Household Survey Questionnaire for KAP Study on WASH

District

Block

Gram Panchayat

Village

Cluster

HH No.

Name of the
Respondent

Age

Section B: Family Member details

Chl. 0-5 Yrs

6-18 Years

19-60 Yrs
F

Aged 60 and
over
F
M

Total
F

Section C: RESPONDENT BACKGROUND CHARACTERISTICS (Ask any one Adult member)

Q No

Questions

Responses

C1.

Do you own this House where you

live?

(Yes-1/No-2)

C2.

Facilities available in the house?

Toilet (Yes-1/No-2)
Bathroom (Yes-1/No-2)
Provision for solid waste

(Yes-1/No-2)
Drainage (Yes-1/No-2)
C3.

Structure of the dwelling

(Dont ask Observe wall, floor & roof
and Record)

C4.

In which caste of you belong?

C5.

Are you coming under APL/BPL category

Kuccha- (1)
Semi-Pucca-(2)
Pucca-(3)
Schedule caste (SC) -1
Schedule Tribe (ST)- 2
Other Backward Classes -3
General -4
BPL- 1
APL- 2

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Section D: Water
Q No

Questions

D1

B.

A. What is the main

source of drinking
water for your
Household?

What is the main

source water for
cooking and Hand
washing?

Piped water into dwelling

Piped water to yard/plot
Public tap/standpipe
Tubewell/borehole
Protected dug well
Unprotected dug well
Protected spring
Unprotected spring
Rainwater collection
Cart with small tank/drum
Surface water (river, dam, lake, pond, stream, canal,
irrigation channels)
Other (specify)

D2

On an average how much water do you collect

from it at one time?

][

D3

Generally in a day, how many times water is

fetched in your household?

Once in a day =1
Twice in a day =2
Thrice in a day =3
Four times in a day =4

D4

How far is this source from your dwelling?

Distance in metres
[
][
][
][

][

] Litres

D5

Who usually goes to this source to fetch the

drinking water for your household?

Adult Woman=1
Adult Man=2
Female child between 6-14
years =3
Male child between 6-14
years =4

D6

How the water is usually transported from the

source to the place where water is stored?

In covered vessel /
Container=1
In Uncovered vessel /
Container=2
Vessel / Container covered
with cloth=3
No need to transport, get it at
home=4
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D7

D8

D9

Please tell me generally how many times do you

wash the vessel / tank in which you store water?

Twice in a day
Once in a day
Thrice in a week
Twice in week
Once in week
Once in 15 days
Once in a month

1
2
3
4
5
6
7

Dont know/ Cant Say

You just told me how you transport the water,

Now please tell me...

How do you treat water?

A. Do you
treat the
water in
any way
before
drinking?

b.

Yes=1

Yes=1

No=2

No=2

Dont
Know=3

Dont
Know=3

Do you treat
the water in
any way
before using it
for cooking
purpose?

Boil

01

Use Alum

02

Add Bleach/Chlorine Tablets

03

Strain through a cloth

04

Use water filter

(Ceramic/Sand/Composite)
Let it stand and settle
(Decantation)

05
09

Others (Specify)
Cant say
D10

99

OBSERVE THE WATER FACILITIES AND RECORD THE FOLLOWING TABLE

Availability
(1)

Item

Condition of Facility
(2)

Condition of
Surroundings
(3)

Storage tank

Checked

Clean

Not Clean

Water containers

Checked

Clean

Not Clean

Ladle

Checked

Clean

Not Clean

Direct pouring
utensils

Checked and
observed

Clean

Not Clean

Instructions for QD11 and D13- Interviewer ask for a glass of water and OBSERVE how the water is poured from the
storage tank / vessel / container in the tumbler / glass. (Observe and Record)
D11 Note if water storage vessel/ tank is kept at an
elevated place?
Yes=1
Elevated place means it should be above reach
No =2
of child less than 5 years of age
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D12

D13

How was water withdrawn from

Vessels/Containers?

Poured from container/vessel

Immersing hand/Glass/tumbler
inside the storage
tank/vessel/container
Closed Completely

Was the container closed completely with a lid

after water was withdrawn?
Single coding only

D14

The Present Water sources are installed how far

from toilets?

D15

Whether water sources were submerged during

flood?
After the flood water sources are disinfected?

