Community service project

Questionnaire for water facility & Drinking water availability

Name of the Student : Group :

Name of the Mentor : Name of the Village :

Name of the Mandal : Name of the District :

1 Name

2 Age

3 Gender Male ⃣
Female ⃣
4 Type of family Nuclear ⃣
Joint ⃣
5 Number of adult males

6 Number of adult males

7 Number of male Children

8 Number of male Children

9 How many members in the

household are employed?
10 What is your main source of Bore well / Hand pump ⃣
water Public tap ⃣
Community well ⃣
House hold water supply ⃣
Others ⃣
11 How far it is (in meters)

12 Do you Store the Rain water Yes ⃣

No ⃣

Regular water

13 What is the frequency of 24 hour supply ⃣ More than once a day ⃣

normal water Supply Once a day ⃣
Once in 2 days ⃣
Once in 3 days ⃣
Once in a week ⃣
 14 Is this frequency sufficient for Yes ⃣
your needs No ⃣
15 (If No) More than once a Day ⃣
How often would you like to Once a Day ⃣
get water?
Enough ⃣
16 Which months do you face Jan ⃣ Feb ⃣ Mar ⃣ April ⃣ May ⃣ June ⃣ July ⃣
scarcity? Aug ⃣ Sep ⃣ Oct ⃣ Nov ⃣ Dec ⃣
17 Generally, how does water Foul Smell ⃣
smells No Smell ⃣
18 Generally, how does waters Clear ⃣
looks likes? Dirty ⃣

Drinking Water Questions

19 What is the frequency of 24 hour supply ⃣
normal water Supply More than once a day ⃣
Once a day ⃣
Once in 2 days ⃣
Once in 3 days ⃣
Once in a week ⃣
20 Is this frequency sufficient for Yes ⃣
your needs No ⃣
21 (If yes) More than once a day ⃣
How often would you like to Once a day ⃣
get water
22 Generally, how does water Foul Smell ⃣
smell? No Smell ⃣
23 Generally, does the water have Yes ⃣
a taste? No(tasteless) ⃣
24 Generally, what does the water Clear ⃣
look like? Dirty ⃣
25 Do you pay for water? Yes ⃣
No ⃣
26 (If yes)
How much do you pay for a
month?
27 (if yes) Yes ⃣
How much do you pay for a No ⃣
month?
28 (If yes)
To whom did you complaint?
29 What was the result of the Prompt action taken ⃣
compliant? Delayed action taken ⃣
No action taken ⃣