Is this your name?

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2020-03-01 and 2020-12-31.

003a. Region

003b. District

003c. Sub-county

004. Enumeration area

005. Structure number

Please record the structure number from the household listing form.

006. Household number

Please record the household number from the household listing form.

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

COVID SCREEN 1) Have you recently developed two or more of these symptoms?

- Flu like symptoms (Fever, Cough, Sore Throat)
- Shortness of breath
- Muscle aches, Headache
- Diarrhea
- Unexplained loss of taste
- Unexplained loss of smell

COVID SCREEN 2) In the past 14 days, have you had unprotected exposure to a person known to have COVID-19?

009a. Please confirm that you have screened the respondent for COVID-19 before continuing.

You will Politely end the interview, refer the respondent to the facility/hotline number, and report this to the supervisor.

Discuss this with your Supervisor to determine next Steps.

INFORMED CONSENT

Find a competent member of the household. Read the greeting on the following screen.

010a. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

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.

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

103. Is ${firstname} male or 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.

106. Does ${firstname} usually live here?

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

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

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.

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.

202. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

203. 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.
Local cattle: ___
Exotic/Cross cattle: ___
Horses, donkeys, or mules: ___
Goats: ___
Sheep: ___
Pigs: ___
Chickens: ___
Other: ___

Section 3 ? Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor

Observe.

302. Main material of the roof

Observe.

303. Main material of the exterior walls

Observe.

Section 4 ? Water Sanitation and Hygiene

Now I would like to ask you a few questions about water, sanitation and hygiene.

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

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

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?

098. In what language was this interview conducted?

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.