Community Questionnaire
Instructions: This questionnaire must be administered to the village elder, or the person in the village who is best
able to respond, preferably the administrative coordinator of the cell or the executive secretary, and who is
capable of delivering the information requested.
Identification
Province _____________
District ______________
Sector ______________
Village ______________
Respondent Name ___________________________________
Respondent Title _____________________________________
Date of Interview _______ month ______________ year
Comments on Specific Questions:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Additional Comments:
_________________________________________________________________________________________________
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Page 1
Community Information
NUM Questions Response Codes Skip To
1 How many health centers are located in this village?
___________ number >>Q.3
None………….. 98
Don’t Know…. -99
2 How far away from this village is the nearest health center?
________________KM
Don’t know………… -99
3 How many primary schools are located in this village?
___________ number >> Q.5
None………….. 98
Don’t Know…. -99
4 How far away from this village is the nearest primary school?
________________KM
Don’t know………… -99
5 Is there a major market in this village? YES .......................................................................
1 >>Q.7
2
NO .........................................................................
(To sell/buy agriculture, clothing, meats, etc)
Don’t Know ............................................................
-99
6 How far away from this village is the nearest major market?
________________KM
Don’t know………… -99
7 What are the primary sources of transportation in this village? Walking……………………………………… 1
……….. 2
Bicycle……………………………………… 3
…………
4
Car……………………………………………
………… 5
Taxi – 6
Motorcycle………………………………… 96
….
Taxi –
Car……………………………………………
…
Bus…………………………………………
……………
Other
(Specify)……………………………………
…..
8 Is there a bus service to the capital (____________)? 1
YES .......................................................................
2
NO .........................................................................
Don’t Know ............................................................
-99
9 On a typical weekday, how many buses or minibuses stop in this
village? _________________number
None …………………98
Don’t know…………. -99
10 How difficult is it to travel to and from this village? 1
Very Difficult ..........................................................
2
Difficult ..................................................................
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Community Information
NUM Questions Response Codes Skip To
3
A little Difficult .........................................................
4
Easy ......................................................................
5
Very Easy ..............................................................
11 What percentage of village households use electricity from the
following sources: Power
grid/authority………………____________
_
Public generator…………………
_____________
Private
generator…………………_____________
Don’t have
electricity………………______________
12 What is the main source of drinking water for most households in this Private 1
village? Tap………………………………………… 2
…. 3
Public 4
Tap………………………………………… 5
….. 6
Non-protected 96
Well…………………………………….
Protected
Well………………………………………….
Spring, lake or river
water……………………………..
Rain
water…………………………………………
…….
Other…………………………………………
…………..
13 What percentage of households has access to centralized treating
system for drinking water? _____________%
14 Is there a water committee in this village? 1
YES .......................................................................
2
NO .........................................................................
Don’t Know ............................................................
-99
15 What is the main sanitation facility used by households in this village? Flush/pour flush:
to piped sewer system ............................................. …………………..
1
“What % of HHs use each of the following as to septic tank ........................................................... …………………..
2
their primary sanitation facility” to pit latrine .............................................................. …………………..
3
to elsewhere ............................................................ …………………..
4
to don’t know where ................................................. ………………….
5
Ventilated improved pit latrine (VIP) .............................. …………………..
6
Pit latrine with slab ........................................................ …………………..
7
Composting toilet .......................................................... …………………..
8
Pit latrine without slab/open pit ..................................... …………………..
9
Bucket ......................................................................... …………………..
10
Hanging toilet / hanging latrine...................................... …………………..
11
No facilities or bush or field ........................................... …………………..
12
96
OTHER (Specify) ____________________________
16 Is this main sanitation facility or area: Private (Household 1
Ownership)……………………… 2
Public (Community 3
Ownership).………………………
96
Outside
Community/Village…………………………
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Community Information
NUM Questions Response Codes Skip To
…
Other
(Specify)……………………………………
…….
17 In general, how clean do you think this village is compared to other 1
Very Clean .............................................................
villages in the area? 2
Clean .....................................................................
(In regards to trash, animals, sanitation) 3
A little clean/dirty ....................................................
4
Dirty .......................................................................
5
Very Dirty ...............................................................
18 In general, do you think that people in this village are poorer, wealthier 1
Much Wealthier.......................................................
or about the same as other villages in the region? 2
Wealthier ...............................................................
3
The Same ...............................................................
4
Poorer ...................................................................
5
Much Poorer ..........................................................
19 Do you think people in the village are poorer, wealthier or the same as 1
Much Wealthier.......................................................
they were 5 years ago? 2
Wealthier ...............................................................
3
The Same ...............................................................
4
Poorer ...................................................................
5
Much Poorer ..........................................................
20 In the last 5 years, have there been any natural disasters or other 1
YES .......................................................................
important events that have affected the households in this village? 2
NO .........................................................................
>>Q22
Don’t Know ............................................................
-99
21 What were the most important events or disasters, and when did they EVENT CODE YEAR (YYYY)
occur?
Event Code
1 Drought/lack of water
2 Flood
3 Hail storm
4 Frost
5 Rainstorm/Hurricane
6 Insects
7 Rodents
8 Animals eating crops
9 Fire
10 Violence
96 Other (specify)
22 During the past 5 years, has this village received any of the following Yes …. 1 >> Number of
types of assistance/programs: NUMBER YEAR Programs
No……. 2>> (If multiple rounds, (in Most
next program Year of most recent recent
round) Round )
A Health Care (Improvements or Access to)
B De-worming
C Nutrition
D Prenatal Care
E Housing Upgrades/Improvements
F Water Supply System
G Water Treatment
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Community Information
NUM Questions Response Codes Skip To
H Sanitation (Supply Side – Building Latrines, Providing Materials, etc)
I Sanitation (Demand Side – Education)
J Hygiene
K Credit/Financing
Page 5
SN 23 24 25 26 27
Please list all the names and codes for programs Did the program provide: When did the program When did the program end? How frequently was program
from Q.22: start? /assistance distributed?
CODES Yes……1 Continuing 9888 1 Every month
Health Care………………....1 No…….2 Don’t Know -99 2 Every 3 months
Nutrition…………………......2 Don’t Know -99 3 Every 6 months
Prenatal Care………………3 4 Every 12 months
Housing Upgrades………....4 5 One time only
Water Supply System….......5
Water Treatment……………6 MM/YYYY 96 Other
Sanitation (Supply Side)……7 MM/YYYY 98 Don’t Know
Sanitation (Demand Side)….8
Hygiene………………………9
Credit/Financing…………….10
Program Name CODE Financing Materials Labor Training Month Year Month Year
1 1 2 3 4 5 96 98
2 1 2 3 4 5 96 98
3 1 2 3 4 5 96 98
4 1 2 3 4 5 96 98
5 1 2 3 4 5 96 98
6 1 2 3 4 5 96 98
7 1 2 3 4 5 96 98
8 1 2 3 4 5 96 98
9 1 2 3 4 5 96 98
10 1 2 3 4 5 96 98
11 1 2 3 4 5 96 98
12 1 2 3 4 5 96 98
13 1 2 3 4 5 96 98
14 1 2 3 4 5 96 98
15 1 2 3 4 5 96 98
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