Annexe II
i
Treball realitzat per:
David Requejo Castro
Dirigit per:
Agustí Pérez Foguet
Màster en:
Enginyeria Ambiental
Barcelona, 23 de Juny de 2016
Departament de Enginyeria Civil i Ambiental
TR
EBA
LL F
INA
L D
E M
ÀST
ER
ANNEXE II
Household and Water-point
Questionnaires
Bayesian Networks as a Decision Support Tool for Rural
Water Supply and Sanitation sector
Annexe II
Bayesian Network as a Decision Support Tool for Rural Water and Sanitation Sector i
ANNEXE II. Household and Water-point questionnaires
In this Annexe, the methodology for data collection is described and the survey instruments are
attached.
The approach adopted for data this important process combined a water point mapping with a
household survey; both of them conducted in Kenya by Polytechnic University of Catalonia
(UPC) in close collaboration with government’s technicians. These processes for information
acquiring are detailed below:
i) Water-point Survey
In brief, the mapping methodology employed was based on the water point mapping (WPM),
which can be described as an “exercise whereby the geographical positions of all improved
water points in an area are gathered in addition to management and technical data” (WaterAid
and ODI, 2005). This WPM involves the presentation of this information in a spatial context
which enables a rapid visualisation of the distribution and status of water supplies. By linking
these point data with demographic information, WPM objectively demonstrates who is and is
not served; thus becoming a valuable analysis and planning tool for decentralised governments.
Nevertheless, and pointed out by Giné garriga, Jiménez and Pérez-Foguet (2013), this
methodology lacked of two important aspects that were introduced in the survey attached: i)
biological testing to ensure water quality; and ii) the inclusion of unimproved sources.
Regarding data collection methodology, once information from households was obtained
regarding drinking-water source, then the identified water-points were visited. The mapping of
water-points was exhaustive regardless functionality issues. At the same time, tackling equity
issues were highlighted from the viewpoint of human rights, as any exercise covering
unimproved water-points would provide inputs to elucidate the access pattern of the population.
In rural contexts, however, this type of water source might be common, thus increasing
significantly the budget and resources devoted to data collection in case of inclusion. Similarly,
where main water technology is piped systems with household connections, the idea of a
comprehensive audit of all these private points-of-use is practically impossible. A more
convenient solution was to visit the distribution tank and a reduced number of domestic taps,
which are taken as representative of the overall system.
i) Household Survey
Besides the mapping, a survey was conducted to assess sanitation and domestic hygiene in
which the household is taken as the basic sampling unit. The design and selection of the
sample draw on the Multiple Indicator Cluster Survey (MICS).
Since its inception in 1995, the MICS has become the largest source of statistically sound and
internationally comparable data on women and children worldwide. In countries as diverse as
Costa Rica, Mali and Qatar, trained fieldwork teams conduct face-to-face interviews with
household members on a variety of topics, focusing mainly on those issues that directly affect
the lives of children and women. MICS was a major source of data on the Millennium
Development Goals (MDG) indicators and will continue to be a major data source during the
2030 Sustainable Development Agenda to measure Sustainable Development Goals (SDGs)
indicators.
Annexe II
Bayesian Network as a Decision Support Tool for Rural Water and Sanitation Sector ii
In terms of methodology, a defined number of households is selected in a statistically random
manner from a comprehensive list of all households in the subunit of study. However, such a list
does often lack. Then, if the population size is small, the optimum alternative may be to create a
list by carrying out a quick census.
In terms of technique, the method relies on a variety of mechanisms to assure quality of
produced outcomes. Among the most important are:
Territorial delimitation of study area. As an exercise to support planning, administrative
subunits in which base data collection should play a relevant administrative role in
decentralised service delivery. Thus, they should be adequately delimited, unambiguous
and well-known by both decision-makers and local population;
Design of survey instruments. On the basis of a reduced set of reliable and objective
indicators, appropriate survey tools should be developed for an accurate assessment of
the WASH status. In this case, the survey instruments are a combination of quantitative
and qualitative study tools, which are specially designed to collect data from the water
point and the household. Field inspections at the source employ a standardized checklist
to evaluate the existence, quality and functionality of the facility and a water sample is
also collected for on-site bacteriological testing. At the dwelling, information related to
service level is captured through a structured interview administered to primary care-
givers. In addition, direct observation enables a complementary evaluation of domestic
hygiene habits that may not be otherwise assessed, as sanitary conditions of the latrine,
existence and adequacy of the hand-washing facility, etc;
Involvement and participation of local authorities. In this case, the process engaged in
various stages of the process with those government bodies with competences in
WASH. Specifically in data collection, the commitment of officers belonging to the
local government i) helped ensure a link between field workers and the local structures
at community level, and ii) promoted sense of ownership over the process, as
prerequisite for incorporating the data into decision-making;
Data processing: The data entry process needed to be supervised, and the produced
datasets needed to be validated on a regular basis. Various quality control procedures
were in place to ensure that the data reflected the true position as accurately as possible,
and routine analysis of database or random checks of a reduced number of
questionnaires helped detect data inconsistencies and improve database robustness.
Once information was collected, a daunting task of post-processing was carried out. In this case,
the author of the master thesis avoided this phase, as it had been done before. Nevertheless, the
decision, related to which information should be taken into consideration, was done by this
author.
In following pages, the survey instruments are attached, as the reader might find it useful for
further consultation.
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 1
Ref:
WATERPOINT QUESTIONNAIRE
Section A. INFORMATION ABOUT THE INTERVIEW
A1. Date of Interview / /20
A2. Name of Interviewer
A3. Name of respondent
A4. Sex of respondent Male ...................................................................... A
Female .................................................................. B
A5. Age of respondent
A6. Position of respondent (in relation with the
waterpoint)
Section B. GENERAL INFORMATION OF THE WATERPOINT (WP)
B1. Name of District
B2. Name of Location
B3. Name of Sub Location
B4. Name of Community (EA)
B5. Community Code (EA Code)
B6. Name of waterpoint / source
B7. Waterpoint / source code
B8. GPS Location - UTM of the waterpoint /
source
x-coordinate:
y-coordinate:
B9. Elevation (m.a.s.l.)
B10. When was the waterpoint constructed?
