Safe
Water System Manual
ANNEX
A:
COLLECTING BACKGROUND DATA:
SAMPLE QUESTIONNAIRE
ON KNOWLEDGE AND PRACTICES
Date
of interview _____/_____/200_
Index subject study no. _______
Household
no. _______
Interviewer's name _________________________________________
Demographic
data
1. Name of principal respondent __________________________
2. Relationship
of respondent to the head of household
a
= Husband b = Wife c = Son
d
= Daughter e = Other (specify) ____________
3. Name of the village _________________________________
I
WOULD LIKE TO ASK YOU ABOUT THE SOURCES OF INCOME FOR YOUR HOUSEHOLD
4.
What are the main sources of income for the household?
a.
Professional technical or managerial job
b.
Large scale agriculture
c.
Small scale agriculture
d.
Sales or services
e.
Skilled manual labor
f.
Unskilled manual labor
g.
Other _______________________________________
5.
What is the type of the house (Look at the house and circle the appropriate choice
below)
a. The walls are
made of mud and the roof is grass-thatched.
b.
The walls made of mud and the roof is of iron sheets.
c.
The walls are made of bricks and the roof is grass-thatched.
d.
The walls are made of bricks and the roof is made of iron sheets.
e.
The walls are made of bricks and the roof is made of tiles.
6.
Which of the following things do you have in your house?
a.
Beds Yes No Don't know
[If
yes] how many? _____
b.
Bicycle Yes No Don't know
c.
Car Yes No Don't know
d.
Truck Yes No Don't know
e.
Radio Yes No Don't know
f.
TV Yes No Don't know
g.
Refrigerator Yes No Don't know
h.
Electricity Yes No Don't know
i.
Stove Yes No Don't know
[if
yes] Is it electric kerosene gas
7.
Do you keep any animals or birds in your household?
(If yes) record
the type and number of animals/birds kept in the table below. (If no go to question
8)
| Type
of animal/bird | 1
= Yes 2 = No | Number
of animals/birds kept |
| Cows | 1
2 | |
| Goats | 1
2 | |
| Sheep | 1
2 | |
| Pigs | 1
2 | |
| Chicken
/ Ducks | 1
2 | |
| Other | 1
2 | |
I WOULD
LIKE TO ASK YOU ABOUT THE SOURCE AND HANDLING OF HOUSEHOLD WATER
8.
From where do you usually collect the water you use in the house? Do not read
the options to the respondent. Mark
all the sources that apply
a.
Pond or dam
b. Lake
c.
Stream or river
d. Well
e.
Borehole
f. Spring
g.
Rainwater
h. Water-tap
i.
Other_____________________________________
9.
With what container do you collect the water you use in the household? (Ask to
see the vessel that is usually used to collect water)
a.
No container
b. Bucket
c.
Jerrycan
d. Barrel /
drum
e. Clay pot
f.
Sauce -pan
g. Directly
from the tap
h. Other
(specify)__________________
10.
Do you think this water is safe to drink without any treatment?
1
= Yes 2 = No 3 = I do not know
11.
What type of container do you use to store water for drinking in the house? (Look
at the vessel usually used to store drinking water) (Do not read, circle all that
apply)
a. No container
b.
Bucket
c. Jerrycan
d.
Barrel/drum
e. Clay-pot
f.
Saucepan
g. Jug
h.
Kettle
i. Bottles
j.
Other (Specify)
12.
What type of water storage vessel does the household use?
See if it is
a.
Wide mouthed
b. Narrow
mouthed
c. Other. (Describe)__________________
13.
Is the water in the storage vessel covered?
1
= Yes 2 = No
14.
Do you process this water in any way to make it safer to drink?
1
= Yes 2 = No 3 = Don't know
15.
If yes what do you do to the water to make it safer to drink? (Circle all that
apply)
a. Boil
b.
Add bleach
c. Sieve it
through cloth
d. Other
(Specify)________________________
16.
What do you use to get/pour drinking water out of the storage container (Look
and circle all that applies)
a.
Nothing
b. Cup
c.
Ladle
d. Pitcher
e. Bowl
f.
Bucket
g. Pour water
directly from container
h.
Other (Specify)______________________
I
WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT THE TOILET HABITS OF THE PEOPLE IN
YOUR HOUSEHOLD
17.
What toilet facility do you use? (Do not read the options. Circle all that apply.)
a.
In the bushes or on the ground?
b.
In a latrine?
c. Other
(specify)_________________________________
18.
Can I see the type of soap that you use? (Look at the soap and comment whether)
1 = Soap available 2 = Soap
not available
Observations
to be made by the interviewer
Ask
to look at the toilet facility and record
19.
What toilet facility does this household use?
a.
No facilities
b. Pit
latrine
c. Other______________________________
20.
Is there water for hand washing near or at the toilet?
1
= Yes 2 = No
Inspect
the compound and observe for
21.
Are there any visible excreta in the yard? (If no go to 22)
a.
Human feces 1 = Yes 2 = No
b.
Animal feces 1 = Yes 2 = No
c.
Unknown excreta 1 = Yes 2 = No
22.
If yes how many stools are observed?
a.
Small amount (1-2 feces)
b.
Moderate amount (3-4 feces)
c.
Large amount (>5 feces)
23. Record the names and age of all people who currently live in the household.
| No | Names | ID
No. | Age | Sex
1
= M
2 = F | Relationship
to head of household
a = Husband
b = Child
c = Grandchild
d = Other
relative
e = Not related |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
| | | | | 1
2 | a
b c d e |
Check
form at the end of the visit
·
Water vessel inspected [__]
·
Water from the household storage vessel sampled [__]
·
Water source inspected [__]
·
Water from the source sampled [__]
·
Toilet facility inspected [__]
·
The compound inspected [__]
Say
goodbye to the family after going through the check form above
