Master List of Households on Environmental Health and Sanitation

Quarter/Year: ________________

Barangay: _____________________ Municipality: _______________________ Date ML Conducted/Completed: __________________

Part 1. Access to Basic Safe Water Supply and Use of Safely Managed Drinking-Water Services
To be accomplished during the visit to the HHs Validation/Random Sampling/Testing Status
No. Name of HH Heads SE Status Type of Water Supply Status Located w/in Available Microbiological Validation Physico-Chemical Test Use of safely-managed
(Family Name, First Name) 1-NHTS (Place a √) HH w/ access to premises 24/7 (7) (8) Drinking-Water Services
2-Non-NHTS (3) basic safe water (Place a √) (Place a √) Dates Results Date Results √ - if Col. 5 + 6
Level I Level II Level III Others, specify √ - WS is Level I Validation √ - absence Testing √ - within allowable PNSDW limit + 7 + 8 is √
(point (communal (individual (for doubtful or II or III Done of E. coli Done for priority chemical (e.g. arsenic) X – If Col 5 or 6
source) faucet) connection) sources, X - if WS not Level X - presence X – above the allowable PNSDW limit or 7 or 8 is X
e.g. open dug I,II, III of E. coli for priority chemical (e.g. arsenic)

(1) (2) (a) well, etc.) (4) (5) (6) (9)

10

Total
 Master List of Households on Environmental Health and Sanitation
Quarter/Year: ____________

Barangay: _____________________ Municipality: _____________________ Date ML Conducted/Completed: _____________

Part 2. Status on Sanitation Facilities and Use of Safely Managed Sanitation Services
Type of Sanitary Facility Type of Unsanitary Facility Status Open Type of Safely Managed Sanitation Facility Status on Using
Place a √ mark Place a √ mark Sanitary Defecation (Applies only to a and c) Safely Managed
(10) (11) Facility Place a √ mark Place a √ Sanitation Facility
Pour/flush Pour flush Toilet Ventilated Water- Over Open Pit Without √ - if any of Col 10 if yes and X if not (14) √ - If any of Col 10 is √;
type with connected to Pit (VIP) sealed hung Latrine toilet is checked 14.1 Toilet 14.2 Disposal /Treatment of Excreta/Sewage If Col 14.1 is √ and if
septic tank septic tank AND Latrine toilet w/o latrine Not shared sewage/excreta is safely sewage/excreta is collected, Col 14.2 a or b is √
to sewerage septic disposed in situ transported, treated and
system tank disposed off-site
(a) (b) (c) (a) (b)
(12) (13) (15)