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
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2. 12.The water source yield 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
……………………………………………………………………………………….……………………
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18.Administrative location of the water facility
1) District……………………………………………………………………….........................................
2) Division…………………………………………………………………...............................................
3) Location…………………………………………………………………..............................................
4) Sub Location……………………………………………………………...............................................
5) Village/Ward……………………………………………………………...............................................
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3. 19. Environmental Impact assessment 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?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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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
………………………………………………………………………………………………………………
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………………………………………………………………………………………………………………
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25.Number of households (HHs) served by the water facility
………………………………………………………………………………………………………………
26.Projected population (taking into considerations the known average family size per HH)
…………………………………………………………………………………………………………
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4. 27. On a monthly 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
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5. 35.Composition of water management team and roles of members
Sex Number
Male
Female
TOTAL
36.What are the roles played by women in the management committee?
...............................................................................................................................................................................
............................................................................................................................. ..................................................
............................................................................................................................. ..................................................
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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
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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?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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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)}
………………………………………………………………………………………………………………
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7. 50.Apron provision (Drainage enclosure 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:
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8. 57.What was the general situation of the area and community before AMREF’s intervention?
………………………………………………………………………………………………………………
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58.What changes have occurred as a result of AMREF’s intervention?
………………………………………………………………………………………………………………
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59.Apart from water provision, what other community development activities is AMREF involved in?
………………………………………………………………………………………………………………
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………………………………………………………………………………………………………………
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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
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9. 74. Services offered by the health institution
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
75. In what other areas of Health and Development is AMREF involved in with the institution?
………………………………………………………………………………………………………………
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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) ……………………………………………………………………………...................................................
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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?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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86. What changes have occurred as a result of AMREF’s intervention?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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87. List any other agencies/government ministries supporting the institution
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
88. Contact persons
89. Name…………………………………...........................................................................................................
90. Phone No…………………………………………………………………………………………………….
91. Email Address………………………………………………………………………………………………
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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
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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
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13. 112.The teachers are able 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?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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116.Is there any other support from AMREF to the institution?
………………………………………………………………………………………………………………
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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?
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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14. 120.What changes have occurred 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
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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…………………………………………………………………………………………...
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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
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