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Community Toilet -Form Fill
Structured Survey: To be conducted with Household Heads (Primary Stakeholder)
Q01
GPS Coordinates
Q07
Project code
Q09
Interviewer code
Q12
Date of Interview
Q13
Interview Start Time
Q14
Interview End Time
Respondent profile
A02
Respondent’s phone number
A03
What is the gender of the respondent?
Female
Male
Transgender
A04
What is your age? (in completed years)
A05
How many members are there in your household?
A05A
Male above 60 Years
A05B
Female above 60 Years
A05C
Males between 14-60 years
A05D
Females between 14-60 years
A05E
Children aged 14 years or less
A06
What is the highest level of education that you have completed?
No formal education
Has attended primary school (up to grade 6)
Has attended up to grade 10
Matriculate (10th pass)
Passed school (10+2)
Graduate
Postgraduate
ITI/ Diploma/ similar vocational course
Others (Specify)
A07
Which ID is used to verify the identity of the respondent?
Aadhar Card
Ration Card
Others (Specify)
A08
Please specify which card you have.
Above Poverty Line (APL)
Below Poverty Line (BPL)
Antyodaya Anna Yojana (AAY)
Don’t know/can’t say
A09
What is your social category?
Scheduled caste (SC)
Scheduled tribe (ST)
Backward caste (BC)
Minority (Muslim, Christian, Jain etc.)
General caste
Others
A10
What is your household’s main source of income?
Farming (on own land)
Farming on leased or rented-in land
Wage or salaried work (agricultural)
Wage or salaried work (non-agricultural)
Agri-business
Non-agri-business
Others (Specify)
A11
What is your annual income range?
Less than 50,000
50-100,000
100,000 -200,000
200,00 – 350,000
350,000 – 500,000
More than 500, 000
Don’t want to share
Community Toilet
B01
How many adults (above 18 years) are there in your household?
Less than 3
Between 4-6
More than 6
B02
How many children under the age of 5 are there in your household?
Less than 3
Between 4-6
More than 6
None
B03
What method do you use for disposing of the stools of the children under the age of 5?
Flushing in the toilet
Burying in the ground
Wrapping in plastic bags and throwing in the garbage
Other (specify)
B04
How many cases of waterborne diseases (diarrhea, cholera, etc.) were reported in your household per month before the construction of toilets?
1-2 cases
2-5 cases
6-10 cases
More than 10 cases
None
B05
How often do you wash your hands with soap and water?
Before meals
After using the toilet
After returning from outside
Whenever hands are visibly dirty
Rarely
Never
B06
Who primarily uses the toilet in your household?
Adults
Children
Both
None use
B07
Is the toilet used for both urination and defecation?
Yes
No
B08
After the construction of toilet, do the women and girls in your household have access to proper menstrual hygiene facilities?
Yes
No
Partially
B09
Are there any challenges or barriers faced by women and girls in your household in maintaining proper menstrual hygiene practices despite the availability of toilets?
Lack of sanitation facilities
Limited access to clean water
Lack of awareness about sanitation
Other (specify)
B10
How much has your household's healthcare expenditure changed after the installation of the toilet?
Decreased
Increased
No change
Structured Survey: To be conducted with Anganwadi worker (Primary Stakeholder)
C02
Respondent’s phone number
C03
What is the gender of the respondent?
Female
Male
Transgender
C04
What is your age? (in completed years)
C05
How many members are there in your household?
C05A
Male above 60 Years
C05B
Female above 60 Years
C05C
Males between 14-60 years
C05D
Females between 14-60 years
C05E
Children aged 14 years or less
C06
What is the highest level of education that you have completed?
No formal education
Has attended primary school (up to grade 6)
Has attended up to grade 10
Matriculate (10th pass)
Passed school (10+2)
Graduate
Postgraduate
ITI/ Diploma/ similar vocational course
Others (Specify)
C07
Which ID is used to verify the identity of the respondent?
Aadhar Card
Ration Card
Others (Specify)
C08
Please specify which card you have.
Above Poverty Line (APL)
Below Poverty Line (BPL)
Antyodaya Anna Yojana (AAY)
Don’t know/can’t say
C09
What is your social category?
Scheduled caste (SC)
Scheduled tribe (ST)
Backward caste (BC)
Minority (Muslim, Christian, Jain etc.)
General caste
Others
C10
What is your household’s main source of income?
Farming (on own land)
Farming on leased or rented-in land
Wage or salaried work (agricultural)
Wage or salaried work (non-agricultural)
Agri-business
Non-agri-business
Others (Specify)
C11
What is your annual income range?
Less than 50,000
50-100,000
100,000 -200,000
200,00 – 350,000
350,000 – 500,000
More than 500, 000
Don’t want to share
Community Toilet (Primary Stakeholder)
D01
How often are community toilets used by community members?
Multiple times a day
Once a day
Few times a week
Rarely
Never
D02
Who primarily uses the community toilets?
Adults
Children
Both
Not in use
D03
Have you participated in any WASH awareness campaigns organized by the project?
Yes
No
D04
How often do community members engage in practices such as handwashing with soap, safe water storage, and waste disposal?
Daily
Weekly
Monthly
Occasionally
Never
D05
How often are community toilets cleaned and maintained?
Daily
Weekly
Monthly
Occasionally
Never
D06
Is toilet cleaner or disinfectant used when cleaning community toilets?
Always
Sometimes
Rarely
Never
D07
Have you or any household member suffered from any communicable diseases in the past year?
Yes
No
D08
If yes, please specify the type of disease(s).
Diarrhea
Cholera
Typhoid
Hepatitis A
Dysentery
Other (specify)
D09
For the specified disease, please indicate the frequency of occurrence
Once a month
Few times a month
Once a week
Few times a week
D10
Are there adequate basic amenities available in the Anganwadi center in your community? (e.g., water supply, toilets, handwashing facilities)
Yes
No
Partially
D11
Do you have knowledge about proper WASH practices such as handwashing, safe water handling, and waste management?
Yes
No
D12
Have you received any training on WASH from the project implementers?
Yes
No
Not sure/don’t remember
D13
How has your household's expenditure on healthcare changed since the availability of community toilets?
Decreased
Increased
No change
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