HOUSEHOLD WATER USE AND

HEALTH SURVEY

HH.ID
Survey date
Survey Day
Location
Interviewer

A. Household Characteristics.

1. Age of respondent (years).

2. Gender of respondent. Male Female
3. How many people including you live in this home?
4. What is the highest level of the education
completed by the female head of this home?
None Primary Secondary
Collage/University Don't know
N/A
B. WATER USE PRACTICES.
5. Where do you get the water you use at home?
(Include water for all purposes drinking, cooking,
cleaning, garden etc. Record all the answer.)
Household tap Rain water
collection
Private tap River/ Stream
Public pipe Spring
Neighbours tap Other(specify)

6. Does your tap provide water 24 hours a day?

7. If no how many hours a day on average is without
water? Hours
8. Are there times when the water pressure is low?
Yes No
9. Have there been periods in the past years with no
tap water service for several days at a time?
Yes No
10. If yes then where do you get your water?
Water stored in tank Purchased
bottle water water stored in drum
Received water from tankers Rain water
other (specify)
11. Do you consider your water shortages to be a
problem.........? Big problem No
problem some problem only
12. Do you have a water storage tank? Yes
 No
13. If yes what type of tank is this?
Elevated
Ground level Underground
14. How many litres of water do you consume
daily?
15. How much do you pay per month for water per
month?
16. How much do you pay for extra water you
used?

C. HEALTH SURVEY

17. Do you think that the water from your tap is

safe to drink? Yes No
18. Do you treat your drinking water at home?
Yes No
19. If yes how do you normally treat it?
Boiling Filtration Add
chlorine Solar disinfection other
20. Do you normally keep drinking water in a
drinking water container? Yes No
21. In what sort of container do you store your
drinking water? Closed container
open container other (specify)
Interviewer Respondent

PREPARED BY: Rohit.K.Pahadi