(if year is unknown, tick one option)
Year:
Less than one year ago .................................... 0001
1 – 5 years ago ................................................ 0002
6 – 10 years ago .............................................. 0003
11 – 15 years ago ............................................ 0004
16 – 20 years ago ............................................ 0005
More than 20 years ago ................................... 0006
Not applicable .................................................. 9995
DK .................................................................... 9999
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 2
B11. Who funded the waterpoint? Community ................................................................ A
NGO / Donor ............................................................. B
Municipality ............................................................... C
Government .............................................................. D
Other (specify) .......................................................... X
Not applicable ........................................................... Y
DK ............................................................................. Z
B12. Did the community contribute with an initial
contribution?
No, there was no initial contribution ........................... A
Yes, by cash ............................................................. B
Yes, by labour ........................................................... C
Yes, by cash + labour ................................................ D
Other (specify) .......................................................... X
Not applicable ........................................................... Y
DK ............................................................................. Z
Section C. TYPE OF WATER SUPPLY
C1. Type of waterpoint Gravity-fed piped system ........................................... A
Borehole with mechanised pumping .......................... B
Borehole with hand pump .......................................... C
Protected dug well with hand pump ........................... D
Protected dug well with windlass ............................... E
Protected dug well with no hand pump/windlass........ F
Unprotected dug well with hand pump .......................G
Unprotected dug well with windlass ........................... H
Unprotected dug well with no hand pump/windlass .... I
Protected spring .........................................................J
Unprotected spring .................................................... K
Rainwater collection .................................................. L
Tanker-truck ............................................................. M
Cart with small tank/drum .......................................... N
Surface water (river, stream, dam, lake, etc.) ............O
Other (specify) .......................................................... X
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 3
C2. For mechanised pump, specify how is it
powered.
Diesel .................................................................... A
Solar...................................................................... B
Wind ...................................................................... C
DK ......................................................................... Z
C3. For hand pump, specify model of the pump Afridev ................................................................... A
India Mark II .......................................................... B
India Mark III ......................................................... C
SWN80 .................................................................. D
Others (specify) ..................................................... X
DK ......................................................................... Z
C4. Type of waterpoint (within the community) Tank of a piped system .......................................... A
Private.................................................................... B
Communal waterpoint ............................................ C
School .................................................................... D
Health facility / Dispensary ..................................... E
Cattle trough .......................................................... F
Other (specify) ....................................................... X
C5. Is the waterpoint part of a piped system? Yes……...……...……………….............….......……..A
No……………………………….............………......…B
C8
C6. Name of the water piped system
C7. Is the water treated to make it safer to drink?
(record all items mentioned)
No treatment ......................................................... A
Chlorination ........................................................... B
Filtration ................................................................ C
Others (specify) ..................................................... X
DK ......................................................................... Z
C8. What is the total number of households served
by the waterpoint / system (roughly)?
No. of HH:
DK ...................................................................... 999
Section D. OPERATIONAL STATUS OF THE WATER SUPPLY
D1. What is the current functioning status of the
waterpoint?
Functional.............................................................. A
Non-functional ....................................................... B
Under rehabilitation ............................................... C
Others (specify) ..................................................... X
D3
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 4
D2. If non-operational, why?
(multiple answers allowed)
Low yield ................................................................ A
Equipment not-functional ........................................ B
Others (specify) ...................................................... X
D3. Last operational problem Year:
Never had a problem ....................................... 0001
DK ................................................................... 9999
E1
D5
D4. If last operational problem is known, specify
reason
(multiple answers allowed)
Low yield ................................................................ A
Equipment not-functional ........................................ B
Others (specify) ...................................................... X
D5. How often is this source non-operational? At least once per week ........................................... A
At least once per month ......................................... B
In the dry season .................................................... C
It is normally operational ........................................ D
Others (specify) ...................................................... X
DK .......................................................................... Z
Section E. MANAGEMENT AND OWNERSHIP
E1. Who owns the waterpoint? No-one ................................................................... A
Individual ................................................................ B
Community ............................................................. C
Municipality ............................................................ D
Government ........................................................... E
Institution (school, health facility, etc.) .................... F
Other (specify) ....................................................... X
DK .......................................................................... Z
E2. Who manages the waterpoint? No management..................................................... A
Water user association (WUA) ............................... B
Management committee ......................................... C
Individual ................................................................ D
Municipality ............................................................ E
Government ........................................................... F
Institution (school, health facility, etc.) ................... G
Other (specify) ....................................................... X
DK .......................................................................... Z
E10
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 5
E3. How many members does the committee or
WUA have?
Male:
Female:
DK .......................................................................... Z
E4. Is the committee or WUA legally registered? Yes ........................................................................ A
No ........................................................................ B
DK .......................................................................... Z
E5. Does the committee or WUA regularly meet? Yes ........................................................................ A
No ........................................................................ B
DK .......................................................................... Z
E6. Does the committee or WUA keep records? Yes ........................................................................ A
No ........................................................................ B
DK .......................................................................... Z
E8
E8
E7. Which types of records are kept?
(multiple answers allowed)
Minutes .................................................................. A
Membership register .............................................. B
Correspondences ................................................... C
Other records (specify) ........................................... X
E8. Does the committee or WUA receive
appropriate support (training, capacity
building, technical assistance ...) from Water
Service Board / Local Authority to operate the
waterpoint?
Yes ........................................................................ A
No ........................................................................ B
DK .......................................................................... Z
E9. Has the committee or WUA received any
training/ capacity building during last two
years?
(multiple answers allowed)
No ........................................................................ A
Yes, in technical issues .......................................... B
Yes, in management .............................................. C
Yes, in hygiene awareness..................................... D
Other (specify) ....................................................... X
E10. Who maintains the waterpoint at local level? No maintenance ..................................................... A
Water user association ........................................... B
Management committee ......................................... C
Individual ................................................................ D
Municipality ............................................................ E
Government ........................................................... F
Institution (school, health facility, etc.) ................... G
Other (specify) ....................................................... X
DK .......................................................................... Z
F1
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 6
E11. Are appropriate technical skills available at
local level to carry out maintenance of the
waterpoint?
Tech. skills are not available when needed ............ A
Tech. skills are available, but not for all repairs ...... B
Tech. skills are available for all repairs ................... C
DK .......................................................................... Z
E13
E12. List which maintenance / repairs cannot be
carried out at local level
E13. Are spare parts available at local level? Spare parts are not available when needed ............ A
Spare parts are available, but not for all repairs...... B
Spare parts are available for all repairs .................. C
DK .......................................................................... Z
E15
E14. List which spare parts / equipment are not
available at local level
E15. Is there any preventive maintenance
programme in place?
