Questionnaire Code: ________

WATER, SANITATION AND HYGIENE ASSESSMENT CLINIC

District Ward Name & Number Name (Optional): Grid reference / GPS code Altitude (in m) Number (Compulsory):

Clinic Name

S:

E:

Name of Enumerator(s)

Name of Respondent(s)

Designation of Respondent(s)

Date (dd/mm/yy)

Organisation conducting assessment

SECTION A. CLINIC PROFILE

Collect data by interview Q1 (a) Number of beds: (b) Number of rooms: This does not include bathrooms/latrines

Q2

Number of villages/households served by the clinic (a) Villages: (b) Households: The number of people can be divided by 5 to give the number of households Number of health staff (a) Male: (b) Female: (a) Nurse in charge: 1 = Yes, 2 = No

Q3

Q4

Is there a nurse in charge and if so, please state type of nurse and what sex (please circle response)

(b) Type: 1 = SRN, 2 = SCN (c) Sex of nurse: 1 = Male, 2 = Female

Q5

Average number of patients per month (a) Male: Under 5s 5-14 Over 14

(b) Female

Under 5s 5-14 Over 14

Q6

(a) If there has been a change in attendance at the clinic over the last year, please indicate what these changes are? Circle the response 1 = Increase in attendance 2 = Decrease in attendance 3 = No change (Skip to Question 6)

(b) What has caused these changes? Circle the response, more than one response is allowed. Do not answer if no changes were seen. 1 = No medicines available 2 = No qualified personnel 3 = No water 4 = Epidemic occurred 5 = Presence of resources 6 = Other, please specify..

SECTION A. CLINIC PROFILE

Continued

Questionnaire Code: ________

What water related diseases Give the number of cases for each disease by age group as indicated are common in this area? & comment on trends # cases in each quarter (Please report for the last 4 quarters, and insert the reported year for each quarter) Is this disease Age Jan-Mar Apr-June July-Sept Oct-Dec Disease trend expected? (yrs) 20__ 20__ 20__ 20__ Explain. M F M F M F M F Diarrhoea a Diarrhoea Diarrhoea 0-4 5-14 15 0-4 5-14 15 0-4 5-14 15 0-4 5-14 15 0-4 5-14 15 0-4 f 5-14 15 Q8 What medical waste disposal facilities are available at this clinic? Circle your answer. (a) Autoway pit: 1 = Yes, 2 = No Is it functional? Comment: (a) Incinerator: 1 = Yes, 2 = No Is it functional? Comment: (a) Rubbish pit: 1 = Yes, 2 = No Is it functional? Comment: (g) Other, specify: 1 = Yes, 2 = No .... Is it functional? Comment: 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No

Q7

Dysentery
b

Dysentery Dysentery
Cholera

Cholera Cholera Bilharzia

Bilharzia Bilharzia Malaria

Malaria Malaria

SECTION B. WATER
GENERAL ASSESSMENT OF WATER FACILITIES

Questionnaire Code: ________

Q9 For each of these type of water facilities, please indicate the number available on the clinic premises, the seasonality, water quality (palatable and clear) and condition of the facility. This table is for water points which are the responsibility (repairs and maintenance) of the clinic. Collect data by observation. For boreholes and wells, please fill in the details for the two main facilities of each type

Number available

Palatable (1 = Yes, 2 = No)

Clear water (1 = Yes, 2 = No)

Seasonalilty (1 = Seasonal, 2 = Perennial)

Condition
(1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4=Not repairable)

a b c d e

Rainwater harvester Well Borehole Piped water Source: Other: .. 1 = Yes, 2 = No

Q10 Do the above facilities provide adequate water? Collect data by interview.

Q11 (a) during the dry season: (a) during the wet season: Q12 If there are no water facilities functional at the clinic or the water facilities are seasonal or the
clinics water supply is inadequate, how does the clinic collect its water? Circle your answer (a) Community borehole (c) Unprotected spring (e) Surface water (river, dam) (g) Other, specify: .... 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No (b) Community well (d) Protected spring (f) Community tap (h) No water 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No 1 = Yes, 2 = No

Number of households using the clinic water point: (Collect data by interview)

Q13 If the clinic water comes from other sources, what is the primary source, average time and
distance (there and back) spent for potable water collection: (a) Source: (b) Time (in min): (c) Distance (in m): What type of containers are available at the clinic for water transport? Circle your answer 1 = No container, 2 = Open container, 3 = Container with lid, 4 = Containers with and without lids, 5 = Other, specify What type of containers are available at the clinic for water storage? Circle your answer 1 = No container, 2 = Open container, 3 = Container with lid, 4 = Containers with and without lids, 5 = Other, specify Additional water needs or issues observed at this clinic (e.g. additional water sources located in proximity of clinic, potential for installation, expansion of rainwater harvesting, water wastage, flooding, sources of contamination, presence of stagnant water, etc.). Collect data through observation and interview.

