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  • Faecal Sludge Management – Performance Monitoring Survey 2017

    1 | P a g e

    ‘000’ if no number

    HOUSEHOLD SURVEY QUESTIONNAIRE (Annex-1) Code:

    Date of interview: ..../ ...../ 2017 Time record: ................Hrs. (start of interview)

    town

    ward

    sample number (ward- wise)

    BUILDING INFORMATION

    B1

    Name of the Interviewee

    B3

    Total number of families

    in the building:

    B2 Position of the Interviewee:

    Owner ...................1

    Caretaker/guard ...................2

    Tenant............. 3

    Others (Specify)............. 4

    B4

    B5

    Total Number of Containment in the building:

    Septic Tank:

    Pit:

    HOUSEHOLD INFORMATION

    HH1 Name of the Interviewee HH2

    HH3

    Age (Year) of the respondents

    Sex: Male......1 Female....2 Other.... 3

    HH4

    HH5

    HH6

    Plot No.:____________

    Holding No:___________

    Name of the road or number ....................

    ............................... .............................

    Area ..............................................

    HH7 Type of household:

    Planned residential area ...................1

    Unplanned residential area ...................2

    Slum located on private land............. 3

    Slum located on government land .........4

    HH8 This floor: [for ground floor ‘1’] HH9 Total floor in this building/ house

    [including ground floor]

    HH10a

    HH10b

    Name of head of household:

    ----------------------------------------

    Sex: Male......1 Female....2 Other.... 3

    HH11 Relationship between the head and the

    Interviewee

    Self .................1 Spouse..........2

    Son/daughter ......3 Others

    ..............4

    HH12 Profession of the HH owner(Code)*:

    HH13 Religion of the head of this household:

    Islam ..........1 Hindu .........2

    Christian .........3 Buddhist ..........4

    Other religion ...5 No religion .......6

    HH14 DO YOU OR SOMEONE IN THIS HOUSEHOLD

    OWN THIS DWELLING, OR DO YOU RENT

    THIS DWELLING?

    Own (both land & house).................1

    Rent (both land & house) ...................2

    Land rented, but own house ............5

    Rent free other ................................4

    HH15 How many years do you live in this

    property /land? Years

    HH16 Width of the access road

    to the dwelling (feet) :

    HH17 Total household members

    HH18a Number of male aged under 5 HH18b Number of female aged under 5

    HH19a Number of male aged 5-18 HH19b Number of female aged 5-18

    ‘000’ if no number

  • Faecal Sludge Management – Performance Monitoring Survey 2017

    2 | P a g e

    *Service ......1 Business (medium and large)........2 Small business ....3, Student........4, driver .......5,

    Day labourer/ rickshaw pooler ......6, No regular job .....7, Housewife ......8, others ........9

    SANITATION

    1(S) Does your household have a

    toilet?

    No facility, practice open defecation ........1

    No, use neighbour’s toilet .................2

    Yes, have own toilet ............................3

    Yes, have community toilet ................4

    Yes, share a toilet by 2 - 3 households ...5

    1,2  Next

    Section

    2(S) How many toilet cubicles does

    the toilet have?

    3(S) How many households in total use

    this toilet facility, including your

    own households?

    Number of households

    If reply ‘Don’t know’ please put (98)

    4(S) Are all the toilet cubicles being

    used as toilet?

    and

    observation>

    Yes ……………………………………….......……………. 1

    No……………………………………………….........…2

    1  6(S)

    5(S) How many of them are not

    being used?

    and

    observation>

    6(S) Are they segregated for male/

    female users?

    and

    observation>

    Yes ……………………………………….......……………. 1

    No……………………………………………….........…2

    2  8(S)

    7(S) How many cubicles for female and

    how many for male?

    and observation>

    Only for female:...

    Only for male: ...............

    Share by female and male: ...........

    8(S) Do the excreta from your

    toilet go to a covered pit or

    septic tank?

    and

    observation>

    Yes ............... ........... ........................1

    No ........................................................2

    Don’t know .........................................3

    HH20 Number of male aged 18-60 HH21 Number of female aged 18-60

    HH22 Number of male aged over 60 HH23 Number of female aged over 60

    HH24 Does anyone in your household have difficulty in walking or climbing steps? Yes .....1 No .......2

    (Physical disability)

    HH25 Does anyone in your household have difficulty in seeing? Yes .....1 No .......2

    HH26

    HH27

    Do you feel secure from eviction from this

    dwelling?

    Yes .....1 No .......2 Don’t know ......8

    Not Applicable ......88

    Have you been evicted from your home at

    any time during the past 5 years?

    Yes .....1 No .......2 Don’t know ......8

    Not Applicable ......88

    HH28 Is the cooking usually done in the house, in

    a separate building, or outdoors?

    Own separate kitchen inside the house .....1

    In the house, but no separate kitchen ........2

    Kitchen outside the house but in a separate

    building (own) ......................................3

    In a common kitchen outside the house ....4

    Other (specify) ................................ 9

  • Faecal Sludge Management – Performance Monitoring Survey 2017

    3 | P a g e

    9(S) How do you flush to clean

    your toilet pan after

    defecation?

    and

    observation>

    No flush required ..............................1

    Pour flush .............................................2

    Automatic flush .................................3

    10(S) What type of toilet do you use?

    Hanging latrine ..................................1

    Direct open pit/ pit without cover .......2

    Latrine conected to open spcae or drain ..3

    Do’t know where it goes after flush ....4

    Bucket latrine .....................................5

    1-5  Next

    section

    Covered Pit latrine ..........................6

    Pit latrine with covered slab and pan .......7

    Ventilated Improved Pit Latrine ...........8

    6-8 

    11(S)

    Septic tank ............................................9 9 21(S)

    Sewer system ...................................10

    Composting toiulet (Eco-san toilet) ...11

    DEWATS ...........................................12

    Bio-gas plant .................................13

    10-13 

    25(S)

    Others (specify) ................................99

    11(S) How many pits are there and

    How are they placed?

    Direct single pit ..................................1

    Offset single pit ....................................2

    Double pit (without ‘Y junction’)............3

    More than 2 pits ..................................4

    Twin pit (with ‘Y junction’) .................5

    1-4

    13(S)

    12(S) Whether the ‘Y Junction’ of the

    twin-pit latrine functional?

    Yes ……………………………………….......……………. 1

    No……………………………………………….........…2

    13(S) Size of the pit

    and

    Diameter: ............ Inches

    Total number of rings (of all pits): ..........

    14(S) Materials of the rings Cement ................................................1

    Clay ................................................2

    No rings, only pit ....................................3

    Don’t know ......................................8

    15(S) When the pit was dug, was any

    groundwater seeping in?

    Yes .....................................................1

    No ..........................................................2

    Don’t know/ don’t remember ..................9

    16(S) Are the walls of the Pit completely

    sealed?

    Wall not cement lining ...........................1

    Part of wall cement lining ...................2

    Wall cement lining ................................3

    No ring ..............................

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