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Bls Tool -Form Fill
ADMINISTRATIVE INFORMATION
Q01
MFI name
Q02
Branch id
Q03
Respondent's MFI ID number
Q04
Respondent Unique ID
Q05
Respondent's name
Q06
Gender of the Respondent
MALE
FEMALE
Q07
Address
Q08
PSU Code
Q09
PSU Name
Q10
Block/Mandal Name
Q11
District Code
Q12
District Name
Angul
Boudh
Balangir
Bargarh
Balasore
Bhadrak
Cuttack
Debagarh
Dhenkanal
Ganjam
Gajapati
Jharsuguda
Jajpur
Jagatsinghpur
Khordha
Kendujhar
Kalahandi
Kandhamal
Koraput
Kendrapara
Malkangiri
Mayurbhanj
Nabarangpur
Nuapada
Nayagarh
Puri
Rayagada
Sambalpur
Subarnapur
Sundergarh
Anantpur
Chittoor
East Godavari
Guntur
Kadapa
Krishna
Kurnool
Nellore
Prakasam
Srikakulam
Visakhapatnam
Vizianagram
West Godavari
Q13
State Code
Q14
State Name
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisagarh
Dadra and Nagar Haveli
Daman and Diu
NCR Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
Q15
As part of this study we would like to have your mobile number. Would you provide your consent to share the same ?
Yes
No
Q16
Mobile number
Q17
Geography Type
Urban
Rural
Semi Urban
Tribal
Q18
Interviewer Name
Q19
Interviewer Code
Q20
Supervisor Name
Q21
Supervisor Code
Q22
Date of the interview
Q23
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
REFUSED
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
Q24
TIME STARTED
Q25
TIME FINISHED
INTRODUCTION AND INFORMED CONSENT
A01A
GPS LONGITUDE
A01B
GPS LATITUDE
A02
Before we start, do you have any questions about the study?
Yes
No
A03
Are you willing to participate in this study?
Yes
No
DEMOGRAPHICS
B01
Name of household member
B02
Relation to Respondent
Respondent
Spouse
Daughter
Son
Respondent’s mother
Mother in law
Respondent’s father
Father in law
NIECE/NEPHEW
DAUGHTER IN LAW
BROTHER/SISTER IN LAW
Extended Family
OTHER NON-RELATIVE
B03
Gender
MALE
FEMALE
B04
Age
B05
Marital Status
MARRIED OR LIVING TOGETHER
DIVORCED/SEPARATED
NEVER MARRIED
WIDOWED
B06
Still in school
Yes
No
B07
Education
Never went to school
Class 5 or less
Completed Class 6,7 or 8
Completed Class 9,10,11 or12
Studying in college
Completed college
Doing post Graduation
Completed post graduation
Others
B08
Occupation of each member
Own farming (Agriculture,fisherman, fish farmer, poultry and livestock farmer)
Worker (Casual or day laborer (farming or nonfarming)
transport worker, rickshaw puller, boatman, mason, carpenters, etc.)
Salaried
Housewife
Student
Entrepreneur (Self employed, small shop owners, contractors/suppliers)
No occupation
Others
B09
Can read newspaper?
Yes
No
B10
Head of the household?
Yes
No
B11
What is your religion?
HINDU
MUSLIM
CHRISTIAN
SIKH
BUDDHIST/NEO-BUDDHIST
JAIN
JEWISH
PARSI/ZOROASTRIAN
NO RELIGION
OTHER (SPECIFY)
B12
Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CASTE
GENERAL
OTHER (SPECIFY)
B13
Does your family have a below poverty line (BPL) card?
YES, CARD SEEN
YES, CARD NOT SEEN
NO
Don't know
B14
Do you own or rent the house/ land/property that you are living in?
Own(including familyowned)
Rent
B15
Who is the legal owner of the land/property that you are living in?
