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Sanitation Interventions -Form Fill
Interview Outcome
Q01A
Number of visits to the household
Q01
Visit-1
Q01_1
Date
Q01_2
Interviewer ID
Q01_3
Result
Completed
Refused
Partially completed, return visit not agreed to
People absent for more than 2 months
Dwelling empty
Unable to locate dwelling
Partially completed, return agreed
No eligible person present
Household relocated—need to find in new location
Q02
Visit-2
Q02_1
Date
Q02_2
Interviewer ID
Q02_3
Result
Completed
Refused
Partially completed, return visit not agreed to
People absent for more than 2 months
Dwelling empty
Unable to locate dwelling
Partially completed, return agreed
No eligible person present
Household relocated—need to find in new location
Q03
Visit-3
Q03_1
Date
Q03_2
Interviewer ID
Q03_3
Result
Completed
Refused
Partially completed, return visit not agreed to
People absent for more than 2 months
Dwelling empty
Unable to locate dwelling
Partially completed, return agreed
No eligible person present
Household relocated—need to find in new location
Q04
If return visit indicated, enter date
Q05
Interviewer
Q06
Field Supervisor
Q07
Study supervisor
Q08
Data entry date
Q09
State
Q10
District
Q11
Has the household moved since the last survey?
Yes
No
Q12
GPS Coordinates
Q13
Time Started
Respondent and Household Information
A01
Respondent’s Name
A02
Respondent’s Age
A03
Respondent’s Gender
Male
Female
A04
Name all persons living in this household from the oldest to the youngest in each subfamily.
A05
Sex
Male
Female
A06
How old is [NAME]?
A07
What is [NAME]’s relationship to the head of household?
Head
Wife/husband
Child/adopted child
Grandchild
Niece/nephew
Father/mother
Sister/brother
Son-in-law/daughter-in-law
Brother-in-law/sister-in-law
Grandfather/mother
Father-in-law/mother-in-law
Other relative
Servant or servant’s relative
Tenant or tenant’s relative
Other (specify: ___________________)
A08
What is the current marital status of [NAME]?
Married
Divorced
Separated
Widow or widower
Never married
Don’t know/not sure
A09
For each of the children under 5 years of age, please identify their biological mother and father, if they live in the home record the serial number of the biological mother and father.
A10
What is [NAME]’s main work?
Housework
Looking for work
Work on own farm only
Work on own farm and other’s farm
Work on other’s farm as wage labor
Work on other’s farm as share cropper
Non-farm work as construction labor
Non-farm work as skilled artisan
Non-farm work as factory worker
Non-farm work as self-employed business
Non-farm work as assistant
Non-farm work in government service (including Panchayat staff)
Non-farm work in private firm
Non-farm work as professional (lawyer, doctor, nurse, teacher, etc.)
Non-farm work as social worker (e.g., Anganwadi worker)
Student
Unable to work (too old, too young)
Handicapped, not working
Other (specify: ___________________)
A11
How many years of education has [NAME] completed?
No education
Primary school
Secondary school
Higher secondary
graduation
post graduation
Don’t know/not sure
A12
Is [NAME] currently enrolled in school
Yes
No
A13
Can [NAME] read newspapers?
Not at all
Yes, easily
Yes, with difficulty
Don’t know/ not sure
A14
Can [NAME] maintain basic household accounts?
Not at all
Yes, easily
Yes, with difficulty
Don’t know/ not sure
A15
Did [NAME] have any loose stool last month?
Yes
No
A16
Did [NAME] have any loose stool last 6 months?
Yes
No
A17
How many days did [NAME] have loose stools?
A18
How any days was [NAME] so sick from diarrhea that (s)he could not perform any of his/her usual activities?
A19
How was [NAME]’s diarrhea treated?
No treatment
Homemade sugar & salt water / government recommended homemade fluid
Medicine from the jungle / traditional remedies / healer
Oral rehydration solution
Pill or syrup
Injection
Intravenous fluid (IV)
Other, specify
A20
In a typical case, how much did you pay for all the treatments and advice you sought for [NAME]? Please include all user fees, medicines, transportation, lodging, meals, and other expenses.
A21
In a typical case, how much of the time were household members unable to work because they were caring for [NAME]? (Record time in days. If less than 1 day, record in hours.)
Public Problems
B01
Which is the most important improvement you would like to see over the next 10 years in this area?
No problem
Corruption
Roads
Transportation
Telecommunication
Household water supply
Sanitation and hygiene
Schools and education
Better Wages
Irrigation
Electricity
Better housing
Unemployment
Pollution
Agricultural production and marketing
Health
Other (specify __________________)
Don’t know/not sure
B02
What is the biggest environmental problem facing the village?
