Vulnerable Orphans Project

Home Visit Form

(TO BE ADMINISTERED TO GUARDIANS)
My name is ______________ and I am working with XXX ORGANIZATION. We are
collecting information that will be used to improve our orphan’s child education grant project.
We would like to ask you some general questions. You are free to choose if you want to
participate in this survey or not. Your participation – or your refusal to participate – will not
affect your involvement in this program. If you agree to participate, please answer the questions
openly and sincerely. We will store and process your information securely, and will only share
the information necessary to make the cash transfers, monitor progress and undertake research.
This information will be used to help us better provide services, ensure accountability and make
our programmes in this region better better. Do you accept to participate? [ ] Yes [ ] No
Social worker name: ____________________ Interview Date (dd/mm/yy): ________

General information
Respondent name: ____________________ gender: _____________ Village/IDP camp_______
Contact ________________
Relationship with the child: [ ] Registered Guardian [ ] Other Family Member
What is the status of the house/home? [ ] Host Community [ ] IDP [ ] Returnee

Did you receive the child grant in last month? [ ] Yes [ ] No

How much did you receive? ____________USD

A. CHILD WELFARE AND SCHOOL ATTENDANCE

How many orphan children have been sponsored from your family? ___________________
Child Name
Ref No.
Gender [ ] Male
[ ] Female
Age
Does the child have any disability? [ ] Yes [ ] No
If YES does the child face any stigma from [ ] Yes [ ] No
the community?
If yes Explain
Is [NAME] currently attending school? [ ] Yes [ ] No

If not attending why? _____________________________________

School Name
what type of school? [ ] Public [ ] private [ ] informal
At which level [ ] Pre-primary
[ ] Primary
[ ] Secondary
[ ] Vocational training
Grade
How would you define average school [ ] Every day
attendance of the orphan child? [ ] Half-week
[ ] Very irregular attendance
If irregular, what is the reason?
Has the [ Name] been supplied with school [ ] Yes [ ] No
bag by XXX ORGANIZATION?
What is the condition of the child school bag? [ ] Good condition
[ ] Slightly worn out
[ ] Completely worn out
[ ] Don’t have(got lost/stolen)
Has the [ Name] been supplied with school [ ] Yes [ ] No
KIT by XXX ORGANIZATION?
Does the child have all the required school [ ] Yes, has everything
items i.e. rubbers, rulers, pens, pencils, text or [ ] Yes, partial
exercise books [ ] No
Which school items does the child lack? [ ] Rubber
[ ] Ruler
[ ] Pen
[ ] Pencil
[ ] Exercise book
Why does the child don’t have or lacks these [ ] Family can’t afford
essential school items? [ ] He/she had but they got lost/stolen
[ ] Other specify__________
Does the orphan have school uniform? [ ] Yes [ ] No
What is the condition of his/her school [ ] Good condition
uniform? [ ] Slightly worn out
[ ] Completely worn out
[ ] Don’t have uniform
Does the orphan child wear shoes when [ ] Yes, always wear shoes
attending school? [ ] Yes, sometimes wears shoes
[ ] No, doesn’t wear shoes
If no, why he/she doesn’t wear shoes? [ ] Family can’t Afford
[ ] He/she don’t like wearing
[ ] Other specify__________
Current health status of the child [ ] Healthy
[ ] Unhealthy
If Unhealthy has he/she visited hospital? [ ] Yes
[ ] No
If Yes which health issues? [ ] Severe stress / depression
[ ] Physical illness(Diarrhea, malaria,
respiratory diseases etc)
[ ] Mental illness
[ ] Injury
If NOT visited hospital, why? [ ] illness not serious
[ ] lack of money
[ ] Given him/her herbal medicine
[ ] Other
How many times [NAME] has visited
hospital in the last 30 days(4 weeks)
Does the orphan child wear protective [ ] Yes, Always wear mask
facemask when attending school to reduce [ ] Yes, sometimes wear mask
changes of contracting COVID-19 Virus? [ ] No, don’t wear mask
If no, why he/she doesn’t wear mask? [ ] We can’t afford buying.
[ ] The child might suffocate.
[ ] Fear of contracting the disease from the
mask.
[ ] Other specify_________