Self
Husband
Wife
Husband and wife (Jointly)
Son/Daughter
Parent
Inlaws
Other (please specify)
B16
Observe and code: Floor material of respondent’s house
Bricks
Cement/Floor tiles/marble stones
Wood/Bamboo
Soil/mud/cow dung
Other (please specify)
B17
Observe and code :Wall material of respondent’s house
Concrete cement
Metal/Asbestos sheet/burnt brick
Stones
Grass/thatch/bamboo/plastic/polythene/mud
Other (please specify)
B18
Observe and code :Roof material of respondent’s house
Grass/ Thatch/ Bamboo/ Wood/Mud/plastic/polythene
Stones
Metal/Asbestos sheet/burnt brick/tiles
Cement/RBC/RCC
Other (please specify)
B19
Do you own any livestock?
Yes
No
B20
If Do you own any livestock?
B20_1
Goat
Yes
No
B20_2
Cow
Yes
No
B20_3
Buffalo
Yes
No
B20_4
Sheep
Yes
No
B20_5
Pig
Yes
No
B20_6
Duck/Chicken
Yes
No
B20_7
Bull/Ox
Yes
No
B20_8
Others
Yes
No
B20A
how many?
B20A_1
Goat
B20A_2
Cow
B20A_3
Buffalo
B20A_4
Sheep
B20A_5
Pig
B20A_6
Duck/Chicken
B20A_7
Bull/Ox
B20A_8
Others
B21
Do you own or rent agricultural land?
Yes
No
B22
If Do you own or rent agricultural land?
own
rented
B23
How much agricultural land you own or rent?
B23A
Units
Acre
Hectare
Bigha
Biswa
Decimal
Guntha
WATER
C01
How many water source/points do you use for your house?
C02
What is the water source type that you use most?
PIPED INTO DWELLING
PIPED TO YARD/PLOT
PUBLIC TAP/STANDPIPE
PUBLIC TUBE WELL/BOREHOLE
PROTECTED WELL
UNPROTECTED WELL
PROTECTED SPRING
UNPROTECTED SPRING
RAINWATER
TANKER TRUCK
CART WITH SMALL TANK
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL)
BOTTLED WATER
GOVERNMENT HAND PUMP
HAND PUMP AT HOME
NEIGHBOUR’S HAND PUMP
TUBE WELL/BOREHOLE AT HOME
NEIGHBOUR’S TUBE WELL/BOREHOLE
OTHER (SPECIFY)
C03
Is the water always available from this source
Yes
No
C04
Who provides this water source?
Client’s own source
Neighbor
Government/local government
NonGovernment Organization (NGO)
Religious/educational Group/Institutions
Other (please specify)
Don't know
C05
Do you share this water source with people outside your household?
Yes
No
C06
Do you know how many households/people outside your household that you share the water source with?
Yes
No
C07
With how many households/people do you share the water facility outside your family?
C08
Who is the primary water collector?
C09
Does this member collects water
Yes
No
C10
How much time does it take to walk to your primary water source?
C11
Once at water point, on average how much time do you wait to get water?
C12
How much time does it take to walk back from your primary water point to your home?
C13
Does your household collect water everyday from the primary water source?
Yes
No
C14
How many trips per week does your household make to collect water from primary water source?
C15
In a day, how many liters of water do you need for basic household needs?
C16
Do you have enough water to meet all of your household daily needs ?
Yes
No
C17
Do you use water to generate income?
Yes
No
C18
For what kind of activities you use water to generate income?
Selling water
Irrigation to farm
Selling service that uses water
Selling product which requires water
Other (please specify)
C19
Do you have sufficient water to fulfill your activity needs that use water to generate income?
Yes
No
C20
Do you store water inside your house ?
Yes
No
C21
How do you mainly store water inside your house?
Open container
Closed container or container with cover
Water storage tank (open or uncovered)
Water storage tank (closed or covered)
Other (please specify)
C22
During rainy season, how often can you collect/access water?