No preventive maintenance .................................... A
Some preventive maintenance, but not regularly .... B
Regular programme of preventive maintenance ..... C
DK .......................................................................... Z
F1
F1
F1
E16. Specify main aspects of the regular
programme of preventive maintenance (type
of activity and frequency)
Yes No Frequency
Cleaning the waterpoint .....A
On equipment ...................B
Other (specify) ..................X
1
1
1
2
2
2
........... months
........... months
........... months
SECTION F. FINANCIAL ISSUES
F1. Is a water payment system in place? No payment system is in place ............................... A
Yes, but many users don’t pay for the service ........ B
Yes, and almost all users pay for the service .......... C
G1
F2. Payment method 1. Method 2. Amount per payment
Per Month.................. A
Per Bucket ................. B
Per repair .................. C
Others (specify) ......... X
In KSch:
DK ............... 9999
F3. Are any households exempt from paying for
water?
Yes ........................................................................ A
No ........................................................................ B
DK .......................................................................... Z
F5
F5
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 7
F4. Which is the basis from exemption?
(multiple answers allowed)
Poor household ...................................................... A
HH headed by female............................................. B
HH headed by child ................................................ C
Others (specify) ...................................................... X
F5. How are the revenues used?
Repair and maintenance ........................................ A
Paying workers / operators ..................................... B
System expansion .................................................. C
Allowances to management committee .................. D
Others (specify) ...................................................... X
F6. How are the revenues kept? Bank account ......................................................... A
Treasurer ............................................................... B
Others (specify) ...................................................... X
F7. Is there a financial control system1 in place? Yes ........................................................................ A
No ........................................................................ B
F8. In case there is a financial control system, do
you keep / have ...?
Yes No
Financial receipts ................................ A
Cash books ......................................... B
Other financial books (specify) ............ X
1
1
1
2
2
2
F9. In general, income is enough to face all
expenses?
No funds readily available ...................................... A
Some funds available but not sufficient for most
expensive repairs .............................................. B
Funds available and sufficient to cover all
expenses ........................................................... C
SECTION G. WATER QUANTITY AND RELIABILITY
G1. Water quantity at the source Always sufficient (for both domestic and other
non-domestic uses) ........................................... A
Only sufficient for domestic use .............................. B
Not sufficient even for domestic use ....................... C
G2. Average distance from dwellings to the
waterpoint (in minutes)
Minimum distance (min):
Average distance (min):
Maximum distance (min):
DK .......................................................................... Z
1 Financial control system means at least regular control of incomes / expenditures.
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 8
G3. Record of conflicts around the waterpoint
(multiple answers allowed)
No conflicts ............................................................ A
Conflicts due to water availability ............................ B
Conflicts due to water use efficiency ...................... C
Conflicts due to different water uses ....................... D
Conflicts due to water tariffs / payments ................. E
Other conflicts (specify) .......................................... X
G4. Is this waterpoint seasonal? Yes, it is seasonal .................................................. A
No, it is a year-round waterpoint ............................. B
DK .......................................................................... Z
G6
G6
G5. Seasonality of the waterpoint
(circle all the months with low / no yield)
January ................... A
February ................. B
March ...................... C
April ........................ D
May ......................... E
June ........................ F
July ......................... G
August ..................... H
September ................ I
October ................... J
November ................ K
December ................ L
G6. How many days per week does the waterpoint
operate?
Less than 2 days per week ..................................... A
3 – 4 days per week ............................................... B
5 – 6 days per week ............................................... C
All 7 days per week ................................................ D
DK .......................................................................... Z
G7. How many hours per day does the waterpoint
operate?
Less than 6 hours per day ...................................... A
6 – 12 hours per day .............................................. B
12 – 18 hours per day ............................................ C
More than 18 hours per day ................................... D
DK .......................................................................... Z
Section H. SANITARY SURVEILLANCE
A “Sanitary Surveillance” is filled out for all waterpoints.
In addition to the sanitary surveillance, and for all waterpoints, ask for a drinking-water sample (and keep it
refrigerated until the analysis is carried out: pH, conductivity, turbidity, free chlorine, faecal coliforms, nitrates
and phosphates)
H1. GRAVITY-FED PIPED WATER
H1.1. Does the pipe leak between the source and storage tank? Yes ................................... A
No .................................. B
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 9
H1.2. Is the storage tank cracked, damaged or leak? Yes ................................... A
No .................................. B
H1.3. Are the vents and covers on the tank damaged or open? Yes ................................... A
No .................................. B
H1.4. Do any tapstands leak? Yes ................................... A
No .................................. B
H1.5. Does surface water collect around any tapstand? Yes ................................... A
No .................................. B
H1.6. Is the area uphill of any tapstand eroded? Yes ................................... A
No .................................. B
H1.7. Are pipes exposed close to any tapstand? Yes ................................... A
No .................................. B
H1.8. Is human excreta on the ground within 10m of any tapstand? Yes ................................... A
No .................................. B
H1.9. Has there been discontinuity n the last 10 days at any tapstand? Yes ................................... A
No .................................. B
H1.10. Are there signs of leaks in the main supply pipe in the system? Yes ................................... A
No .................................. B
H1.11. Does the community report any pipe breaks in the last week? Yes ................................... A
No .................................. B
H1.12. Is the main supply pipe exposed anywhere in the system? Yes ................................... A
No .................................. B
H2. BOREHOLE WITH HAND PUMP
H2.1. Is there a latrine within 10m of the borehole? Yes ................................... A
No .................................. B
H2.2. Is there a latrine uphill of the borehole? Yes ................................... A
No .................................. B
H2.3. Are there any other sources of pollution within 10m of borehole? (e.g.
