMERATION AREA WHERE THE HOUSEHOLD IS LOCATED
F. Structure number
Please record the number of this structure from the Household Listing Form.

Structure Number:

G. Household number
Please record the number of this household from the Household Listing Form.

Household Number:

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

[] Yes 1
[] No 0

INFORMED CONSENT
Find the competent member of the household. Read the following greeting:

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.
At this time, do you want to ask me anything about the survey?
I. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

[] Yes 1
[] No 0
Respondent's signature
Ask the respondent to sign their name or check the box to confirm that they consent to participate.

GATHER SIGNATURE:
Check box []

I. Interviewer's signature
Record your name as a witness to the consent process.
J. Interviewee's name
Record the first name of the respondent only.
SECTION 1 - Household Roster
I will now ask you questions about all members of the household. Let's begin with you. For each person who usually lives here or slept in the house last night, please record the following information:
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
[] Never Married 5
[] No response -99

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
[] No response -99

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
[] No response -99

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 the information for another member if needed:
9. Are there any other usual members of your household or persons who slept in the house last night?

[] 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. Does your household have:
Read out all types and select all that apply.

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?
[] Yes 1
[] No 0

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
[] No response -99

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
[] No Response -99

11b. How many of the following animals does this household own?
HINT: 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
[] Cattle (indigenous)____
[] Cows or bulls____
[] Pigs____
[] Horses/Donkeys/ Mules____
[] Goats____
[] Sheep____
[] Chickens____

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
[] No response 0

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
[] Cattle (indigenous)____
[] Cows or bulls____
[] Horses/Donkeys/ Mules____
[] Goats____
[] Sheep____
[] Pigs____
[] Chickens____

Section 3 - Household Observation
Please observe the floors, roof and exterior walls
13. Main material of the floor
OBSERVE
[] Earth/Sand 11
[] Earth and Dung 12
[] Parquet or polished wood 31
[] Mosiac or Tiles 33
[] Bricks 34
[] Cement 35
[] Stones 36
[] Other 96
[] No response -99

14. Main material of the roof
OBSERVE
[] Thatched 11
[] Mud 12
[] Wood Planks 21
[] Iron sheets 22
[] Asbestos 23
[] Tiles 24
[] Tin 25
[] Cement 26
[] Other 96

15. Main material of the exterior walls
OBSERVE
[] Thatched/Straw 11
[] Mud poles 12
[] Un-burnt bricks
[] Un-burnt bricks with plaster
[] Burnt bricks with mud
[] Cement blocks
[] Stone
[] Timber
[] Burnt bricks with Cement
[] Other 96
[] No response -99

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

17a. Can you show it to me?

[] Yes 1
[] No 0

18a. 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: running 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 family use on a regular basis for any part of the year for any household purpose?
READ OUT ALL TYPES AND CHECK ALL THAT ARE USED.
Piped Water
Piped into dwelling/indoor
[] Yes 1
[] No 0

Pipe to yard/plot
[] Yes 1
[] No 0

Public tap/standpipe
[] Yes 1
[] No 0

Tube well or borehole
[] Yes 1
[] No 0

Dug Well
Protected Well
[] Yes 1
[] No 0

Unprotected Well
[] Yes 1
[] No 0

Water from Spring
Protected Spring
[] Yes 1
[] No 0

Unprotected Spring
[] Yes 1
[] No 0

Rainwater
[] Yes 1
[] No 0

Tanker Truck
[] Yes 1
[] No 0

Cart with Small Tank
[] Yes 1
[] No 0

Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Yes 1
[] No 0

Bottled Water
[] Yes 1
[] No 0

Sachet Water
[] Yes 1
[] No 0

No response -99

20. What is the main source of drinking water for members of your household?
Read out all types and check the main source. Must be a selection in HQ19
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
[] No response -99

21. What is the main source of water used by your household for other purposes such as cooking and handwashing?
Read out all types and check the main source. Must be a selection in HQ19.
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
[] No response -99

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.
22. You mentioned you used [WATER SOURCE]. At any time of the year, does your family 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

No response -99

23 Is [WATER SOURCE] typically available:

[] 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 there, get water, and come back? [WATER SOURCE]?
Zero is a possible answer
Enter -88 for do not know
Enter -99 for no response
Convert answer into minutes.
Answer includes waiting time in line.
The same question will be generated by the ODK software for all water sources selected in HQ19.

Minutes____

26. Does your family have a garden?
A garden is a place to grow vegetables
[] Yes 1
[] No 0
[] No response -99

27. Do members of your household use any of the following toilet facilities?
READ OUT ALL TYPES AND CHECK ALL THAT ARE USED.
Flush/pour flush toilets connected to:
Piped sewer system
[] Yes 1
[] No 0

Septic tank
[] Yes 1
[] No 0

Elsewhere
[] Yes 1
[] No 0

Unknown/ Not sure / Don't know
[] Yes 1
[] No 0

Ventilated improved pit latrine
[] Yes 1
[] No 0

Pit latrine with slab
[] Yes 1
[] No 0

Pit latrine without slab/open pit
[] Yes 1
[] No 0

Composting toilet
[] Yes 1
[] No 0

Bucket toilet
[] Yes 1
[] No 0

Hanging toilet /Hanging latrine
[] Yes 1
[] No 0

Other (please explain):
[] Yes 1
[] No 0

No facility/ bush / field
[] Yes 1
[] No 0


No response -99

28. What is the main toilet facility used by members of your household?
The main facility. Must be selected in HQ27.
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/open pit 7
[] Composting toilet 8
[] Bucket toilet 9
[] Hanging toilet /Hanging latrine 10
[] Other: 11
[] No facility / bush / field 12
[] No Response -99

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.
29a. How often does your family typically use [TOILET FACILITY TYPE]?
REGULAR PRACTICES AT THE HOUSEHOLD ONLY
[] Always 1
[] Most of the time 2
[] Occasionally 3
[] Rarely 4
[] No response -99

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

[] Not shared 1
[] Shared with less than ten households 2
[] Shared with ten or more households 3
[] Shared with the public. 4
[] No response -99

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 Households____

[pg. 9]
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 Enter -88 for do not know, Enter -99 for no response.
Number of People____

CHECK HQ 3: Are there any household members aged 5 years or under?

[] Yes 1
[] No 0

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 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
[] Yes 1
[] No 0


No response
[] Yes 1
[] No 0

31. 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 his/her time.
THE RESPONDENT IS FINISHED, BUT THERE ARE STILL TWO MORE QUESTIONS FOR YOU TO COMPLETE OUTSIDE THE HOUSE.
LOCATION AND QUESTIONNAIRE RESULT
L. GPS: 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.

Instructions are given directly by the ODK software
RECORD LOCATION

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

[] Yes 1
[] No 0

Mb. Ensure that no people are in the photo.

TAKE PICTURE

N. 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
[] Entire household absent for extended period 9