Do not collect
Frequently every day (More than 3 times)
Few times a day (2-3 times)
Once a day
Few times a week
Once a week
Once every 2 weeks
Other (please specify)
Don’t know
C23
During dry season, how often can you collect/access water?
Do not collect
Frequently every day (More than 3 times)
Few times a day (2-3 times)
Once a day
Few times a week
Once a week
Once every 2 weeks
Other (please specify)
Don’t know
C24
What are the reasons that water from the source used by your household is not always available?
Local regulation
Turned off/access denied (by the owner of water source)
Water scarcity
Broken pump
Unable to pay
Corruption
Other (please specify)
Don’t know
C25
How do you rate the personal safety of your male household members during the process of water collection?
Not safe at all
Not very safe
Neither safe nor unsafe
Safe
Very safe
C26
How do you rate the personal safety of your female household members during the process of water collection?
Not safe at all
Not very safe
Neither safe nor unsafe
Safe
Very safe
C27
Do you feel the water from your current water source is safe to drink?
Not safe at all
Not very safe
Neither safe nor unsafe
Safe
Very safe
C28
What makes you feel the water is unsafe?
Dirty/muddy water
Iron
Makes family sick
Polluted/contamindated
Salty
Poisoned/contain arsenic
Bad smell
Unclean collection point
Other (please specify)
Don’t know
C29
Is water that your household uses from primary source treated prior to your collection i.e. is it treated at source?
Yes
No
C30
Does your household do any treatment of water prior to drinking?
Yes
No
C31
What type of treatment does your household do?
C31_1
Boiling
Yes
No
C31_2
Add bleach/chlorine
Yes
No
C31_3
With water purifier
Yes
No
C31_4
Strain through cloth
Yes
No
C31_5
Solar disinfection
Yes
No
C31_6
Let it stand and settle
Yes
No
C31_7
Others (please specify in the Comments...
Yes
No
C32
Does your household do any type of treatment of water prior to using (for nondrinking purpose)?
Yes
No
C33
When do you do this treatment?
C33_1
Boiling
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_2
Add bleach/chlorine
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_3
With water purifier
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_4
Strain through cloth
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_5
Solar disinfection
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_6
Let it stand and settle
Always
When family member is sick
When water looks or smells bad
When told by local authority
C33_7
Others (please specify in the Comments...
Always
When family member is sick
When water looks or smells bad
When told by local authority
C34
Do you or your family pay any water tax/tariff/bill?
Yes
No
C35
How often do you pay?
Every day
Every week
Every two week
Every month
Every three months
Every six months
Yearly
Other (please specify)
Don't know
C36
How much do you pay on average per payment
C37
Is your water tax/tariff based on meter reading or flat/standard rate?
Meter reading (depends on usage)
Fixed rate /Flat/standard rate
Don't know
C38
Other than your main water source, does your household ever use a secondary water source?
Yes
No
C39
Why do you use a secondary water source?
Scarcity of water
Long queu
Broken
Doubt water quality of primary source
Primary source too expensive
Other (please specify)
C40
Which is the secondary water source you use other than the primary water source?
PIPED INTO DWELLING
PIPED TO YARD/PLOT
PUBLIC TAP/STANDPIPE
PUBLIC TUBE WELL/BOREHOLE
PROTECTED WELL
UNPROTECTED WELL
PROTECTED SPRING
UNPROTECTED SPRING
RAINWATER
TANKER TRUCK
CART WITH SMALL TANK
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL)
BOTTLED WATER
GOVERNMENT HAND PUMP
HAND PUMP AT HOME
NEIGHBOUR’S HAND PUMP
TUBE WELL/BOREHOLE AT HOME
NEIGHBOUR’S TUBE WELL/BOREHOLE
OTHER (SPECIFY)
C41
Do you have to pay for the water from this secondary source ?
Yes
No
C42
How often do you pay?
Every day
Every week
Every two week
Every month
Every three months
Every six months
Yearly
Other (please specify)
C43
How much do you pay on average per payment
C44
Are you satisfied with the quantity of water that you receive from your primary source?
