Interview date: __________

Interview code: __________

Household Data POST-DISTRIBUTION MONITORING FORM

Location of interview: Village/IDP Site:
Governorate: District: Sub-District:
Gender of A.3 Age of Household
☐ Male ☐ Female _____Years ☐ IDP ☐ Host ☐ Returnee
HoH HoH: Description:
If IDP what was the main reason for your ☐ Conflict ☐ Flood ☐ Fire
displacement? ☐ Eviction ☐ Other (Specify) _____________
5> years 5-17 years 18-59 years 60+ years Total
Household Size: M F M F M F M F

☐ Between 1 to 3 ☐ Over 3 months but less

☐ Less than a month
How long has the family been at this location? months than 6
☐ 6 months to a year ☐ Over a year
How many members of your household have the following vulnerabilities?
Pregnant or Lactating women Physical disability Mental disability Chronic illness Others: ________________

Feedback on the Assistance Provided

What did you receive? ☐ Emergency Shelter Kit ☐ NFI Kit ☐ Shelter Repair Kit
What modality did you receive the
☐ In-kind ☐ Cash ☐ Voucher
assistance?
Date of recent distribution (dd/mm/yyyy) __________ Which agency distributed the items/kits? _______________
How Use
Quality
Useful/appropriate (Kept/used;
(1-Very Was the
Quantity was the item? Loaned; Sold
Poor; 2- quantity
B.3 Item provided (accordin Quantity (1–Not Useful at all; (price); Stolen;
Poor; 3- received
g to received 2-Not so useful; 3- Exchanged;
Average; 4- adequate?
agency) Average; 4- Gifted;
Good; 5- (Yes/No)
Useful;5-Very Destroyed;
Very Good)
useful) Lost)

If an Emergency Shelter or Shelter Repair kit was provided:

Did the HH receive technical support from the organization to construct a shelter? ☐ YES ☐ NO
Was the shelter constructed properly? ☐ YES ☐ NO
What other items for shelter construction would you have preferred,
1. ________ 2. ________
which you did not receive or need more?
If an NFI kit was provided:
What other items (NFIs) would you have preferred that you did not
1. ________ 2. ________
receive or need more of?
Alternative Uses of Assistance Provided
If items were Sold or Exchanged then for: (Check all that apply)
☐ Rent ☐ Food ☐ Water ☐ Medical ☐ Education ☐ Clothes ☐ Kat
Other: (not indicated in D.1 above) 1. ________ 2. ________
Accountability to Affected Population
Were you provided information on the date, time, and place of the distribution? ☐ YES ☐ NO
Were you provided information on what items you would receive? ☐ YES ☐ NO
Were you provided information on the selection criteria? ☐ YES ☐ NO

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 Interview date: __________
Interview code: __________

Did someone explain to you how POST-DISTRIBUTION MONITORING FORM ☐ ☐ NO

you could channel feedback or YES
complaints about the
distribution?
Were you consulted on your shelter/NFI needs prior to the ☐ Not at ☐ Very ☐ ☐
☐ Moderately
assistance? all little Somewhat Extensively
To what extent do you think your views influenced the design ☐ Not at ☐ Very ☐ ☐
☐ Moderately
of the assistance? all little Somewhat Extensively
☐ None ☐ Hotline ☐ SMS system ☐ Agency field staff
What feedback mechanism did you
use? ☐ ☐ Suggestion ☐ Community
☐ Other:_____________
Helpdesk Box representative/leader
If you shared feedback or complained, did the organization's response address your concern? ☐ YES ☐ NO
Distribution Process
Was the distribution done within the timeframe indicated by the organization? ☐ YES ☐ NO
☐ No shades ☐ No drinking water ☐ Long
☐ Overcrowding
What challenges did you face during the provided provided distance
distribution? (Except security) ☐ Not treated with
☐ No latrines ☐ Other:______________
dignity by staff
Protection And Safety Risks
☐ Community leader ☐ local authorities
Were you asked to pay for the ☐ YES ☐ F.4 If yes, by WHOM were you
☐ youth leaders ☐ service provider
assistance received? NO asked to pay?
☐ Organization staffs ☐ Other:________
Did you experience or witness any form of violence, extortion, abuse,
or exploitation related to enrolment, registration, or access ☐ NO ☐ YES — If Yes, Explain:
distribution of the support provided?
Were persons with disabilities or other vulnerable populations given
special support during the intervention? (e.g., Special ☐ NO ☐ YES — If Yes, Explain:
communication, access or assistance delivery arrangement)
Distribution Impact
☐ Not at
To what extent has the distribution improved your living conditions? ☐ Very High ☐ High ☐ Moderate ☐ Low
all
Any other comments?

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