No problem
Air pollution
Water pollution
Garbage and solid waste
Poor drainage of waste water
Flies, mosquitoes, cockroaches
Soil erosion
Floods
Droughts
Extreme climate (heat or cold)
Loss of forests and forest products
Loss of wildlife
Drying of rivers and streams
Other (specify _____________________)
Don’t know / not sure
B03
Which disease is a child in this village most likely to contract?
Diarrhea
Severe cough
Malaria
Other (specify _____________________)
B04
Which disease is most likely to cause death in a child in this village?
Diarrhea
Severe cough
Malaria
Other (specify _____________________)
Health Knowledge and Information Receipt
C01
In your opinion, what are the symptoms of diarrhea?
C01_1
Loose and watery stool
Yes
No
C01_2
Blood / mucus in stool
Yes
No
C01_3
Abdominal pain
Yes
No
C01_4
Soft part sunken
Yes
No
C01_5
Fever
Yes
No
C01_6
Vomiting
Yes
No
C01_7
Weakness (loss of weight, thinned/weakened limbs, not eating or drinking well)
Yes
No
C01_8
Dehydration (marked thirst, absence of tears, dried lips, persistent skin fold)
Yes
No
C01_9
Loss of sense (mental stupor, dizziness, convulsion, unconscious)
Yes
No
C01_10
Headache
Yes
No
C01_11
Constipation
Yes
No
C02
Does [CAUSE] cause diarrhea?
C02_1
Eating stale foods
Yes
No
C02_2
Eating food from street vendors
Yes
No
C02_3
Eating food touched by flies
Yes
No
C02_4
Unclean/smelly food
Yes
No
C02_5
Drinking contaminated water
Yes
No
C02_6
Using unhygienic latrines/open defecation
Yes
No
C02_7
Not washing hands
Yes
No
C02_8
Bad weather/weather change
Yes
No
C02_9
Exposure to sun
Yes
No
C02_10
Teething/net teeth
Yes
No
C02_11
Some types of vaccines
Yes
No
C02_12
Household uncleanliness
Yes
No
C02_13
Village uncleanliness
Yes
No
C03
Are you aware of any sanitation and toilet use related information campaigns, education messages, and information campaigns that have taken place in your village?
Yes
No
C04
Do you remember any of these activities ever happening in your village?
C04_1
Walk of shame (group of people marched through village and looked at current sanitation)
Yes
No
C04_2
Defecation mapping (created map of where defecation occurs in village)
Yes
No
C04_3
Fecal calculation (calculated amount of feces in village)
Yes
No
C04_4
Calculation of medical expenses of open defecation related diseases (e.g., cholera, diarrhea)
Yes
No
C04_5
Discussion / presentation of latrine technologies
Yes
No
C04_6
Messages from TV, radio, other sources
Yes
No
C04_7
Distribution of pamphlets
Yes
No
C05
Approximately how many years ago did this activity occur?
C05_1
Walk of shame (group of people marched through village and looked at current sanitation)
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_2
Defecation mapping (created map of where defecation occurs in village)
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_3
Fecal calculation (calculated amount of feces in village)
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_4
Calculation of medical expenses of open defecation related diseases (e.g., cholera, diarrhea)
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_5
Discussion / presentation of latrine technologies
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_6
Messages from TV, radio, other sources
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C05_7
Distribution of pamphlets
This year
Last year
2-5 years ago
6-10 years ago
>10 years ago
C06
Did you participate in this event?
C06_1
Walk of shame (group of people marched through village and looked at current sanitation)
Yes
No
C06_2
Defecation mapping (created map of where defecation occurs in village)
Yes
No
C06_3
Fecal calculation (calculated amount of feces in village)
Yes
No
C06_4
Calculation of medical expenses of open defecation related diseases (e.g., cholera, diarrhea)
Yes
No
C06_5
Discussion / presentation of latrine technologies
Yes
No
C06_6
Messages from TV, radio, other sources
Yes
No
C06_7
Distribution of pamphlets
Yes
No
C07
Have you received Public health messages from the following?
C07_1
Posters/hordings
Yes
No
C07_2
TV advertisement/radio advertisment
Yes
No
C07_3
Radio Ad
Yes
No
C07_4
Visits by aanganwadi, ANM
Yes
No
C07_5
School lessons & teachers
Yes
No
C07_6
Television shows
Yes
No
C07_7
Street Play
Yes
No
C07_8
Local tales
Yes
No
C07_9
Grafitti
Yes
No
C07_10
Family members & friends
Yes
No
C07_11
Leaflets / pamphlets /Brochures/newspaper/magazine
Yes
No
C07_12
Newspaper and magazine
Yes
No
C07_13
Temple / mosque / church
Yes
No
C07_14
Self-help group meetings
Yes
No
C08
How often do you receive such message?