Very unsatisfied
Unsatisfied
Neither satisfied nor unsatisfied
Satisfied
Very satisfied
C45
Are you satisfied with the quality of water that you receive from your primary source?
Very unsatisfied
Unsatisfied
Neither satisfied nor unsatisfied
Satisfied
Very satisfied
C46
What do you like about your water collection processes from your current water source?
Easy to collect
Time for self, or to gather with friends/family
Close distance
Can be access anytime you need
Private to household
Doesn’t have to queue
Appropriate water pressure
The taste of water
Cheap/Less costly
There’s nothing to like
Other (please specify)
Don’t know/Respondent is not primary water collector
C47
What do you feel can be improved/ made better about the process of water collection from your current source?
Easy to collect
Time for self, or to gather with friends/family
Close distance
Can be access anytime you need
Private to household
Doesn’t have to queue
Appropriate water pressure
The taste of water
Cheap/Less costly
There’s nothing to like
Other (please specify)
Don’t know/Respondent is not primary water collector
C48
Are you interested in getting service improvement in your current primary water source ?
Yes
No
C49
Why are you not interested?
Water service already good
Already have own water source
Don’t have money/ Expensive
Not a priority
There’s no water system available around neighborhood
Don’t have own house
Other (please specify)
C50
What kind of improvement would you like?
Household piped water connection
Installing handpump in house
Shallow well with hand pump
Installing open well
Installing deep motored borehole
Water purifier/filter
Water and toilet together
Rain water harvesting
Other (please specify)
C51
If you want an improvemnet in water connection, why haven’t you done it till now ?
Don’t have money/too expensive
Scarcity of water
Not important/not a priority
No access to system
Do not own house
Do not know how to get it
Other (please specify)
SANITATION
D01
Does your household have a toilet?
Yes
No
D02
Where all do you and your household members defecate?
Own Toilet
Neighbours Toilet
Public Toilet
Open defecation
D03
What is the type of sanitation facility that is currently used in your household?
FLUSH TO PIPED SEWER SYSTEM
FLUSH TO SEPTIC TANK
FLUSH TO PIT LATRINE
FLUSH TO SOMEWHERE ELSE
FLUSH, DON'T KNOW WHERE
VENTILATED IMPROVED PIT (VIP)/BIOGAS LATRINE
PIT LATRINE WITH SLAB
PIT LATRINE WITHOUT SLAB/ OPEN PIT
TWIN PIT/COMPOSTING TOILET
DRY TOILET
OTHER (SPECIFY)
D04
Does member of any other household also generally uses your household toilet ? Do you share a house with others households?
Yes
No
D05
How many people outside your family share your HH toilet on regular basis?
D06
Is there room to install a toilet in the house?
Yes
No
D07
How many people in your household use the sanitation facility/toilet everyday?
D08
On average, how many times do you use the toilet each day for defecation ?
D09
How much time does it take you to walk there?
D10
How much time does it take you to walk back?
D11
Under normal conditions, where do the male HH members generally defecate?
Toilet
Open defecation
No Children in the HH below 5 years of age
Other (please specify)
D12
Under normal conditions, where do the female HH members generally defecate?
Toilet
Open defecation
No Children in the HH below 5 years of age
Other (please specify)
D13
Under normal conditions, where do children of the HH defecate ?
Toilet
Open defecation
No Children in the HH below 5 years of age
Other (please specify)
D14
How satisfied are you with the sanitation system (toilet, pit latrine, etc) that you currently use?
Very unsatisfied
Unsatisfied
Neither satisfied nor unsatisfied
Satisfied
Very satisfied
D15
What do you like about thesanitation system you use?
Close to house
Private owned
Cleanliness
Inside the house
Saves Time to spend with friends/family
No queue
Fresh air
Nothing to like about
Other (please specify)
D16
How do you rate the sanitation facilities that you currently use on the following aspects?