D16

Using Ladle

4
1

Closed partially

Was not closed

Less than 10mt.=1

10mt.- 15mt.=2
More than 15 mt.=3
Yes=1
No=2
Yes=1
No=2

Section E: SANITATION
Q No.
E1.

E2.

E3.

Questions

Responses

Does your household have a toilet within the

premises?
Apart from members of your HH does any other
HH also share the toilet facility?

Yes

No

Yes

No

a. Can you tell me most often which type of

toilet is used by the adult men in your
household?

A. Adult
men

B. Adult
women

C. Male
child
between
5- 15
years

ii.Shared Toilet

iii. Community
toilet

iv. Open
Defecation

b. Can you tell me most often which type of

toilet is used by the women in your
household?
i. Private toilet
c. Can you tell me most often which type of
toilet is used by male child (5-15 years)
in your household?
d. Can you tell me most often which type of
toilet is used by female child (5-15 years)
in your household?

E10.

What is the type of toilet facility that

members of your household use?

Answer

Codes

D.
Female
child
between
5- 15
years

POUR FLUSH
Single pit direct

01

Single pit offset

02

Twin pit offset

03

Connected to sewer

04

Connected to septic tank with

soak pit

05
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PIT LATRINES

E11.

(Observe and Record the following E11

E17)
Is there running water available in the toilet?

E12.

Is the chappal available in the toilet?

E13.

Is there a hand washing area near/ outside

the toilet?
Is water readily available for cleaning toilet?

E14.
E15.
E16.

E17.

Is water readily available near the hand

washing area?
Are any hand washing materials placed in the
hand washing area?

Simple pit latrines

06

Dry / Bucket Latrines

07

Others (Specify)
_______________________
YES
NO

DK / CS

Yes, Soap

Yes, Ash

Yes, Soil/Mud

Yes, Other material

No

Dont Know

Ask only to the mother/caregiver of child

less than 2 years
How is the faeces of the child aged less than
2 years disposed most of the times?

Child uses toilet

01

Thrown in Toilet

02

Flushed in Toilet

03

Here we refer to children who cannot walk

and defecate on his/her own

Buried in the ground

04

Thrown in drain

05

Flushed in drain

06

Thrown in other places

07

No child in that age group

88

Others (Specify)
_______________________
E18.

Ask only to the mother/caregiver of child

more than 2 and less than 5 years
How is the faeces of child aged 2-5 years
disposed?

Here we refer to children who can walk and

defecate on his/her own

Child uses toilet

01

Thrown in Toilet

02

Flushed in Toilet

03

Buried in the ground

04

Child defecates in Drain

05

Thrown in drain

06

Flushed in drain

07

Child defecates in open

ground

08

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Thrown in other places

09

Section F. HAND WASHING PRACTICE

Ask with adult women of the household
F1.
Use the following codes for each of the activity (codes to be written in Colunn A & B).
Before
Activity
A
B
Washed hands (prompted)
Material Used (Not to be Prompted)
Yes=1

No=2

NA=99

Water
only = 1

Water
+
soap/d
etergen
t=2

water +
fresh
ash = 3

Water
+
mud/so
il = 04

Other
= 77

Before eating food

Before cooking
Before serving food
Before feeding child
After

F2.

After defecation
After cleaning child's
stools
After disposing child's
stools
After handling cattle dung
Why do you think one
should wash hands?

It kills all germs an disease causing

microbes (Yes-1/No-2)
It cleans the dirt from the skin

(Yes-1/No-2)
(Multiple Coding Possible)

It removes odour (Yes-1/No-2)

It removes irritation caused by dirt

(Yes-1/No-2)
It softens the skin (Yes-1/No-2)
Others (Specify)
F3.

Do you think one can avoid

diseases by washing hands
with soap?

F4.

Ask in the household

where there are kids who
go to school
Do you know if your child
washes his hand before
eating meal at school?
In your knowledge, what
all diseases are caused due
to unhygienic living
condition?

F5.

Yes- 1
No -2
Dont Know -9

Yes- 1
No -2
Dont Know -9
Diarrhoea (Yes-1/No-2)
Loose motions (Yes-1/No-2)

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Blood in motion (Yes-1/No-2)

(Multiple Coding Possible)
Typhoid (Yes-1/No-2)
Hepatitis A/E (Yes-1/No-2)
Malaria (Yes-1/No-2)
Observation
F6.

Can you show me hand washing place most used

in your house?

Yes Shown=1
Not Shown=2

F7.

