SOMALIA WASH CLUSTER DETAILED ASSESSMENT Questionnaire Number: |__|__|__|__|
0. To be completed by EnumeratorPlease complete before the Interview
0.1 - / |__|__|__|__|__|__|__|__|__|__|__|__| Enumerator Name
0.2 - / Date: |__|__| / |__|__| / 2012
Day Month / 0.3 GPS Coordinates
X|__|__|.|__|__|__|__| Y: |__|__|.|__|__|__|__|
0.4 / |__|__|__|__|__|__|__|__|__|__|__|__| _|__|__|__|__|
Village/Location Name
|__|__|__|__|__|__|__|__|__|__|__|__|
District Name
|__|__|__|__|__|__|__|__|__|__|__|__|
Region Name
|__|__|__|__|__|__|__|__|__|__|__|__|
Setting Type (Urban/Rural)
SECTION 0: DEMOGRAPHICS & Background
0.5 / Total number of people living in Village/Location / Adults / |___|__| / Female / |___|__| / Male / |___|__|
Children / |___|__| / Girls / |___|__| / Boys / |___|__|
0.6 / Have people been displaced from the village/location? / 1 = Yes / 0 = No
0.7 / Total number of displaced from theVillage/Location / Adults / |___|__| / Female / |___|__| / Male / |___|__|
Children / |___|__| / Girls / |___|__| / Boys / |___|__|
0.8 / Total number of displaced from other villages in thisVillage/Location / Adults / |___|__| / Female / |___|__| / Male / |___|__|
Children / |___|__| / Girls / |___|__| / Boys / |___|__|
0.9 / Are there any agencies providing assistance in this village / 1 = Yes / 0 = No
0.10 / If yes, list the name of Agency and item they are providing / Name / Item provided / Name / Item provided / Name / Item provided
0.11 / What does the people of this Village/Location regard as the most urgent priorities / 1 / 2 / 3
SECTION A - HEALTH
A1 / What are the most common health problems that adults suffer from?)
A2 / What are the most common health problems that mainly affect the children under 5?
A3 / How many people have had diarrhoea in the last 2 weeks? / Adults / |___|__| / Female / |___|__| / Male / |___|__|
Children (Under 5) / |___|__| / Girls / |___|__| / Boys / |___|__|
5
SECTION B: WASHB1 / How much water can each family collect per day? / 1 = less than 75Lt / 2 = 75 to 100lt / 3 = more than 100lt
B2 / What water sources are available in this village/location? See the details in the table below
Water Source / Available (1=Yes, 0=No) / Number
of
Sources / population using Source(s) / Number of
functioning
Sources / Condition of non-functioning sources (broken, dry, polluted, collapsed, silted,
low yield, reduced storage capacity) / Average distance between source(s) and users' homes (km) / How many months a year does this source provide water?
1 / 2 / 3 / 4 / 5 / 6 / 7
1 / Borehole
2 / Protected spring
3 / Shallow Well withhandpump
4 / Unprotected spring
5 / Unprotected Shallowwell
6 / Lake, river, stream
7 / Rain water catchment
8 / Other, Please specify
B3 / Does the population (or displaced population) have access to these sources?? |__| / 1 = Yes / 0 = No
B31 / If no, why not and where do they get their water
B4 / Is it safe for people to collect water from these water points/sources? |__| / 1 = Yes / 0 = No
B5 / Do people have containers for storing and/or fetching water? |__| / 1 = Yes / 0 = No
B51 / What size (in litres)______
B52 / Number per family?
B53 / What type of container is generally used?
B6 / Do people do anything to improve the quality of their drinking water? / 1 = Yes / 0 = No
B61 / If yes, which treatment method(s) are used? Select all that apply?
(1=Yes, 0=No,) / 1= Chlorination |__| / 2= Sedimentation |__|
3= Simple sand filtration|__| / 4= Cloth filtration |__|
5= Boiling |__| / 6= Sun exposure |__|
7=Others|______|
SECTION C - Sanitation
C1 / How many families have their own latrines? |__||__||__|
C2 / How many people use a latrine |__||__||__|
C3 / Do people think it is important to use a latrine? / 1 – Yes / 0 – No
C31 / If yes, why is it important
SECTION D: Hygiene
D1 / What do people use to wash their hands / 1=.Water only / 2=.Water with Soap
3=Water with Ash / 4=Other|______|
D2 / What time do people normally wash their hands? /
- After defecation or using a latrine
- After Cleaning Child’s Bottom
- Before Preparing Food
- Before eating Food
- Before Feeding or Breast Feeding a Child
D3 / Do people have access to soap? / 1 = Yes / 0 = No
D31 / If no, why not
D4 / How many Mothers know how to prepare oral rehydration solution (ORS) and use it at home? / |__||__||__|
D5 / What items are available or accessible to the families
D5.1 / Soap / |__|
D5.2 / Water Treatment Chemicals / |__|
D5.3 / Jerry Cans for Collecting Water / |__|
D5.4 / Feminine Hygiene Items (Napkins) / |__|
D6 / Do people think soap is important?|__| / 1= Yes / 0= No
If yes(in B6 above), what are the reasons?
E:VECTOR BORNE DISEASES
E1 / How many families or households use mosquito nets / |__||__|
F:SHELTER
F1 / What type of shelters are people living in now?
F2 / What kind of problems does this cause, if any?
SECTION G - MISCELLANEAOUS
G1 / How has the current situation affected the life and living for women and girls?
G2 / How has the emergency situation affected your livelihoods and access to markets?
G3 / Does the local health facility have access to water, latrines and medical waste facilities / 1= Yes0= No
1