D16_1
Cleanliness
Very poor
Poor
Neutral
Good
Very good
D16_2
Functioning
Very poor
Poor
Neutral
Good
Very good
D16_3
Privacy
Very poor
Poor
Neutral
Good
Very good
D16_4
Safety
Very poor
Poor
Neutral
Good
Very good
D17
Are you interested in improving the current condition of your sanitation system?
Yes
No
D18
What would you like to improve?
Close to house
Safety
Always functioning
Cleanliness
Private owned
No queue
Bigger or more toilet
Other (please specify)
D19
Why haven’t you done it?
Do not have money/expensive
Scarcity of water
Not important
No access to water connection
Doesn’t have a house
Was Not in my priority
No space to install toilet
Doesn’t know how
Other (please specify)
D20
Why aren’t you interested in improving your current sanitation facility?
Already have it
Not a priority
Don't have money yet
No water connection in the neighborhood
Do not have own house
Other (please specify)
HEALTH AND CLEANLINESS
E01
When your household member is ill, usually where does your family get it treated ?
Take to local private practitioner
Take to government primary health care center /civil hospital
Take to traditional doctor
Local medicine shop/pharmacy
Self heal (with common drugs)
Other (please specify)
E02
In the last 3 months, have you or your household member been sick?
Yes
No
E03
What type of sickness she/he has had?
Malaria
Typhoid
Eye infections
Stomach
Fever
Worm infestation
Chikungunya
Dengue
Skin Diseases
Scabies
Other (please specify)
Don't know
E04
Have you or any of your household member above 18 years of age, experienced Diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks
Yes
No
E05
How many adult members of the household i.e. 18 and above experienced diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks?
E06
Has any of your household member between 18 and six years of age experienced Diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks
Yes
No
E07
How many household member between 18 and 6 years of age experienced Diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks?
E08
Has any child (five years or below) of your household experienced Diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks
Yes
No
E09
How many children (five years or below) of your household experienced Diarrhoea (i.e. experienced at least 3 loose watery stools or more in 24 hours) at any point in the last 2 weeks?
E10
In a normal day, do you wash hands?
Yes
No
E11
In a normal day, when do you wash your hands?
After using toilet/defecating
Before feeding children
Before cooking
Before eating
After eating
(children's feces, garbage etc.)
Other (please specify)
E12
How do you mainly wash your hands?
Water and soap
Ash and water
Soil and water
Wipe only on cloth
Only water
Other (please specify)
E13
Where all do you dispose your household garbage?
Dump in own land
Compost
Dump on roadside or field (here and there)
Private or public garbage service or designated space
Burn
Other (please specify)
E14
Please indicate for each of the five statements which is closest to how you have been feeling over the last two weeks.
E14_1
I have felt cheerful and in good spirits
AT NO TIME
SOME OF THE TIME
LESS THAN HALF OF THE TIME
MORE THAN HALF OF THE TIME
MOST OF THE TIME
ALL OF THE TIME
E14_2
I have felt calm and relaxed
AT NO TIME
SOME OF THE TIME
LESS THAN HALF OF THE TIME
MORE THAN HALF OF THE TIME
MOST OF THE TIME
ALL OF THE TIME
E14_3
I have felt active and vigorous
AT NO TIME
SOME OF THE TIME
LESS THAN HALF OF THE TIME
MORE THAN HALF OF THE TIME
MOST OF THE TIME
ALL OF THE TIME
E14_4
I woke up feeling fresh and rested
AT NO TIME
SOME OF THE TIME
LESS THAN HALF OF THE TIME
MORE THAN HALF OF THE TIME
MOST OF THE TIME
ALL OF THE TIME
E14_5
My daily life has been filled with things that interest me
AT NO TIME
SOME OF THE TIME
LESS THAN HALF OF THE TIME
MORE THAN HALF OF THE TIME
MOST OF THE TIME
ALL OF THE TIME
CHILDREN, WATER AND SANITATION
F01
Are there any children in the household who go to school?