animal breeding, cultivation, roads, industry etc)
Yes ................................... A
No .................................. B
H2.4. Is the drainage faulty allowing ponding within 2m of the borehole? Yes ................................... A
No .................................. B
H2.5. Is the drainage channel cracked, broken or need cleaning? Yes ................................... A
No .................................. B
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 10
H2.6. Is the fence missing or faulty? Yes ................................... A
No .................................. B
H2.7. Is the apron less than 1m in radius? Yes ................................... A
No .................................. B
H2.8. Does spilt water collect in the apron area? Yes ................................... A
No .................................. B
H2.9. Is the apron cracked or damaged? Yes ................................... A
No .................................. B
H2.10. Is the hand pump loose at the point of attachment to apron? Yes ................................... A
No .................................. B
H3. BOREHOLE WITH MECHANISED PUMPING
H3.1. Is there a latrine or sewer within 100m of pump-house? Yes ................................... A
No .................................. B
H3.2. Is there any source of other pollution within 50m? Yes ................................... A
No .................................. B
H3.3. Is there an uncapped well within 100m? Yes ................................... A
No .................................. B
H3.4. Is the drainage around pump-house faulty? Yes ................................... A
No .................................. B
H3.5. Is the fencing damaged allowing animal entry? Yes ................................... A
No .................................. B
H3.6. Is the floor of the pump-house permeable to water? Yes ................................... A
No .................................. B
H3.7. Does water forms pools in the pump-house? Yes ................................... A
No .................................. B
H3.8. Is the well seal insanitary? Yes ................................... A
No .................................. B
H4. PROTECTED SPRING
H4.1. Is the spring unprotected? Yes ................................... A
No .................................. B
H4.2. Is the masonry protecting the spring faulty? Yes ................................... A
No .................................. B
H4.3. Is the backfill area behind the retaining wall eroded? Yes ................................... A
No .................................. B
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 11
H4.4. Does spilt water flood the collection area? Yes ................................... A
No .................................. B
H4.5. Is the fence absent or faulty? Yes ................................... A
No .................................. B
H4.6. Can animals have access within 10m of the spring? Yes ................................... A
No .................................. B
H4.7. Is there a latrine uphill and/or within 30m of the spring? Yes ................................... A
No .................................. B
H4.8. Does surface water collect uphill of the spring? Yes ................................... A
No .................................. B
H4.9. Is the diversion ditch above the spring absent or non-functional? Yes ................................... A
No .................................. B
H4.10. Are there any other sources of pollution uphill of the spring? (e.g. solid
waste)
Yes ................................... A
No .................................. B
H5. DUG WELL WITH HANDPUMP/WINDLASS
H5.1. Is there a latrine within 10m of the well? Yes ................................... A
No .................................. B
H5.2. Is the nearest latrine uphill of the well? Yes ................................... A
No .................................. B
H5.3. Is there any other source of pollution within 10m of well? (e.g. animal
breeding, cultivation, roads, industry etc)
Yes ................................... A
No .................................. B
H5.4. Is the drainage faulty allowing ponding within 2m of the well? Yes ................................... A
No .................................. B
H5.5. Is the drainage channel cracked, broken or need cleaning? Yes ................................... A
No .................................. B
H5.6. Is the fence missing or faulty? Yes ................................... A
No .................................. B
H5.7. Is the cement less than 1m in radius around the top of the well? Yes ................................... A
No .................................. B
H5.8. Does spilt water collect in the apron area? Yes ................................... A
No .................................. B
H5.9. Are there cracks in the cement floor? Yes ................................... A
No .................................. B
H5.10. Is the hand pump loose at the point of attachment to well head? Yes ................................... A
No .................................. B
Survey Instruments for the Baseline Survey
Waterpoint Questionnaire 12
H5.11. Is the well-cover insanity? Yes ................................... A
No .................................. B
H6. RAINWATER COLLECTION AND STORAGE
H6.1. Is rainwater collected in an open container? Yes ................................... A
No .................................. B
H6.2. Are there visible signs of contamination on the roof catchment? (e.g.
plants, excreta, dust)
Yes ................................... A
No .................................. B
H6.3. Is guttering that collects water dirty or blocked? Yes ................................... A
No .................................. B
H6.4. Are the top or walls of the tank cracked or damaged? Yes ................................... A
No .................................. B
H6.5. Is water collected directly from the tank (no tap on the tank)? Yes ................................... A
No .................................. B
H6.6. Is there a bucket in use and is this left where it can become
contaminated?
Yes ................................... A
No .................................. B
H6.7. Is the tap leaking or damaged? Yes ................................... A
No .................................. B
H6.8. Is the concrete floor under the tap defective or dirty? Yes ................................... A
No .................................. B
H6.9. Is there any source of pollution around the tank or water collection
area?
Yes ................................... A
No .................................. B
H6.10. Is the tank clean inside? Yes ................................... A
No .................................. B
H7. SURFACE WATER (river, dam, pond, lake, ...)
H7.1. Is there a latrine within 10 m of the point used for water collection? Yes ................................... A
No .................................. B
H7.2. Is the nearest latrine uphill of the point used for water collection? Yes ................................... A
No .................................. B
H7.3. Is there any other source of pollution within 10m of the point used for
water collection? (e.g. animal breeding, cultivation, roads, industry
etc)
Yes ................................... A
No .................................. B
Survey Instruments for the Baseline Survey
Household Questionnaire 1
Ref:
HOUSEHOLD QUESTIONNAIRE
Section A. SITE INFORMATION
A1. Date of Interview / /20
A2. Name of Interviewer
A3. Name of District Garissa
Wajir
Mandera
Ijara
Tana River
Marsabit
Isiolo
Mwingi
Kitui
Kajiado
West Pokot
Turkana
Uasin Gishu
Kwale
Kieni
Rachuonyo
Kisumu
Nyando
Busia
Siaya
Molo
Bondo
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
A4. Name of Location
A5. Name of Sub Location
A6. Community (EA)
A7: Community Code (EA Code)
A8: GPS Location - UTM x-coordinate:
y-coordinate:
Survey Instruments for the Baseline Survey
Household Questionnaire 2
Interviewer visit Date Day Time Results Next Visit
First visit
Second Visit
Third Visit
Total Number of visits
Result codes
1. Interview completed 7. Dwelling vacant or address not a dwelling
2. No household member at home 8. Dwelling destroyed
3. No competent respondent at home at time of the visit 9. Dwelling not found
4. Entire household absent for extended period of time 10. Selected person physically/mentally not fit to be interviewed
5. Postponed 11. Selected person cannot communicate in any interview language
6. Refused 12. Other (specify):
Start time Finish time
Section B. INFORMATION ABOUT THE RESPONDENT
B1. Name
B2. Sex Male
Female
A
B
B3. Age
B4. Relationship of Respondent to the
Household Head
Household head……………………………………………
Spouse………………………………………………………
Father……………………………………………………….
Mother……………………………………………………….
Other relation (specify)………..………......……………….
A
B
C
D
X
B5. Name of Household Head
Survey Instruments for the Baseline Survey
Household Questionnaire 3
Section C. INFORMATION ABOUT SAMPLE HOUSEHOLD (HH)
Always start with the household head
C1.