Q14

Q15

Q16

SECTION C. SANITATION
GENERAL ASSESSMENT OF SANITATION FACILITIES

Questionnaire Code: ________

Q17
For each of these type of sanitation facilities, please indicate the number available on the clinic premises and condition of the facility Collect data by observation Number of squat holes Men Women Staff

Functional
a b c d e Blair (Ventilated) Improved Pit Latrine Pit Latrine Ecological Sanitation Flush Toilet Other, (Specify:

Nonfunctional

Functional

Nonfunctional

Functional

Non-functional

.)

Q18

For sanitation facilities that are available on clinic premises, are there any factors which prevent or reduce the use of these facilities? Circle the answers given do NOT prompt. Collect data by interview. (a) Too far away 1 = Yes (b) Smell 1 = Yes

(c) lack of gender separate facilities

1 = Yes

(d) Not clean

1 = Yes

(e) Doors cannot be closed from the inside 1 = Yes (g) Other, please specify:

(f) Collapsing

1 = Yes

Q19

1 = Yes .. (a) Are there other institutions or surrounding households using these toilets? 1 = Yes 2 = No (b) If yes, please specify .

Q20

Are there any old latrines/pits which are hazardous to people and need filling in or knocking down? 1 = Yes 2 = No

Q21 Additional sanitation needs or issues observed at this clinic (e.g. additional sanitation facilities
located in the proximity of the clinic, etc) collect data through observation and interview

Questionnaire Code: ________

SECTION D. HYGIENE
Collect data by observation for Q22-Q25 Circle your answers

Q22

(a) Are the sanitation facilities clean?

(b) Is the area around the sanitation facilities clean? (c) Is the area around the sanitation facilities maintained? For example is the grass cut? (a) Are hand-washing facilities available in the proximity of the sanitation facilities? (less than 10m away) (b) If present, are the hand washing facilities functioning?

Q23

1 = Very clean 2 = Clean 3 = Dirty 4 = Very dirty 5 = No facilities 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No

1 = Yes 2 = No (c) Comments (Include the type of handwashing facility and any other issues) :

Q24

Is soap available for hand-washing at the clinic? 1 = Yes 2 = No Is the area around the water facilities clean? Circle your answer 1=Very clean, 2=Clean, 3=Dirty, 4=Very dirty, 5=No facilities Additional hygiene related needs or issues observed at this clinic: (Collect data through observation and interview)

Q25 Q26

SECTION E. WATER
TECHNICAL ASSESSMENT OF WATER FACILITIES
For each of these type of water facilities, please answer the following questions concerning the status, the seasonality, water quality and condition of the facility. Circle your answer

Questionnaire Code: ________

Collect data by observation this section is optional depending on the requirements of the assessment Water facility Provide information on component details (condition, quantity, Water Facility component dimensions, material, construction details, age, etc) Status 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable Type 1 = Roof 2 = Rocks 3 = Artificial Clean 1 = Yes 2 = No Run-Off Area 1 = Yes 2 = No Protected from animals Status 1 = Good repair 2 = Needs repair Gutter Status 1 = Good repair 2 = Needs repair Pipe Status 1 = Good repair 2 = Needs repair Rainwater Present 1 = Yes 2 = No Screen harvester Status 1 = Good repair 2 = Needs repair Present 1 = Yes 2 = No Tank Roof Status 1 = Good repair 2 = Needs repair Walls Status 1 = Good repair 2 = Needs repair Slab Status 1 = Good repair 2 = Needs repair Tap Status 1 = Good repair 2 = Needs repair Palatable 1 = Yes 2 = No Water Quality Clear 1 = Yes 2 = No Piped water scheme Source: .. Seasonal: 1=Yes, 2=No Overall Status Main system Storage tank on premises Pipe network on premises Tap on premises Status 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable If not functional, what work is needed? 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable 1 = Functional, 2 = Mal-functional, 3 = Non-functional, 4 = Not repairable
1 = Functional 2 = Mal-functional 3 = Non-functional 4 = Not repairable

Number of strokes to water: Time to fill 20l container: 1=A 2=B 3=C 4 = Windlass 1 = Functional, 2 = Mal-functional, 3 = Non-functional
1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No

