Promoting Resilience of Vulnerable through Access to Infrastructure, Improved Skills and

Information (PROVATi3), LGED

Baseline Survey Form for School cum Flood Shelter

Name of the School ………………………...............................................................................

Location: Village………………………………………….Union………………………………………Upazila………………………
District……………………………………………...

Name of the data collector……………………………………………………………………….Date …………………………………

1. Year of Establishment of the school………………………….………………………….…………………………………

2. Total School boundary ( including the ground belong to school) ………………………………Decimal

(Attached Sketch map for school area)
3. Structure of the School:

Construction type Number of houses Remarks

Pucca
Semi-Pucca
Irion sheet side
structure and roof
Others

4. School building Facilities

Facilities Number Area

( m2)
Floor area coverage N/A
Number of floor
Number of class rooms
Teacher room
Store room
Available/Not available
Toilet ( disaggregated by gender) N/A
Tube-well/ water facility N/A
Electricity/power

5. Information regarding flood affected H.H: (Within 2km for proposed flood shelter)

Name No. of Total Distance from Connectivity No. of Distance

of H.H Population in proposed Earthen/HBB/BC Cattle from
Village the village flood shelter nearby
river
6. Nearby River Information:

Name of Distance From HFL in 2019 Flood Water Any Embankment

River Proposed (m) Depth In 2019 Embankment Top level
Flood Shelter Flood on Bank (Y/N) (m)

(Attach map showing proposed position for flood shelter)

7. Has it ever been used as flood shelter, If yes, when and how many people took shelter ( year-
wise of last 10 years)

8. Is the school get affected by yearly flood : Yes/No

9. Education facilities/enrollment

Number of teacher Number of student Attendance Dropout Remarks

rate rate
Male Female Total Male Female Total ( %) ( %)

10. Management:
11.1 Name of the Committee chairperson:

11.2 Number of members (M+F):

11.3 Is regular in arranging meeting and keep resolution, and follow the decisions:

11. Others if any: