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Data collection wash questionnaire (3)
- 1. WASH INFRASTRUCTURE MAPPING QUESTIONNAIRE NO : 1.Date…………………………………………………………………………………………………………… 2.Interviewer …………………………………………………………………………………………………… 3.Verifier………………………………………………………………………………………………………... 4.Name of water facility………………………………………………………………………………………... 5.GPS Location No……………………………………………………………………………………………... 6.Photo No: 7.Physical location (co-ordinates) of the water facility 8. X………………………………………………………………………………………………………………. 9.Y……………………………………………………………………………………………………………….. A) Water Facilities 10.Type of water source/facility or infrastructure 1) Pipeline 2) Borehole 3) Spring 4) Conventional well 5) Giant well 6) Open earth dam 7) Sand river bed dam 8) Storage tank 11. If the water source has a pipeline, please fill in the following: Name of the source No. of water kiosks on the pipeline Length of the pipeline Project funded Community funded Project funded Community funded 1 | 16P a g e
- 2. 12.The water sourceyield is adequate and meets the needs of the beneficiaries. Strongly Somewhat Disagree Somewhat Agree Strongly agree disagree disagree strongly agree 0 2 3 4 5 6 13.Type of water pump installed 1) Afridev 2) Indian Mark II 3) Motorized (Lister engine & monopump) 4) Submersible and generator 5) Submersible with solar panels 14.Pump functionality status Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 15. Is there a pump house? (for boreholes) 1) NO 2) YES 16.If yes, how do you rate the status of the pump house? Very Poor Fair Good Very Good Excellent Poor 0 1 3 3 4 5 17.Give reason for your response to question 16 ……………………………………………………………………………………….…………………… ………………………………………………………………….………………………………………… …………………………………………….……………………………………………………………… …………………………………………………………………………………………………………… 18.Administrative location of the water facility 1) District………………………………………………………………………......................................... 2) Division…………………………………………………………………............................................... 3) Location………………………………………………………………….............................................. 4) Sub Location……………………………………………………………............................................... 5) Village/Ward……………………………………………………………............................................... 2 | 16P a g e
- 3. 19. Environmental Impactassessment is critical in the development and maintenance/ management of water and sanitation interventions: Strongly Somewhat Disagree Somewhat Agree Strongly agree disagree disagree strongly agree 0 2 3 4 5 6 20.What interventions are you involved in to ensure conservation of water? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ………………................................................................................................................................................ 21.Physical characteristic of the surrounding area 1) Mountainous 2) Swampy 3) Plain 4) Forested 5) Arid /semi-arid 6) Valley 22. What is the functionality status of the water facility? 1) Not functional 2) Functional but needs repair 3) Functional and in good condition 23.How well does the water facility function? Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 24.Please give reasons for your answer in Q 23 ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ………………................................................................................................................................................ 25.Number of households (HHs) served by the water facility ……………………………………………………………………………………………………………… 26.Projected population (taking into considerations the known average family size per HH) ………………………………………………………………………………………………………… 3 | 16P a g e
- 4. 27. On amonthly basis, how much does a HH pay for operation and maintenance of the water facility? 1) None 2) Ksh. 1-10 3) Ksh. 11-20 4) Ksh. 21-50 5) Ksh. >50 28. What is the cost of a 20 litre jerrican of water? …………………………………………………………………………………………………………… 29.How much are you willing to pay for a 20 litre jerrican of water? ……………………………………………………………………………………………………………… 30.How much water does a family use in a day? ............................................................................................................................. ........................................... 31. Indicate if the WMC operates a bank account 1) YES 2) NO 32.How much do you have in your account? 1) None 2) Ksh. 1-1,000 3) Ksh. 1,001-5,000 4) Ksh. 5,001-10,000 5) Ksh. >10,000 33.How do you use or plan to use the income generated from water? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 34.The water facility is managed by 1) Private operators 2) Water user group 3) Elected village water committee 4) Government constituted water management board 4 | 16P a g e
- 5. 35.Composition of watermanagement team and roles of members Sex Number Male Female TOTAL 36.What are the roles played by women in the management committee? ............................................................................................................................................................................... ............................................................................................................................. .................................................. ............................................................................................................................. .................................................. ............................................................................................................................................................................... 37.What are the roles played by men in the management committee? ................................................................................................................................................................................ ............................................................................................................................. ................................................... ............................................................................................................................. ................................................... ................................................................................................................................................................................ 38.Based on the composition and roles, how would you rate the water management team gender sensitivity Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 39.Skills of the water management team (Training) Category Male Female TOTAL Trained members Untrained members TOTAL 40.Based on the work and performance of the water management team, Please award it marks with 0 as the lowest and 5 as the highest Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 41. Is there a trained pump caretaker (for borehole and wells) 1) YES 2) NO 42.Based on the work and performance of the pump caretaker, please award marks with 0 as the lowest and 5 as the highest Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 5 | 16P a g e