Pump
Facility Type: 1 = Borehole 2 = Shallow Well (<15m deep) 3 = Deep Well (>15m deep) Circle the appropriate facility type Slab Apron

Type
Functioning Vandalised

Spillway Waste water disposal Fencing

Clothes washing facilities

Cattle trough Water Quality Facility Type: 1 = Borehole 2 = Shallow Status

Present Cracked Present Cracked Is it wide enough (at least 2m in diameter) Present Cracked Present Status Type Present Status Present Status Present Status Palatable Clear Seasonality
1 = Functional 2 = Mal-functional 3 = Non-functional 4 = Not repairable

1 = Functional, 2 = Mal-functional, 3 = Non-functional

1 = Soak away, 2 = Sump, 3 = Evapotranspiration 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Yes 2 = No 1 = Seasonal 2 = Perennial

Number of strokes to water: Time to fill 20l container: 1=A 2=B 3=C 4 = Windlass 1 = Functional, 2 = Mal-functional, 3 = Non-functional

Pump

Type
Functioning

Questionnaire Code: ________

Vandalised

Slab Apron

Spillway Waste water disposal Fencing

Clothes washing facilities

Well (<15m deep) 3 = Deep Well (>15m deep) Circle the appropriate facility type

Cattle trough Water Quality Status

Present Cracked Present Cracked Is it wide enough (at least 2m in diameter) Present Cracked Present Status Type Present Status Present Status Present Status Palatable Clear Seasonality
1 = Functional 2 = Mal-functional 3 = Non-functional 4 = Not repairable

1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes

2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No

1 = Functional, 2 = Mal-functional, 3 = Non-functional

1 = Soak away, 2 = Sump, 3 = Evapotranspiration 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Yes 2 = No 1 = Seasonal 2 = Perennial

Number of strokes to water: Time to fill 20l container: 1=A 2=B 3=C 4 = Windlass 1 = Functional, 2 = Mal-functional, 3 = Non-functional
1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Yes 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No 2 = No

Pump
Facility Type: 1 = Borehole 2 = Shallow Well (<15m deep) 3 = Deep Well (>15m deep) Circle the appropriate facility type Slab Apron

Type
Functioning Vandalised

Spillway Waste water disposal Fencing

Clothes washing facilities

Cattle trough Water Quality Other (specify )

Present Cracked Present Cracked Is it wide enough (at least 2m in diameter) Present Cracked Present Status Type Present Status Present Status Present Status Palatable Clear Seasonality

1 = Functional, 2 = Mal-functional, 3 = Non-functional

1 = Soak away, 2 = Sump, 3 = Evapotranspiration 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Good repair 2 = Needs repair 1 = Yes 2 = No 1 = Yes 2 = No 1 = Seasonal 2 = Perennial

SECTION F. SANITATION
TECHNICAL ASSESSMENT OF SANITATION FACILITIES For each of the blocks of sanitation facilities, please indicate the condition of the facility and the type of facility Separate sections should be filled in for staff and students
Collect data by observation this section is optional depending on the requirements of the assessment. For the number of squat holes, if only one hole is available for males and females, fill in 0.5 for males and 0.5 for females.

Questionnaire Code: ________

Component
Users Squat holes

Pit

Latrine type: 1 = Blair (Ventilated) Improved Pit Latrine, 2 = Pit Latrine, 3= Ecological Sanitation

Slab Super Structure

Provide information on component details 1 = Staff 2 = Patients Number functional for males: Number non-functional for males: Number functional for females: Number non-functional for females: Depth of the pits (in m)? How full are the pits (%)? What is the lining of the pits made of? 1 = Brick, 2 = Stones, 3= Concrete, 4 = No lining Linings need repair 1 = Yes 2 = No Do the slabs need repair? 1 = Yes 2 = No Are the slabs properly sealed to the collar 1 = Yes 2 = No (top of the pit)? Do the roofs need repair? 1 = Yes 2 = No Do the walls need repair? Are there ventilation pipes? If yes, what are the pipes made of? If yes, were fly screens originally installed? If yes, are the ventilation pipes functional?
Carry out a smoke test

