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

001a. Your name: Is this your name?
[ODK will display the name of the Enumerator 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 1
[] No 0


001b. Enter your name below. Please record your name
Interviewer's Name _________

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

[] Yes 1
[] No 0


003a. Region

[] Central 1
[] Eastern 2
[] Northern 3
[] Western 4


003b. District ODK will populate a list of appropriate districts based on the region

003c. Sub-county ODK will populate a list of appropriate subcounties based on the district

004. Enumeration area ODK will populate a list of appropriate Enumeration Areas based on the sub-county

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.

[] Yes 1
[] No 0

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

[] There are new household members on this form 1
[] I am correcting a mistake made on a previous form 2
[] The previous form disappeared from my phone without being sent 3
[] I submitted the previous form and my supervisor told me that is was not received 4
[] Other reason(s) 5

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

[] Yes 1
[] No 0


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

[] Yes 1
[] No 0
[] Do not know -88
[] No response -99

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 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? 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

010b. Respondent's signature Please ask the respondent to sign or check the box in agreement of their participation. Gather signature:
Check box: ????
010c. Interviewer's name Please record your name as a witness to the consent process. You previously entered "[NAME FROM 001]."
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.
Household Roster Screen #1

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?

[] Head

[] Wife/Husband

[] Son/Daughter

[] Son/Daughter-in-law

[] Grandchild

[] Parent

[] Parent in law

[] Brother/Sister

[] Other

[] Don't know

[] No response


103 What is the sex of [NAME]?

[] Male
[] Female

[] No response


104. How old was [NAME] at their last birthday? If less than one year old, enter 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, widowed, or have never been married.

[] Married

[] Living with a partner

[] Divorced / separated

[] Widow / widower

[] Never Married

[] No response

106 Does [NAME] usually live here?

[] Yes
[] No
[] No response

107 Did [NAME] stay here last night?

[] Yes
[] No
[] No response

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

[] Yes
[] No

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.

[] Yes 1
[] No 0

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.

[] Electricity
[] Radio
[] A Cassette Player
[] Television
[] Mobile Phone
[] A Fixed Telephone
[] Refrigerator
[] Table
[] Chair
[] Sofa Set
[] Bed
[] Cupboard
[] Clock
[] Watch
[] Bicycle
[] Motorcycle/Scooter
[] Animal-Drawn Cart
[] Car/Truck
[] Boat With Motor
[] Boat Without A Motor
[] None of the above -77
[] No response -99

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 1
[] No 0
[] No response -99

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.

LOCAL CATTLE
EXOTIC/CROSS CATTLE
HORSES/DONKEYS/MULES
GOATS
SHEEP
PIGS
CHICKENS

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.

[] Yes 1
[] No 0
[] No response -99

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.

LOCAL CATTLE
EXOTIC/CROSS CATTLE
HORSES/DONKEYS/MULES
GOATS
SHEEP
PIGS
CHICKENS

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

301. Main material of the floor Observe.

[] Earth/Sand 11
[] Earth and Dung 12
[] Parquet or polished wood 31
[] Mosaic or Tiles 33
[] Bricks 34
[] Cement 35
[] Stones 36
[] Other 96
[] No response -99

302. 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
[] No response -99

303. Main material of the exterior walls Observe.

[] Thatched/Straw 11
[] Mud and Poles 21
[] Un-burnt Bricks 22
[] Un-burnt Bricks with Plaster 23
[] Burnt bricks with mud 24
[] Cement Blocks 31
[] Stone 32
[] Timber 33
[] Burnt Bricks with Cement 34
[] 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.
401a. Do you have a place to wash your hands?

[] Yes 1
[] No 0
[] Don't know -88
[] No response -99

401b. Can you show it to me?

[] Yes 1
[] No 0

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

[] Soap is present
[] Stored water is present
[] Running water is present
[] Handwashing area is near a sanitation facility
[] None of the above -77

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

[] Piped into dwelling/indoor
[] Pipe to yard/plot
[] Public tap/standpipe
[] Tube well or borehole
[] Protected Well
[] Unprotected Well
[] Protected Spring
[] Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart or Bicycle with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No Response -99

403. What is the main source of drinking water for members of your household? Selections from Q402: [ODK will list water sources selected for Q402 Read out Q402 selections only. Piped Water

[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Public tap/standpipe 3
[] Tube well or borehole 4
[] Protected Well 5
[] Unprotected Well 6
[] Protected Spring 7
[] Unprotected Spring 8
[] Rainwater 9
[] Tanker Truck 10
[] Cart or Bicycle with Small Tank 11
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel) 12
[] Bottled Water 13
[] Sachet Water 14
[] No response -99

404. What is the main source of water used by your household for other purposes such as cooking and hand washing? Selections from Q402: [ODK will list water sources selected for Q402]
Read out Q402 selections only.

[] Piped into dwelling/indoor 1
[] Pipe to yard/plot 2
[] Public tap/standpipe 3
[] Tube well or borehole 4
[] Protected Well 5
[] Unprotected Well 6
[] Protected Spring 7
[] Unprotected Spring 8
[] Rainwater 9
[] Tanker Truck 10
[] Cart or Bicycle with Small Tank 11
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel) 12
[] Bottled Water 13
[] Sachet Water 14
[] No Response -99

405. You mentioned that you used [WATER SOURCE]. At any time of the year, does your household use water from this source for:

[] Drinking
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing
[] No response -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
Number of months ______
407. At a time of year when you expect to have water from [WATER SOURCE], is it usually available?

[] Yes, 1
[] No, intermittent and predictable 2
[] No, intermittent and unpredictable 3
[] No response -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 time into minutes. Answer includes waiting time in line.
Minutes: ____
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:

[] Piped sewer system
[] Septic tank
[] Pit latrine
[] Elsewhere
[] Unknown / Not sure / Don't know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab/open pit
[] Bucket toilet
[] Composting toilet
[] Hanging toilet /Hanging latrine
[] No facility / bush / field
[] Other:
[] No Response -99

410. What is the main toilet facility used by members of your household? Q409: [ODK will display Q409 selections]
The main facility must have been selected in Q409.

Flush/pour flush toilets connected to:
[] Piped sewer system 1
[] Septic tank 2
[] Pit latrine 13
[] 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
[] Bucket/pan 8
[] Composting toilet 9
[] Hanging toilet /Hanging latrine 10
[] Other: 11
[] No facility / bush / field 12
[] No Response -99

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

[] Always 1
[] Most of the time 2
[] Occasionally 3
[] No response -99

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

[] 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

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.
Number of Households: __________
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.
Number of People: __________

414. 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. PROBE: Other methods?

[] Children use a latrine / toilet
[] Leave waste where it is
[] Bury waste in field / yard
[] Dispose of waste in latrine / toilet
[] Dispose of waste with rubbish / garbage
[] Dispose of waste with waste water
[] Use it as manure
[] Burn it
[] Don't know -88
[] No response -99

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?

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

098. In what language was this interview conducted?

[] English 1
[] Ateso 2
[] Luganda 3
[] Lugbara 4
[] Lusoga 5
[] Luo 6
[] Runyankole-Rukiga 7
[] Runyoro-Rutoro 8
[] Ngakaramojong 9
[] Other 96

099. 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 of time 9