What is the provision of the water in the

washing area?
(Observe and Record)

Functional Tap/Hand pump=1

Single Coding Only

Others (Specify)

What is the provision for hand washing

material?

Soap (Yes-1/No-2)
Ash (Yes-1/No-2)

F8.

Storage Tank/ Container=2

Soil/Mud (Yes-1/No-2)

(Observe and Record)

Detergent / Shampoo (Yes-

1/No-2)

Multiple coding possible

No hand washing material

(Yes-1/No-2)
Others (Specify)
F9.

Do you trim the nails regularly?

(Yes-1/No-2)

F10.

Do you take bath regularly?

(Yes-1/No-2)

F11.

Do you comb your hair regularly?

(Yes-1/No-2)

F12.

Do you wash your cloths regularly?

(Yes-1/No-2)

F13.

(Yes-1/No-2)

F14.

Do you brush your teeth and clean your tongue

regularly?
Where do you dump your solid waste?

F15.

Where liquid waste of your household drained?

(Connected to main drain=1,

(Dustbin=1, Throw outside=2)

Soak pit=2, Kitchen Garden=3)

F16.

Do you wash your vegetables before cooking?

(Yes-1/No-2)

F17.

Do you wash your vegetables before cutting?

(Yes-1/No-2)

F18.

Do you keep the cooked food well covered?

(Yes-1/No-2)

F19.

Do you keep the cooked food safely in a rack or

raised platform which is not reachable by
children or animals?
Section G: Diarrhea Management

(Yes-1/No-2)

Ask G1- G5 only if there is a child of less than 5 years in the Household
G 1.

What according to you are

the main causes of child
diarrhoea?

Contaminated Water

01

Poor diet of food/Improper Diet

02

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G 2.

What according to you are

the critical
signs/Symptoms of child
diarrhoea?

Food Poisoning/ intolerance

Other specify ______________________

03

Child becomes sicker

01

Vomiting

02

Child not able to drink/ breast-feed properly

03

Child extremely thirsty

04

Loose and Watery stools

05

Blood in childs stool

06

Child has fever

07

Restlessness/irritable behavior

08

Sunken eyes

09

Child not eating normally

10

Others Specify _________________________

SECTION I: INFORMATION, EDUCATION & COMMUNICATION

I1.

I2.

I3.

I4.

Are there Health, Hygiene and

Sanitation related messages
displayed/conveyed in village/ slum?
Have any campaigns or projects been
conducted by any organization respect
to Hygiene & Sanitation in last one
year?
Type of campaign

According to you which are the most

effective way for communicating
hygiene and sanitation practices?

Yes

No

Yes

No

Street play/Skit
Rally
Cultural programs
One-on-one counseling
Films/Videos
Audio/Baithak sessions
Discussion groups
Others (Specify)
__________________________
Street play/Skit
Rally
Cultural programs
One-on-one counseling
Films/Videos
Audio/Baithak sessions
Discussion groups
Others (Specify)
__________________________

01
02
03
04
05
06
07

01
02
03
04
05
06
07

SECTION J: COMMUNITY INVOLVEMENT

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O1. Is there any community participation forum

for water and sanitation in village/ slum?

O2. What is the forum called?

Multiple coding possible
Read out options

O3. Are you member of any of this forum?

O4. How regularly does the forum meet?

O5. What are the issues normally discussed in

these meetings?
(Multiple coding possible
Do not prompt)

O6. What are the activities in which this forum

is actively involved in?

Yes

No

Village education committee

(VEC)
Womens Self Help Group
Mahila Mandal
Village Health Committee(VHC)
Village Health and Sanitation
Committee (VHSC)
Village water and Sanitation
committee (VWSC)
Others (Specify)
__________________________
Yes

1
2
3
4
5
6

No

Monthly
Bi-monthly
Six monthly
Whenever Required
Dont Know
Funds/financials
Mid day meal
Hygiene & sanitation facilities
Water supply
Hand washing
Others (Specify)
________________________

1
2
3
4
9
01
02
03
04
05

Installation of water supply

facilities
Cleaning of water supply facility
O&M of water supply
installations
Installation of sanitation
facilities
Cleaning of sanitation facilities
O&M of sanitation facilities
Construction of installations
Community support
Supplies for improved hygiene
and sanitation

01
02
03
04
05
06
07
08
09

Name of the Surveyor:

Signature of the Surveyor:

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