Ventilation Pipe

1 = Yes 1 = Yes 1 = Brick 1 = Yes 1 = Yes 1 = Yes

2 = No 2 = No 2 = PVC 3 = Other 4 = NA 2 = No 3 = NA 2 = No 2 = No 3 = NA 3 = NA

General

If no, were holes left in the slab to install a ventilation pipe? How light are the insides of the latrines? How clean are the latrines? Where are the latrines on the slope in relation to any water points? Are the doors of the latrines facing the prevailing wind? Are the latrines placed so that rain water runs into the squat holes? If yes, has any effective effort been made to stop the runoff? 1 = Staff 2 = Patients Number functional for males: Number functional for females: Depth of the pits (in m)? How full are the pits (%)? What is the lining of the pits made of? Linings need repair Do the slabs need repair? Are the slabs properly sealed to the collar (top of the pit)? Do the roofs need repair? Do the walls need repair? Are there ventilation pipes? If yes, what are the pipes made of? If yes, were fly screens originally installed? If yes, are the ventilation pipes functional?
Carry out a smoke test

1 = Light 2 = Semi-dark 3 = Dark 1 = Very clean, 2 = Clean, 3 = Dirty, 4 = Very dirty 1 = Above 1 = Yes 1 = Yes 1 = Yes 2 = Below 3 = NA 2 = No 2 = No 2 = No

Comments

Latrine type: 1 = Blair (Ventilated) Improved Pit Latrine, 2 = Pit Latrine, 3= Ecological Sanitation

Users Squat holes

Number non-functional for males: Number non-functional for females:

Pit

1 = Brick, 2 = Stones, 3= Concrete, 4 = No lining 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Brick 1 = Yes 1 = Yes 1 = Yes 2 = No 2 = No 2 = No 2 = No 2 = PVC 3 = Other 4 = NA 2 = No 3 = NA 2 = No 2 = No 3 = NA 3 = NA

Slab Super Structure

Ventilation Pipe

General

If no, were holes left in the slab to install a ventilation pipe? How light are the insides of the latrines? How clean are the latrines? Where are the latrines on the slope in relation to any water points? Are the doors of the latrines facing the prevailing wind? Are the latrines placed so that rain water runs into the squat holes?

1 = Light 2 = Semi-dark 3 = Dark 1 = Very clean, 2 = Clean, 3 = Dirty, 4 = Very dirty 1 = Above 1 = Yes 1 = Yes 2 = Below 3 = NA 2 = No 2 = No

Questionnaire Code: ________

If yes, has any effective effort been made to stop the runoff?
Comments Users Squat holes

1 = Yes

2 = No

Pit

Latrine type: 1 = Blair (Ventilated) Improved Pit Latrine, 2 = Pit Latrine, 3= Ecological Sanitation

Slab Super Structure

1 = Staff 2 = Patients Number functional for males: Number functional for females: Depth of the pits (in m)? How full are the pits (%)? What is the lining of the pits made of? Linings need repair Do the slabs need repair? Are the slabs properly sealed to the collar (top of the pit)? Do the roofs need repair? Do the walls need repair? Are there ventilation pipes? If yes, what are the pipes made of? If yes, were fly screens originally installed? If yes, are the ventilation pipes functional?
Carry out a smoke test

Number non-functional for males: Number non-functional for females:

1 = Brick, 2 = Stones, 3= Concrete, 4 = No lining 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 1 = Yes 1 = Yes 1 = Yes 1 = Brick 1 = Yes 1 = Yes 1 = Yes 2 = No 2 = No 2 = No 2 = No 2 = PVC 3 = Other 4 = NA 2 = No 3 = NA 2 = No 2 = No 3 = NA 3 = NA

Ventilation Pipe

General

If no, were holes left in the slab to install a ventilation pipe? How light are the insides of the latrines? How clean are the latrines? Where are the latrines on the slope in relation to any water points? Are the doors of the latrines facing the prevailing wind? Are the latrines placed so that rain water runs into the squat holes? If yes, has any effective effort been made to stop the runoff? 1 = Staff 2 = Patients Number functional for males: Number functional for females: Do the flushing mechanisms work? Are there lids on the cisterns? Do the cisterns fill properly? Do the ball valves float? Are the toilet bowls cracked? Is there a ventilation pipe? Do the walls need repair? Do the roofs need repair? Do the floors need repair? Do the septic tanks need emptying? Are the septic tanks functioning? Are the soakaways functional?

1 = Light 2 = Semi-dark 3 = Dark 1 = Very clean, 2 = Clean, 3 = Dirty, 4 = Very dirty 1 = Above 1 = Yes 1 = Yes 1 = Yes 2 = Below 3 = NA 2 = No 2 = No 2 = No

Comments Users Number of latrines

Toilet component

Flush Toilet
Super Structure Septic Tank Comments

Number non-functional for males: Number non-functional for females: 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No 1 = Yes 2 = No

Other (specify )

Questionnaire Code: ________

10