Does the child have a ‘proper’ study area at [ ] Yes [ ] No

home?
(a place where there is chair, a table, and
proper lighting)
Which items are available in the child study [ ] Chair
area at home? [ ] Table
[ ] Lighting facility
How is the child’s attitude/behavior due to [ ] Improved
his/her attendance in school? [ ] Remained the same
[ ] Deteriorated
If deteriorated or improved, What are these
changes?
How would you gauge the child’s school [ ] Improved
progress (based on the feedback he/she is [ ] Remained the same
giving you, assessing the exercise books, the [ ] Deteriorated
attitude the child has towards education etc)
If Deteriorated what could be the reason?
Are there any special need(s) for the child? [ ] yes [ ] No
If yes what are these needs
B. CHILD PROTECTION
Which mean(s) did you apply to discipline or [ ] Shouting, yelling or screaming at the child
control children in the home? [ ] Calling child, dumb, lazy or other names
(Don’t read answers) [ ] Canning/slapping him/her
[ ] Counseling him/her
[ ] Do nothing
Does the orphan child join you to work for [ ] Yes
salary when out of school particularly [ ] No
weekends (Child labor)
If yes how regularly? [ ] Every time when not in school
[ ] Sometimes when not in school
How many hours per week did the child
engage in the work?

Has the orphan child reported any sexual [ ] Yes

abuses to you over the past 30 days? [ ] No

If YES, record the details of the incidence as

narrated by the guardians, (When it happened?
where it happened school/home? who did the
action and action taken by the family so far, was
it reported to relevant authorities? To whom was
it reported and what was the outcome?)
If there is an issue of exploitation, or abuse, [ ] Yes [ ] No
do you know where to report?
If yes, where? [ ] Relevant Government Authorities
[ ] Community leaders/Camp leaders
[ ] Religion Leaders
[ ] Teacher
[ ] Other Specify__________
How safe is the route to School for the orphan [ ] Very safe
child? [ ] Somehow unsafe
[ ] Very Unsafe
[ ] don’t know
Do you know your child’s hobbies? [ ] Yes [ ] No
If yes, what are the hobbies?
Has his/her hobbies changed? [ ] Yes [ ] No
If yes, what are the changes and cause?

C.FAMILY WELL BEING

Has your family been able to cater for the [ ] Yes, Fully able
family basic household needs(food, water, [ ] Yes, Partially able
health, education etc.) in the past 30 days(one [ ] No
month)
What is the average number of meals per day Adults_____________
your family has been taking for the last 7 days
Children____________
Has your family been able to take the variety [ ] Yes, fully able to take variety of food
of food you needed in the past 30 day? [ ] Yes, Partially able to take variety of food
[ ] No, was not able to take variety of food
Did your household incur any unexpected [ ] Yes [ ] No
household expenses, such as a house repair or
urgent medical treatment, in the last 30 days
(one month)?
If yes, how much did you incur?

Was your household able to pay for these [ ] Yes, Completely was able
expenses? [ ] Yes, Somewhat was able
[ ] No, was unable
How would you describe your household’s [ ] We have no productive assets
productive assets? (Read options). [ ] We have few productive assets
(Productive assets are the resources used [ ] We have a lot of productive assets
to generate income, like livestock, land
for agriculture, tools, or equipment for a
business).
What new thing have you done (including
business) as a result of the grant?
(Exclude ability to buy food, water, health
and education)

D. COMMENTS
Do you have any recommendation about how
the orphan education assistance provided by
XXX ORGANIZATION could work better?
Social worker comments/feedback

E. TAKE GPS CORDINATES________________________