Sex
C2.1
Age
C2.2
Age band
C3.
Marital status
C4.
Education completed
C5.
Currently
enrolled
C6.
Is ... head
of HH?
Household
member
code
Male or
Female Age
In years
A = < 18 years
B = 18 - 24
C = 25 - 34
D = 35 - 44
E = 45 - 55
F = 56 - 65
G = > 66 years
A = Single
B = Married
C = Divorced
D = Separated
E = Widowed
A = No formal education
B = Some primary
C = Primary complete
D = Some secondary
E = Secondary completed
F = Post secondary
Yes No
M F Yes No
HH Head A B A B C D E F G A B C D E A B C D E F A B A B
2 A B A B C D E F G A B C D E A B C D E F A B A B
3 A B A B C D E F G A B C D E A B C D E F A B A B
4 A B A B C D E F G A B C D E A B C D E F A B A B
5 A B A B C D E F G A B C D E A B C D E F A B A B
6 A B A B C D E F G A B C D E A B C D E F A B A B
7 A B A B C D E F G A B C D E A B C D E F A B A B
8 A B A B C D E F G A B C D E A B C D E F A B A B
9 A B A B C D E F G A B C D E A B C D E F A B A B
10 A B A B C D E F G A B C D E A B C D E F A B A B
11 A B A B C D E F G A B C D E A B C D E F A B A B
12 A B A B C D E F G A B C D E A B C D E F A B A B
13 A B A B C D E F G A B C D E A B C D E F A B A B
14 A B A B C D E F G A B C D E A B C D E F A B A B
15 A B A B C D E F G A B C D E A B C D E F A B A B
Survey Instruments for the Baseline Survey
Household Questionnaire 4
Section D. WATER SUPPLY
D1. What is the main source of drinking-water for
members of your household for most part of
the year?
Piped water
Piped into dwelling ............................................ A
Piped into yard or plot ........................................ B
Public tap/standpipe .......................................... C
Borehole ................................................................ D
Protected dug well .................................................. E
Protected spring ..................................................... F
Rainwater collection .............................................. G
Unprotected dug well.............................................. H
Unprotected spring .................................................. I
Tanker-truck ........................................................... J
Cart with small tank/drum ....................................... K
Surface water (river, stream, dam, lake,
pond, canal, irrigation channel) .......................... L
Other (specify)........................................................ X
D2. Code of the main drinking waterpoint / source
(link with the waterpoint code)
D3. Why do you choose to get water from this
waterpoint / source?
(multiple answers allowed)
Distance ................................................................. A
Cost (water is free) ................................................. B
Cost (water is cheap) ............................................. C
Quality of water ...................................................... D
Reliability of the source (there is always water) ...... E
This is the only operational source ......................... F
Other (specify) ....................................................... X
D4. In case this source is not only for drinking
purposes, what do you use this water for?
(multiple answers allowed)
Only for drinking ..................................................... A
Cooking .................................................................. B
Bathing ................................................................... C
Laundry .................................................................. D
Livestock ................................................................ E
Gardening .............................................................. F
Other (specify) ....................................................... X
D5. How long does it take to go to source, get
water, and come back?
No. of minutes:
Water on premises ............................................. 995
DK ...................................................................... 999
Survey Instruments for the Baseline Survey
Household Questionnaire 5
D6. Are you satisfied with the distance between
your dwelling and the main water source?
(check answer with question D5)
Satisfied...…………...……………....………….……..A
Unsatisfied……….…………………....……...….……B
DK…….……………………………....………….……..Z
D7. How long does it take queuing at this source? No. of minutes:
Water into dwelling ............................................. 995
DK ...................................................................... 999
D8. Are you satisfied with the time queuing at the
source?
(check answer with question D7)
Satisfied...…………...……………....………….……..A
Unsatisfied……….…………………....……...….……B
DK…….……………………………....………….……..Z
D9. Are there times when you cannot use this
waterpoint?
Yes……...……...……………….............….......……..A
No, the waterpoint is always accessible...…........…B
D12
D10. Which are the reasons why you cannot use
this source?
(multiple answers allowed)
Low yield ................................................................ A
Equipment not-functional ........................................ B
Cost of water .......................................................... C
Conflicts at / on the way to the waterpoint .............. C
Others (specify) ...................................................... X
D11. How often can’t you use this source? At least once per week ........................................... A
At least once per month ......................................... B
In the dry season .................................................... C
Rarely, the waterpoint is normally accessible ......... C
Others (specify) ...................................................... X
D12. Are your satisfied with the reliability of main
water source?
(check answer with question D9 and D11)
Satisfied...…………...……………....………….……..A
Unsatisfied……….…………………....……...….……B
DK…….……………………………....………….……..Z
D13. Are there any other sources where members
of your household get water from?
Yes……………...……………….............……….....A
No……...……………………….............……...……B
D15
Survey Instruments for the Baseline Survey
Household Questionnaire 6
D14. What is the alternative source of water for members of your household? (list them according to their importance)
D14.1.
Name of the alternative source
(waterpoint / source)
D14.2.
Type of waterpoint
D14.3.
Seasonality
D14.4.
Reasons to choose this
source
D14.5.
Time to fetch water
(in min)
D14.6.
Water Uses
A B C D E
F G H I J X A B
A B C D
E F G X
A B C D
E F X
A B C D E
F G H I J X A B
A B C D
E F G X
A B C D
E F X
A B C D E
F G H I J X A B
A B C D
E F G X
A B C D
E F X
A B C D E
F G H I J X A B
A B C D
E F G X
A B C D
E F X
Type of waterpoint Seasonality Why do you choose to get water from
this source?
What do you use this water for?
Piped water ........................................ A
Borehole ............................................ B
Protected well .................................... C
Protected spring ................................. D
Rainwater collection ........................... E
Unprotected dug well .......................... F
Unprotected spring ............................. G
Tanker-truck ....................................... H
Cart with small tank/drum ..................... I
Surface water (river, stream, etc.) ....... J
Other (specify) ................................... X
Perennial ............................. A
Seasonal ............................. B
Main source is dry / not operational..... A
Distance.............................................. B
Cost (water is free).............................. C
Cost (water is cheap) .......................... D
Quality of water ................................... E
Reliability of the source ........................ F
This is the only operational source ...... G
Other (specify) .................................... X
Drinking ..................... A
Cooking ..................... B
Bathing ...................... C
Laundry ...................... D
Livestock .................... E
Gardening ................... F
Other (specify) ........... X
Survey Instruments for the Baseline Survey
Household Questionnaire 7
D15. Who usually fetches the water for your household?
(circle code that best describes this person)
Adult woman ............................................. A
Adult man .................................................. B
Female child (under 15) ............................. C
Male child (under 15) ................................. D
DK ............................................................. Z
D16.1. What kinds of container
do your household use to fetch
and carry water during the
rainy season?
(multiple answers allowed)
A. Jerry can ................................ A
B. Bucket ................................... B
C. Clay pot ................................. C
C. Bottles ................................... D
D. Others (specify) ..................... X
D16.2. How big are the
containers?
(visually check the size)
Approximate litres
……………….. DK
……………….. DK
……………….. DK
……………….. DK
……………….. DK
D16.3. How many containers does your
household fetch every day in rainy
season for domestic purposes? (if less
than one per day, specify per week)
No. of containers:
Per day Per week
………….. ……………
………….. ……………
………….. ……………
………….. ……………
………….. ……………
D17.1. What kinds of container
do your household use to fetch
and carry water during the dry
season?
(multiple answers allowed)
A. Jerry can ................................ A
B. Bucket ................................... B
C. Clay pot ................................. C
C. Bottles ................................... D
D. Others (specify) ..................... X
D17.2. How big are the
containers?
(visually check the size)
Approximate litres
……………….. DK
……………….. DK
……………….. DK
……………….. DK
……………….. DK
D17.3. How many containers does your
household fetch every day in dry
season for domestic purposes? (if less
than one per day, specify per week)
No. of containers:
Per day Per week
………….. ……………
………….. ……………
………….. ……………
………….. ……………
………….. ……………
Survey Instruments for the Baseline Survey
Household Questionnaire 8
Section E. WATER QUALITY INSPECTION
In addition to the inspection, ask for a drinking-water sample (and keep it refrigerated until the analysis is
carried out: pH, conductivity, turbidity, free chlorine, faecal coliforms, nitrates and phosphates)
E1. Is drinking water kept in a separate container?
(ask to be shown this)
Yes……......………………………………….....……..A
No…………………………………………...….......… B
E2. Is drinking water container away from
contamination?
(check through observation)
Yes……......………………………………….....……..A
No…………………………………………...….......… B
E3. Do containers have a lid/cover, and this is in
place in time of visit?
(check through observation)
Yes……......………………………………….....……..A
No…………………………………………...….......… B
E4. How is water taken from the container? Poured ................................................................... A
Cup ........................................................................ B
Jug ......................................................................... C
Other utensil (specify) ............................................ X
E5. Is the utensil used to draw water from the
container clean and stored in a hygienic
manner?
(check through observation)
Yes……......………………………………….....……..A
No…………………………………………...….......… B
E6. How often is the container cleaned? Every time before it is refilled with fresh water ........ A
Once a week .......................................................... B
When it looks dirty .................................................. C
Never ..................................................................... D
Others (specify) ...................................................... X
E7. How do you usually wash the water container
in the house before filling?
(multiple answers allowed)
Wipe with a damp cloth .......................................... A
Using soap/detergent ............................................. B
Rinse with water only ............................................. C
Others (specify) ...................................................... X
E8. Do you do anything to your water to make it
safer to drink?
Yes……...……...……………….............…….......…..A
No……………………………….............……......……B
DK………...…………………….............……......……Z
F1
F1
Survey Instruments for the Baseline Survey
Household Questionnaire 9
E9. What do you usually do to the water to make it
safer to drink?
(record all items mentioned)
Boil ......................................................................... A
Boil (at least 10 minutes) ........................................ A
Add waterguard/bleach/chlorine ............................. B
Use water filter (ceramic, sand, composite) ............ C
Solar disinfection (at least six hours) ...................... D
Strain it through a cloth .......................................... E
Let it stand and settle/Sedimentation ...................... F
Others (specify) ..................................................... X
DK ......................................................................... Z
SECTION F. WATERPOINT MANAGEMENT AND PAYMENTS FOR WATER1
F1. Has any household member being involved in
waterpoint management in the last five
years?
Yes………...…...………………....................………..A
No……………………………….............….............…B
DK….…………...……………….............…….......…..Z
F2. Do you pay for your water? Yes………...…...………………....................………..A
No……………………………….............….............…B
DK….…………...……………….............…….......…..Z
F4
F4
F3. How do you pay for your water? 1. Method 2. Amount per payment
Per Month............................ A
Per Bucket ........................... B
Others (specify) ................... X
In KSch:
DK ............... 9999
F4. Do you pay to maintain / repair the
waterpoint?
Yes………...…...………………....................………..A
No……………………………….............….............…B
DK….…………...……………….............…….......…..Z
F7
F7
F5. How do you pay to maintain / repair the
waterpoint?
1. Method 2. Amount per payment
Per Month............................ A
Per repair ............................ B
Per month and per repair .... C
Others (specify) ................... X
In KSch:
DK ............... 9999
1 Section F should be answered based on the main water source
Survey Instruments for the Baseline Survey
Household Questionnaire 10
F6. In case you pay per repair, when was the last
time you paid for a repair?
Less than a month ago .......................................... A
Between one month and a year ago ...................... B
More than a year ago ............................................ C
Not applicable ....................................................... Y
DK ......................................................................... Z
F7. How much did you spend for water in the last
month?
(summation of the amount paid per water “F3”
and the amount paid per maintenance “F5”)
In KSch:
Not applicable .................................................. 9995
DK .................................................................... 9999
F8. How do you find the amount you spend on
water currently?
(check answer with question F7)
Cheap ................................................................... A
Fair ........................................................................ B
Expensive.............................................................. C
Not applicable ....................................................... D
DK ......................................................................... Z
Section G. USER SATISFACTION
This section assesses overall user satisfaction with the water supply service (other questions throughout the
questionnaire might complement this section: D6, D8, D12 and F8)
G1. Are your satisfied with the amount of water
available for your household?
(domestic purposes include drinking, cooking,
hygiene and laundry)
Yes, it is always sufficient (for all different uses) ..... A
No, it is only sufficient for domestic purposes ......... B
No, not sufficient even for domestic purposes ........ C
DK…….……………………………...………….……..Z
G2. Are you satisfied with management of the
waterpoint?