Yes
No
F02
In your assessment, how is the water situation in the children's school or schools?
Good
Bad
Neither good nor bad
Don't know
F03
What are your concerns?
Water quality
Access to water
Water quantity
Other (please specify)
F04
Does fetching water interfere with your children going to school?
Yes
No
F05
If yes, who is mostly affected?
Girl
Boy
Both equally
F06
In what ways fetching water interfere with your children going to school ?
Coming late to school
Absent from school
Leaving school/ Dropped out
Other (please specify)
F07
In your assessment, how is the sanitation situation in the children's school or schools?
Good
Bad
Neither good nor bad
Don't know
F08
What are your concerns ?
Poor Quality (safety/cleanliness/hygiene)
Lack of Access (not available/closed frequently)
Privacy
Other (please specify)
F09
Does the school’s sanitation facility prevent your children from going to school?
Yes
No
F10
If yes, who is mostly affected?
Girl
Boy
Both equally
INCOME AND EXPENDITURE
G01
In last one year, did your household’s income vary from monthtomonth?
Yes
No
G02
If yes, why did your household’s income vary from monthtomonth?
Seasonal work
Government program
Daily Wage worker
Other (please specify)
G03
How much is the minimum Income in a month
G04
How much is the maximum Income in a month
G05
How much is the estimated average of your household’s income in a month?
G06
Does your household have any of the following items?
G06_1
A radio or transistor
Yes
No
G06_2
Motorcycle/scooter
Yes
No
G06_3
Refrigerator/fridge
Yes
No
G06_4
An electric fan
Yes
No
G06_5
Television
Yes
No
G06_6
Mobile Phone
Yes
No
G06_7
Bicycle
Yes
No
G06_8
Kerosene lamp
Yes
No
G06_9
Sewing machine
Yes
No
G06_10
Car/jeep
Yes
No
G06_11
Air Conditioner
Yes
No
G06_12
PC/Laptop
Yes
No
G06_13
Pressure cooker
Yes
No
G06_14
Furniture (chair, stool, bench, table)
Yes
No
G06_15
A mattress
Yes
No
G06_16
A cot or bed
Yes
No
G06_17
Washing machine
Yes
No
G06_18
Others (Specify)
Yes
No
G06A
how many ?
G06A_1
A radio or transistor
G06A_2
Motorcycle/scooter
G06A_3
Refrigerator/fridge
G06A_4
An electric fan
G06A_5
Television
G06A_6
Mobile Phone
G06A_7
Bicycle
G06A_8
Kerosene lamp
G06A_9
Sewing machine
G06A_10
Car/jeep
G06A_11
Air Conditioner
G06A_12
PC/Laptop
G06A_13
Pressure cooker
G06A_14
Furniture (chair, stool, bench, table)
G06A_15
A mattress
G06A_16
A cot or bed
G06A_17
Washing machine
G06A_18
Others (Specify)
G07
On average, how much do you spend every month on the following?
G07_1
Repayment of loan
G07_2
Food
G07_3
Clothes
G07_4
Housing (rent, repair, furniture, etc
G07_5
Transport
G07_6
Education (School tuition fee, books, etc.)
G07_7
Health (hospitals, medicines, etc)
G07_8
Water (tariff/tax, buying drinking water) and sanitation
G07_9
Electricity
G07_10
Mobile phone
G07_11
Others (please specify)
G08
Do you have electricity in your house?
Yes
No
G09
On average, how many hours per day do you get electricity?
Less than 6 hours
612 hours
1318 hours
More than 18 hours
Don't know
G10
Can every household member have two proper meals or more everyday during the year?
Yes
No
G11
During which months your family didn’t get two square meals or more a day?
January
February
March
April
May
June
July
August
September
October
November
December
G12
Does your household save money on a regular basis?
Yes
No
G13
On average how much does your household save per month ?
CREDIT AND WATERCREDIT
H01
Has anyone in your household ever taken any loan?