- 6. 43.Quality of water(based on chemical and physical analysis) 1) Soft 2) Salty 3) Coloured/Dirty 44.What methods of treatment is the WMC using to ensure quality of water is maintained and how often is this done? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 45.What is the depth of the well/borehole? ………………………………………………………………………………………………………………… 46.Water quantity/yield from the water facility 1) Dry/no water at all 2) Insufficient 3) Seasonal 4) Enough /satisfactory 47.The amount of water I get now is sufficient as compared to the period when we did not have this water facility: Strongly Somewhat Disagree Somewhat Agree Strongly agree disagree disagree strongly agree 0 2 3 4 5 6 48.Use of water from the facility 1) Vegetable growing/small-scale irrigation 2) Tree nurseries 3) Commercial farming/large-scale irrigation 4) Consumption by livestock 5) Human consumption 6) Mixed use (Please give a breakdown) 49.Approximate the number of livestock served {if the answer is (4)} ……………………………………………………………………………………………………………… 6 | 16P a g e
- 7. 50.Apron provision (Drainageenclosure of the water facility) 1) Present 2) Present-needs repair 3) Non-existent 51.What is the Drainage status of the water facility? Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 52.Water protection (Fence availability) 1) Fenced 2) Not fenced 53.Status of the fence {if the answer is (1)} Very Poor Fair Good Very Good Excellent Poor 0 1 2 3 4 5 54.Date commissioned and source of funding Date Commissioned Initial Capital Cost Source of Funding/Donors *Community Input Others *Take note of community contribution – if in monetary or in kind 55.What was AMREF’s input to the water facility? 1) Rehabilitation 2) Drilling (Full input) 3) Pump provision 56.Renovations, cost and source of funding Latest Renovation/Repairs Undertaken Date: Cost: What was renovated Source of Funding/Donor Name: 7 | 16P a g e
- 8. 57.What was thegeneral situation of the area and community before AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 58.What changes have occurred as a result of AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 59.Apart from water provision, what other community development activities is AMREF involved in? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 60.Contact persons (beneficiary but not a member of the water management committee) 61.Name……………………………………………………................................................................................. 62.Phone No ……………………………………………………………………………………………………. 63.Email Address……………………………………………………………………………………………… 64.Name……………………………………………………................................................................................. 65.Phone No ……………………………………………………………………………………………………. 66.Email Address……………………………………………………………………………………………… B) Health Institutions/other health development related activities 67.Name of the Health institution/Intervention/activity ……………………………………………………………………………………… ………………… 68.GPS Location No……………………………………………………………………………………………. 69.Photo No: 70.Physical location (Coordinates) of the health facility 71.X……………………………………………………………………………………………………………… 72.Y……………………………………………………………………………………………………………… 73.Type of health institution 1) Hospital 2) Health centre 3) Clinic 4) Pharmacy/Drug shop 5) Nursing home 8 | 16P a g e
- 9. 74. Services offeredby the health institution ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 75. In what other areas of Health and Development is AMREF involved in with the institution? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 76. Administrative location of the health facility 1) District…………………………………………………………….......................................................... 2) Division…………………………………………………………............................................................ 3) Location………………………………………………………................................................................ 4) Sub Location…………………………………………………................................................................. 5) Village/Ward…………………………………………………................................................................ 77. Population served by the health facility (Catchment area) 1) Number of villages/locations served………………………………………………………………… 2) Projected population/Number of households………………………………............................................ 78. Average number of patients served by the health facility on a monthly basis Category Male Female TOTAL Children {Below 18yrs} Adults {Above 18yrs} TOTAL 79. Number of hospital staff Category Male Female Doctors Nurses Pharmacists Clinical officers Support staff TOTAL 80. Common ailments in the catchment area (at least three in their order of severity) 1) ……………………………………………………………………………................................................... 2) ……………………………………………………………………………................................................... 9 | 16P a g e
- 10. 3) ……………………………………………………………………………................................................... 4) ……………………………………………………………………………................................................... 5) ……………………………………………………………………………................................................... 81. If AMREF has supported construction of latrines, how many are they? ……………………………………………………………………………………………………………… 82. What is the completion status of the latrines? 1) Fully complete 2) Half complete 3) Partially complete 4) Not yet started 83. What is the functionality status of the latrines? 1) Not functional 2) Functional but needs repair 3) Functional and in good condition 84. What is the hygiene status in and outside the latrine? Very Poor Poor Fair Good Excellent 0 1 2 3 4 85.What was the general situation of the Health Institution before AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 86. What changes have occurred as a result of AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 87. List any other agencies/government ministries supporting the institution ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 88. Contact persons 89. Name…………………………………........................................................................................................... 90. Phone No……………………………………………………………………………………………………. 91. Email Address……………………………………………………………………………………………… 10 | 16P a g e