Satisfied...…………...……………....………….……..A
Unsatisfied……….…………………....……...….……B
Not applicable ....................................................... D
DK…….……………………………....………….……..Z
G3. What is your perception of water quality? Good ..................................................................... A
Bad ....................................................................... B
DK ......................................................................... Z
Survey Instruments for the Baseline Survey
Household Questionnaire 11
Section H. SANITATION
H1. What kind of sanitation facility does this
household have?
If “flush” or “pour flush” probe where does it
flush to.
(ask permission to observe the facility)
Flush
Flush to a septic tank ......................................... B
Flush to pit (latrine) ............................................ C
Poor Flush
Flush to somewhere else .................................. G
Flush to unknown place / not sure / DK.............. H
Ventilated Improved Pit latrine (VIP) ....................... D
Pit latrine with slab ................................................. E
Pit latrine without slab / open pit .............................. I
Bucket .................................................................... J
Hanging latrine ....................................................... K
No facility, bush or field .......................................... K
Other (specify)........................................................ X
H2. If your household doesn’t have a latrine, what
are major reasons why your household does
not have a latrine in your house?
(multiple answers allowed)
Do not have enough money ................................... A
Do not know how to construct ................................ B
Do not have enough physical space ..................... C
Terrain is not appropriate (sandy or rocky terrain).. D
The family does not own the terrain ....................... E
It’s not part of our culture ....................................... F
Lack of habit to use it ............................................ G
Other (specify) ....................................................... X
H3. If your household has a latrine, where is it
located?
Inside the house ..................................................... A
In this compound .................................................... B
In the neighbour’s compound ................................. C
In a public place ..................................................... D
H4. Is the latrine being used?
(check through observation)
Yes, it is in use ....................................................... A
It is not in use ......................................................... B
H6
H5. Why the latrine is not being used? The latrine is collapsed / fear of collapsing ............. A
The pit is already filled ............................................ B
Poor privacy. .......................................................... C
Poor cleanliness (insects, bad smell, etc). .............. D
Other (specify)........................................................ X
H14
H14
H14
H14
H14
Survey Instruments for the Baseline Survey
Household Questionnaire 12
H6. Does the latrine hygienically separate human
excreta from human contact?
(check through observation)
Yes ........................................................................ A
No. ......................................................................... B
H7. Does the interviewer observe presence or
absence of a convenient source of water and
soap around the latrine (< 3 metres)?
(tick all items observed)
Hand washing device (with water) .......................... A
Soap / ash .............................................................. B
Clean towel or cloth ................................................ C
Other (specify)........................................................ X
H8. Does the interviewer observe the presence of
insects?
(check through observation)
No, there are no insects ......................................... A
Yes, a few .............................................................. B
Yes, a lot ................................................................ C
H9. Does the interviewer notice an unpleasant
smell?
(check through observation)
No smell ................................................................. A
Yes, a slight unpleasant smell ................................ B
Yes, a strong unpleasant smell............................... C
H10. Does the latrine present adequate conditions
of privacy?
(check through observation)
Adequate privacy ................................................... A
Poor privacy ........................................................... B
No privacy .............................................................. C
H11. Does the latrine present adequate conditions
of cleanliness?
(check through observation)
Adequately clean (no faeces or urine) .................... A
Poorly clean (some dirt, but no faeces or urine) ...... B
No clean (faeces or urine on the floor) .................... C
H12. How many times does your household clean
the latrine per week?
Every day ............................................................... A
4-6 times a week .................................................... B
2-3 times a week .................................................... C
Once a week .......................................................... D
Only when the dirtiness is recognized .................... E
Other (specify)........................................................ X
H13. If required, do you have access to adequate
skills and materials for repairing the latrine?
No, skills and materials are not accessible ............. A
Yes, but access only to skills .................................. B
Yes, but access only to materials ........................... C
Yes, access to both skills and materials ................. D
DK .......................................................................... Z
Survey Instruments for the Baseline Survey
Household Questionnaire 13
H14. What kind of sanitation facility do members of
your household usually use?
If “flush” or “pour flush” probe where does it
flush to.
(ask permission to observe the facility)
Flush
Flush to a septic tank ......................................... B
Flush to pit (latrine) ............................................ C
Poor Flush
Flush to somewhere else .................................. G
Flush to unknown place / not sure / DK.............. H
Ventilated Improved Pit latrine (VIP) ....................... D
Pit latrine with slab ................................................. E
Pit latrine without slab / open pit .............................. I
Bucket .................................................................... J
Hanging latrine ....................................................... K
No facility, bush or field .......................................... K
Other (specify)........................................................ X
H15. Do members of your household share the
sanitation facility that is currently being used?
Yes, it is a shared facility.................…..................…B
No, the facility is for this household only.............…..A
No facility, bush or field...…..................…….......…..C
H17
I1
H16. With how many households do you share the
sanitation facility?
Less than 3 ............................................................ A
More than 3 but less than 10 .................................. B
More than 10 .......................................................... C
DK .......................................................................... Z
H17. Can any member of the public use this
sanitation facility?
Yes ........................................................................ A
No. ......................................................................... B
H18. Overall, how many people use the sanitation
facility?
No. of people (roughly):
DK .......................................................................... Z
Section I. HYGIENE
I1. When was the last time you or one of your
household members has been to a meeting
or training on water, sanitation or health?
Less than a month ago .......................................... A
Between a month and one year ago ...................... B
More than a year ago ............................................ C
More than 5 years ago ........................................... D
Never .................................................................... E
DK ......................................................................... Z
Survey Instruments for the Baseline Survey
Household Questionnaire 14
I2. Who organized the meeting / training? NGO / CBO (specify) ............................................. A
Community health group........................................ B
Health worker ........................................................ C
Community leader ................................................. D
Other (specify) ....................................................... X
I3. If you have a child of less than 3 years old,
how did you dispose of the faeces the last
time she/he passed stools?
Child used latrine ................................................... A
Put / rinsed into latrine ........................................... B
Buried the faeces .................................................. C
Put / rinsed into drain or ditch ................................ D
Faeces thrown into garbage .................................. E
Faeces left or buried in the open ........................... F
Others (specify) ..................................................... X
N/A (no children aged 0 – 3 years in household) ... Y
DK ......................................................................... Z
I4. Is there a drying rack for plates and cups?
(check through observation)
Yes ........................................................................ A
No. ......................................................................... B
I5. Does the compound present adequate
conditions of cleanliness?
