Questionnaire on Effectiveness and outcome of CLTS

uaLe ___/___/___
lnLervlewer name
vlllage
Pouse hold number (opLlonal)

1 Pow many are Lhe number of Lhe household?
2 Pow many are under flve
3 uoes Lhls household own lLs own laLrlne?
?es
no
4 lf yes when was lL bullL?
8efore 2007
AfLer 2007
uon'L remember
3 lf yes whaL klnd
A
llush/pour
flush Lo
lped sewer sysLem
SepLlc Lank
8 lL laLrlne
venLllaLed lmproved plL
laLrlne (vl)

lL laLrlne wlLh slab
lL laLrlne wlLhouL slab
C CLher (speclfy)
6 uo you share Lhls faclllLy wlLh oLher households?
?es
no
7 lf yes Pow many? (lnserL uk lf Lhey don'L know)
8
Where do members of Lhe household go Lo
defecaLe?
a 1o Lhelr own/shared laLrlne
b 1o publlc laLrlne
c 1o Lhe bush/fleld
9 uoes Lhe laLrlne of Lhe household possess hand washlng faclllLy?
yes
no
10 lf Lhe answer for number 7 ls yes Where?
lnslde Lhe LolleL
CuLslde Lhe LolleL
11 When do you wash your hands
a AfLer uslng Lhe LolleL
b 8efore preparlng food
c AfLer cleanlng chlld's boLLom
d 8efore breasLfeedlng
e 8efore and afLer eaLlng
f ln Lhe mornlng
g uon'L know
12
WhaL ls Lhe maln source of drlnklngwaLer
for members of your household?
a lped waLer lnLo dwelllng
b lped waLer Lo yard/ploL
c ubllc Lap/sLandplpe
d 1ube well / borehole
e roLecLed dug well
f unproLecLed dug well
g roLecLed sprlng
h unproLecLed sprlng
l 8aln waLer collecLlon
[ CarL wlLh small Lank/drum
k 1ankerLruck
l
Surface waLer(rlver dam lake
pond sLream)

m
CLher (speclfy)


13
WhaL ls Lhe maln source of waLer used by
your household for oLher purposes such as
cooklng and hand washlng?
a lped waLer lnLo dwelllng
b lped waLer Lo yard/ploL
c ubllc Lap/sLandplpe
d 1ube well / borehole
e roLecLed dug well
f unproLecLed dug well
g roLecLed sprlng
h unproLecLed sprlng
l 8aln waLer collecLlon
[ CarL wlLh small Lank/drum
k 1ankerLruck
l
Surface waLer(rlver dam lake
pond sLream)
CLher (speclfy)



m
CLher (speclfy)


14
Pow long does lL Lake Lo go Lhere geL waLer
and comeback?
number of mlnuLes
WaLer on premlses
uon'L know
13
Who usually goes Lo feLch Lhe waLer for
your household?
a AdulL woman
b AdulL man
c Male/female under 13 years
d don'L know
16
uo you LreaL your waLer ln any way Lo make
lL safer Lo drlnk?
?es
no
uonL know
17
lf Lhe answer for C no 13 ls ?es WhaL do
you usually do Lo Lhe waLer Lo make lL safer
Lo drlnk?
a 8oll
b Add bleach/chlorlne LableL
c SLraln lL Lhrough a cloLh
d use a waLer fllLer (ceramlc sand)
e Solar dlslnfecLlon
f LeL lL sLand and seLLle
g
CLher (speclfy)


18
WlLhln Lhe pasL monLh have any of your household members who
are under 3 been slck of anyLhlng?
?es
no
uk
19 lf yes whaL was lL?
a neumonla
b Cough/cold
c ularrhea
d uysenLery
e Malarla
f lever of unknown orlgln
g Lye dlsease/Lrachoma
h CLher (speclfy)