Yes
No
H02
Does your household have any current loan outstanding?
Yes
No
H03
From whom all did your household take loan?
Family
Friend/Colleague
Bank
Micro finance institutions (MFI)
Borrow from employer
Traditional local money lender
Other (please specify)
Don't know
H04
How long have you been a group member of {insert MFI name}?
H05
Does your household currently have any loans from [insert MFI name]?
Yes
No
H06
If yes, what is the purpose of your last loan from [insert MFI name]?
Food
Water
House
Business
Sanitation
Health
Education
Other (please specify)
H07
Are you interested in taking loans from [insert MFI name] to improve the quality or quantity of water and sanitation?
Yes
No
H08
If no, why are you not interested in taking loan for water and sanitation?
I already have what I need
Doesn’t like to take loan/or too much debt
Family won't agree
Not interested in water or sanitation improvement
No money to repay loan
Unable to do, even if money is available
Do not own the house where living
Other (please specify)
H09
If yes, what are you going to do with the loan?
Household toilet improvement/construction
Rain water (or for other alternative options)
Water purifier/filter
Household water connection (from piped supply)
Hand pump / bore well
Well with submergable pump
Construction of tubewell platform and other improvement
Other (please specify)
H10
How much amount will you be interested to take as loan from [insert MFI name]?
H11
What is the maximum amount would you be willing to pay as your monthly installment?
H12
What is the maximum interest rate would you be willing pay for this loan?
H13
In how many month(s) would you be willing to repay the loan?
H14
Who have/would make decision of whether to take loan for improving water and sanitation facility of your HH?
Male HH member
Female HH member
Both Male and Female HH member
H15
Who have/would make decision regarding the source of taking this loan?
Male HH member
Female HH member
Both Male and Female HH member
H16
Who have/would make decision regarding the amount of loan to be taken?
Male HH member
Female HH member
Both Male and Female HH member
H17
Who have/would make decision regarding the type of improvement(improving water source or sanitation source) to be done using the loan?
Male HH member
Female HH member
Both Male and Female HH member
H18
How do you think havingbetter water and sanitation facilities be helpful fot you and your family ?
Fewer diseases/ health costs
Dignity/pride/ social acceptance
Easy for elderly /children/women
Save time
Easy access to water
Personal and family safety
Other (specify)
ENVIRONMENT
I01
Have you noticed any changes in level of rainfall in the last 5 years ?
Yes, the rainfall has increased
Yes, the rainfall has decreased
No change
Didn't notice
I02
Has there been any increase in flooding within the last 5 years?
Yes
No
I03
Has there been an increase in drought / lack of rainfall in the last 5 years?
Yes
No
I04
Has the supply of drinking water changed over the past 5 years?
Yes
No
I05
In what way has the supply of drinking water been changed?
The supply has increased
The supply has decreased
I06
How did you cope with declining supply of drinking water?
Consume less water
Spend more time collecting water
Collect water from alternative source
Other (please specify)
I07
Has the weather effected your toilet situation or water supply in the last 5 years?
Yes
No
I08
How has the weather affected your toilet situation or water supply in the last 5 years?
I09
In about 13 years we would need to do followup interviews with you with the same type of questions. Would you be willing and available to do another interview during that time?
Yes
No
INTERVIEWER FEEDBACK
J01
Overall, how would you rate the quality of this interview?
Good
Fair
Poor
J02
Do you think the respondent felt comfortable answering the questions?
Yes
No
J03
Was anyone else from the community listening to the interview?
Yes
No
J04
If yes, who?
Spouse/partner
Other adult household members
Neighbor
Children
Local government official
Local health officer/staff
Staff member from NGOs/Banks/other financing institutions
Other (please specify)
Don't know
J05
In which language was most of the interview conducted?
English
Hindi
Kannada
Marathi
Tamil
Bengali
Gujarati
Malayalam
Oriya
Telugu
J06
Additional information shared by the interviewee:
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