(check through observation)
Yes No
Presence of human / animal faeces
Animals running around freely
Compound swept on day of visit
A
A
A
B
B
B
Survey Instruments for the Baseline Survey
Household Questionnaire 15
Section I (cont). Hand washing matrix (appropriate hand washing behaviour)2
I6. Are household members present at dwelling
in time of visit?
(check through observation)
Yes No
Child caregivers
Other Adults
School-going children
Other children
A
A
A
A
I6
I6
I6
I6
B
B
B
B
J1
J1
J1
J1
For household members available at time of visits:
Would you explain and show me what you do when you wash your hands?
(check through observation)
I7.
Washing the
hands
I8.
Clean
water?
I9.
Use of soap
/ ashes?
I10.
Both
hands?
I11.
Drying the hands after
washing
yes or no
(where answer is
no, skip the
other questions)
yes or no yes or no yes or no
A = Air drying
B = Use clean towel or cloth
C = Use unclean towel or cloth
D = Use clothes you are wearing Yes No Yes No Yes No Yes No
1. Child caregivers A B A B A B A B A B C D
2. Other Adults A B A B A B A B A B C D
3. School-going children A B A B A B A B A B C D
4. Other children A B A B A B A B A B C D
I12. When do you wash your hands?3
Before eating Before food
preparation After defecation
Before feeding
children
After handling
children's faeces
Yes No Yes No Yes No Yes No Yes No
1. Child caregivers A B A B A B A B A B
2. Other Adults A B A B A B A B A B
3. School-going children A B A B A B A B A B
4. Other children A B A B A B A B A B
2 Instead of direct questioning, it is suggested to assess hand washing behaviour through observation. The interviewer asks an
open-ended question without prompting and checks off all the items mentioned by the interviewee: “Would you explain and show me
what you do when you wash your hands?”
3 Instead of direct questioning, it is suggested to assess critical times of hand washing behaviour through an open-ended question:
“When do you wash your hands?” The interviewer checks off all the items mentioned by the interviewee.
Survey Instruments for the Baseline Survey
Household Questionnaire 16
Section J. HEALTH STATUS
J1. Record information about household sample
(Section C)4.
Male Female
No. of children <36 months old:
No. of children 36 months – 5 years old:
No. of children 5 – 15 years old:
J2. Has any child in the household had diarrhoea
within the last two weeks (diarrhoea is defined
as more than three loose stools passed in a
twenty-four hour period)?
(specify no. of episodes of diarrhoea)
Male Female
No. of children <36 months old:
No. of children 36 months – 5 years old:
No. of children 5 – 15 years old:
J3. How many school days were missed by
children in the last 6 months due to diarrhoea
or cholera?
(specify code of household member, from
Section C)
No. days Children 1:
No. days Children 2:
No. days Children 3:
No. days Children 4:
No. days Children 5:
HH member:
HH member:
HH member:
HH member:
HH member:
Not applicable (no school-going children) .............. Y
DK ......................................................................... Z
J4. What kind of treatment was given the last time
a child of less than 3 years old was affected by
diarrhoea?
(multiple answers allowed)
No treatment ......................................................... A
Medicine ................................................................ B
Oral rehydration solution (ORS) ............................. C
Maternal milk ......................................................... D
Traditional solution (salty water) ............................ E
Traditional herbs .................................................... F
Soup or gruel made from cereals .......................... G
Other (specify) ....................................................... X
Not applicable (no children aged 0 - 3 years) ......... Y
DK ......................................................................... Z
K1
K1
J5. Who treated the child? Household member ............................................... A
Medical staff at clinic ............................................. B
Traditional healer ................................................... C
Other (specify) ....................................................... X
DK ......................................................................... Z
4 Check from Section C number of children <36 months of age, number of children <15 years of age and number of adults
Survey Instruments for the Baseline Survey
Household Questionnaire 17
Section K. HEALTH KNOWLEDGE AND AWARENESS
Do you agree or disagree with the following statements?
K1. Human faeces are a principle source of
diarrhoea.
Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K2. Children’s faeces are not dangerous. Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K3. Wash our hands once a day everyday is
sufficient to avoid the diarrhoea.
Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K4. Washing hands with ash is almost same as
effective as washing hands with soap.
Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K5. Using the soap/ash is not necessarily
effective to reduce diarrhoea diseases.
Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K6. Hot weather causes diarrhoea disease. Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K7. The only cause of malaria is mosquitoes. Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
K8. Poor drinking-water quality causes diarrhoea
disease.
Agree .................................................................... A
Don’t agree ............................................................ B
DK ......................................................................... Z
Survey Instruments for the Baseline Survey
Household Questionnaire 18
Section L. SOCIO-ECONOMIC CHARACTERISTICS
L1. What are the principle livelihoods sources for
your household?
(rank them according to their importance)
Most
important 2
nd 3
rd
Agriculture……………………..........…
Fisheries…………………….................
Small livestock……………...............…
Small trade………………….............…
Temporary work…..………..............…
Permanent employment…...............…
Pension…………………………....……
Remittances from family elsewhere....
Other (specify).....................................
A
B
C
D
E
F
G
H
I
A
B
C
D
E
F
G
H
I
A
B
C
D
E
F
G
H
I
L2. What assets does the household own?
(record all items mentioned)
Yes No
Electricity…………..…………...………..…..
Radio…………………….....……....……..….
Television…………………....…..…………...
Mobile phone………......……………...…….
Bicycle………………………...…......……....
Motorbike………………....…………......…...
Ox cart………………........………..…..........
Livestock…………………………..........…...
A
A
A
A
A
A
A
A
B
B
B
B
B
B
B
B
L3. Housing Type (Roof Material)
(check through observation)
Thatch / Grass / Makuti .......................................... A
Corrugated Iron (mabati) ........................................ B
Asbestos sheets ..................................................... C
Tiles ....................................................................... D
Concrete ................................................................ E
Others (specify) ...................................................... X
L4. Housing Type (Floor Material)
(check through observation)
Earth / Mud / Dung / Sand ...................................... A
Wood planks .......................................................... B
Cement .................................................................. C
Ceramic tiles .......................................................... D
Bamboo / Palm ...................................................... E
Others (specify) ...................................................... X
Survey Instruments for the Baseline Survey
Household Questionnaire 19
L5. Housing Type (Wall Material)
(check through observation)
Bamboo / Palm ...................................................... A
Mud and wood ....................................................... B
Mud / Mud bricks .................................................... C
Timber with iron sheets .......................................... D
Concrete blocks ..................................................... E
Burnt bricks ............................................................ F
Others (specify) ...................................................... X