This is a detailed questionnaire that was used to select eligible participants of an adolescents program

1. Beneficiary location:
District: Subcounty: Settlement Name:
Zone/Parish: Block/Village:
Beneficiary Personal information
Names: Date of birth: Age: Sex:
Residency
status:
⃝ National
(Skip to
National ID
No.)
⃝ Refugee
Individual Attestation
number:
(use guardian’s number if
own not available)
[_______________________]
Group Attestation
number:
[____________________]
National ID No: (use
guardian’s number if own
not available)
[______________________]
Next of Kin:(insert names)
[______________________]
Telephone No. of Next of Kin:
[______________________]
A. Vulnerability category: Child headed household and/or Unaccompanied minor
A1. Who do
you live
with? (Select
one)
1= With both
my parents
2= With only
my father
3= With only
my mother
4= With other
relative
5= With my
brother/sister
6= Foster
Parent(s)
7= Institutional
Care
8= Alone
A2. Who is the head of
the household where
you live? (Select one)
1= Male adult
2= Female adult
3= Male child
4= Female child
A3. What are the social
characteristics of the
household head?
1= Person with special
Needs
2= Chronically ill
3= Elderly
4= widow/widower
5= community/religious
leader
6= Other:
Specify___________
A4. How many people live in your
household?(Insert number, 0 for
None)
Age M F
0-5Yrs
6-13 Yrs
14-19 Yrs
20+ Yrs
A5. How many children aged between 6-19 years are currently not in school in your household?
(Insert number, 0 for None)
Male: [_______]
Females: [_______]

2. B. Vulnerability Category: Special Needs
B1. Do you have any special needs
1= Yes
0= No (Skip to next section)
B2. If yes; Specify
1= Visual impairment
2= Hearing impairment
3= Speech difficulty
4= Physical Impairment
5= Chronically ill
6= Other Specify:
________________
C. Vulnerability category: School drop out
C1. Are you
in school?
1= Yes
2= No (Skip to
C3)
C2. What is your current level of education? (select one)
1= Lower Secondary
2=Upper primary
3= Lower Primary
0= Other, Specify: ____________
C3. If not in school, what
was your highest level of
education?
1= Lower secondary
2= Upper primary
3= Lower primary
4= Never attended school
0= Other, Specify:
_______________
C4. If not in school, how
long ago did you live
school? (Insert duration in
years)
[_________]

3. D. Vulnerability category: No skills training received
D1. Have you received any skills
training from the time you
dropped out school?
1= Yes 2= No (Skip to Next Section)
D2. In what areas did you receive
training? (Select all that apply)
1= Vocational skills
2= Life skills
3= Counseling
4= Other, Specify: _______________
D3. Who funded your skills
training?
1= Private sponsorship (family and
friends)
2= Private sponsorship (INGO, NGO)
3= Private sponsorship (Faith Based
Organisations)
4= Government sponsorship
5= Non Government sponsorship (UN
and Other International Charities)
6= Other, Specify: ____________
E. Vulnerability category: Adolescent mother
E1. Are you a parent?
1= Yes, with child(ren)
2= Yes, Expectant
0= No (Skip to E5)
E2. How many children do you
have? (Insert #)
[________]
E4. How old is your youngest
child (if has more than one
child)? (Insert age in months)
[______]E3. How many of the children in
E2. Have:
1=Special Needs: [_____]
2=Chronic illness: [_____]
( Insert Number)
E4. Do you live with the
father/mother of your
child(ren)?
1= Yes 2= No
E5. How many children are
under your care? (insert #, 0 for
none)
[________]
E6. What are the usual sources
of income for you (or in your
household)?
1= Petty trade
2= sale of own labor
3= hand outs from well wishers
4= Salary from Household head
5= Donations from I/NGOs and charities
6= No income source
7= Other Specify: _______________