- 11. 92. Name……………………………………………………………………………………………………… 93. Phone No………………………………………………………………………………………………… 94.Email Address……………………………………………………………………………………………. C) Educational Institutions 95.Date…………………………………………………………………………………………………………... 96.Name of the Educational institution……………………………………………………………………….. 97.GPS Location No……………………………………………………………………………………………. 98.Photo No: 99.Physical location of the educational facility 100.X…………………………………………………………………………………………………………… … 101.Y…………………………………………………………………………………………………………… … 102.Type of educational facility 1) Nursery School/ECDC 2) Primary School 3) Secondary School 4) Non-formal Education/Vocational training 5) College 6) University 103.Administrative location of the educational facility 1) District……………………………………………………………........................................................ 2) Division……………………………………………………….............................................................. 3) Location……………………………………………………….............................................................. 4) Sub Location…………………………………………………............................................................... 5) Village/Ward………………………………………………….............................................................. 104.Number of students enrolled Sex Number Male Female TOTAL 11 | 16P a g e
- 12. 105.Number of staff Category Male Female TOTAL Trained teachers Untrained teachers Support staff TOTAL 106.Number of school management committee Sex Number Male Female TOTAL 107.Existence of any school health club 1) YES 2) NO 108.What is its composition of the school health club? Sex Number Male Female TOTAL 109. Has the School Health club received any training on HPSI? Category Students Teachers TOTAL Male Female TOTAL 110.What type of training has been received and duration? Type Duration Students Teachers PTA 111.The students are able to articulate clearly what HPSI activities they are involved in. Very Poor Poor Fair Good Excellent 0 1 2 3 4 12 | 16P a g e
- 13. 112.The teachers areable to articulate clearly what HPSI activities they are involved in. Very Poor Poor Fair Good Excellent 0 1 2 3 4 113.Evidence of Health Promotion interventions/activities in the school. Leaky Tins Talking walls Dish Racks Compost pits Kitchen gardens Work plans Other 114.Have funds been allocated to health promotion activities in the school 1) YES 2) NO 115.What are some of the achievements of the health club? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 116.Is there any other support from AMREF to the institution? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 117.If AMREF has supported the construction of classrooms, how many are they? ……………………………………………………………………………………………………………… 118.What is the completion status of the classrooms? 1) Fully complete 2) Half complete 3) Partially complete 4) Not yet started 119.What was the general situation of the Institution before AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 13 | 16P a g e
- 14. 120.What changes haveoccurred as a result of AMREF’s intervention? ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 121.The general life situation is better now than before AMREF supported intervention(s) were implemented. Strongly Somewhat Disagree Somewhat Agree Strongly agree disagree disagree strongly agree 0 2 3 4 5 6 122.If AMREF has supported the construction of latrines, how many are they? …………………………………………………………………………………………………………… 123.What is the completion status of the latrines? 1) Fully complete 2) Half complete 3) Partially complete 4) Not yet started 124.What is the status of the latrines? 1) Not functional 2) Functional but needs repair 3) Functional and in good condition 125.How is the hygiene status in and outside the latrine? Very Poor Poor Fair Good Excellent 0 1 2 3 4 126.Is the school fenced? 1) YES 2) NO 127.What is the status of the fence? Very Poor Poor Fair Good Excellent 0 1 2 3 4 128.Any trees available? 1) YES 2) NO 14 | 16P a g e
- 15. 129.Contact persons 130.Name……………………………………………………............................................................................... 131.Phone No…………………………………………………………………………………………………… 132.Email Address……………………………………………………………………………………………... 133.Name………………………………………………………………………………………………………... 134.Phone No…………………………………………………………………………………………………… 135.Email Address……………………………………………………………………………………………... D) Road Network 136.Name of the road or description………………………………………………………………………….. 137.Type of the road 1) Primary Road (Main road-carries all traffic) 2) Secondary Road (Connects to the primary road) 3) Tertiary Road (Links to estates or neighbourhoods) 4) Access Road (Connects to homesteads) 138.Nature of the road 1) Seasonal road 2) Tarmacked 3) Murram road E) Economic centre {trading centre, markets, shopping centre etc} 139.Are there demonstration VIP latrines? 1) YES 2) NO 140.What is the status of the latrines? 1) Not functional 2) Functional but needs repair 3) Functional and in good condition 141.Name of the economic centre…………………………………………………………………………… 142.GPS Location No…………………………………………………………………………………………... 15 | 16P a g e
- 16. 143.Photo No: 144.Physical location of the economic centre 145.X…………………………………………………………………………………………………………… 146.Y…………………………………………………………………………………………………………….. 147.Type of economic centre 1) Village Market 2) Township 3) City 148.Administrative location of the economic centre 1) District………………………………………………………………........................................................... 2) Division...….…………………………………………………….................................................................. 3) Location…………………………………………………………................................................................. 4) Sub Location…………………………………………………...................................................................... 5) Village/Ward…………………………………………………….................................................................. NB: Also map out other physical features of importance e.g. rivers, bridges, railway line etc 16 | 16P a g e