C08_1
Posters/hordings
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_2
TV advertisement/radio advertisment
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_3
Radio Ad
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_4
Visits by aanganwadi, ANM
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_5
School lessons & teachers
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_6
Television shows
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_7
Street Play
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_8
Local tales
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_9
Grafitti
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_10
Family members & friends
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_11
Leaflets / pamphlets /Brochures/newspaper/magazine
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_12
Newspaper and magazine
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_13
Temple / mosque / church
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C08_14
Self-help group meetings
Just once
Daily
Weekly
Once every 2 weeks
Once every month
Once every 3 months
Once every 6 months
Once every year
C09
What is the key message?
C09_1
Posters/hordings
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_2
TV advertisement/radio advertisment
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_3
Radio Ad
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_4
Visits by aanganwadi, ANM
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_5
School lessons & teachers
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_6
Television shows
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_7
Street Play
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_8
Local tales
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_9
Grafitti
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_10
Family members & friends
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_11
Leaflets / pamphlets /Brochures/newspaper/magazine
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_12
Newspaper and magazine
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_13
Temple / mosque / church
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C09_14
Self-help group meetings
Poor hygiene causes disease
use tap water
stop open defecation/ use IHL
wash hands with soap regularly
safely handle and store drinking water
boil, filter, or treat drinking water
safely handle and prepare food
C10
How much did you learn from these messages?
C10_1
Posters/hordings
A lot
Some
Little bit
Nothing (already knew)
C10_2
TV advertisement/radio advertisment
A lot
Some
Little bit
Nothing (already knew)
C10_3
Radio Ad
A lot
Some
Little bit
Nothing (already knew)
C10_4
Visits by aanganwadi, ANM
A lot
Some
Little bit
Nothing (already knew)
C10_5
School lessons & teachers
A lot
Some
Little bit
Nothing (already knew)
C10_6
Television shows
A lot
Some
Little bit
Nothing (already knew)
C10_7
Street Play
A lot
Some
Little bit
Nothing (already knew)
C10_8
Local tales
A lot
Some
Little bit
Nothing (already knew)
C10_9
Grafitti
A lot
Some
Little bit
Nothing (already knew)
C10_10
Family members & friends
A lot
Some
Little bit
Nothing (already knew)
C10_11
Leaflets / pamphlets /Brochures/newspaper/magazine
A lot
Some
Little bit
Nothing (already knew)
C10_12
Newspaper and magazine
A lot
Some
Little bit
Nothing (already knew)
C10_13
Temple / mosque / church
A lot
Some
Little bit
Nothing (already knew)
C10_14
Self-help group meetings
A lot
Some
Little bit
Nothing (already knew)
C11
What were the major changes you made in your house because of these messages?
C11_1
Posters/hordings
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_2
TV advertisement/radio advertisment
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_3
Radio Ad
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_4
Visits by aanganwadi, ANM
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_5
School lessons & teachers
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_6
Television shows
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_7
Street Play
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_8
Local tales
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_9
Grafitti
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_10
Family members & friends
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_11
Leaflets / pamphlets /Brochures/newspaper/magazine
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_12
Newspaper and magazine
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_13
Temple / mosque / church
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
C11_14
Self-help group meetings
Nothing
Use tap water
Stop open defecation
Use IHL
Wash hands with soap regularly
Safely handle and store drinking water
Boil, filter, or treat drinking water
Safely handle and prepare food
Water Treatment, Storage, and Hygiene
D01
Do you treat or filter your water in any way before you drink it?
Yes
No
D02
Do you do any of the following to treat your drinking water?
D02_1
Boil
Yes
No
D02_2
Filter (e.g., sieve through cloth, zeroB)
Yes
No
D02_3
Use chemicals (e.g., bleach, chlorine, alum, potash)
Yes
No
D02A
How often does your household boil your drinking water?
More than once a day
Once a day
A few times each week
Once a week
Only during monsoon season
Only when cooking
Rarely or never (Go to next treatment option)
Other, specify: ____________________________________________
Don’t know/not sure
D02A1
How many minutes do you boil your drinking water on each such occasion?
D02B
How do you primarily filter your water?
Cloth
Filter (e.g., candle)
Electric filter (e.g., aquaguard)
Chemical filter (e.g., ZeroB)
Other, specify
D02B1
How much would it cost today to buy this filtering device?
D02C
How much do you spend on chlorine/alum/potash per month?
D03
Could you tell the main reason you do not treat the water before you drink it?
Water is already clean
Treatment does not help
Don’t think that cleaning is necessary
Too expensive
No time for treatment
Other, specify: ____________________________________________
Don’t know/not sure
D04
Do you usually wash your hands after defecation?
Yes
No
D05
Did you wash your hands in the past 24 hours?
Yes
No
D06
When and how did you wash your hands?
D06_1
Before preparing food or cooking
Water
Soap
Soil
Ash
D06_2
After preparing food or cooking
Water
Soap
Soil
Ash
D06_3
Before eating
Water
Soap
Soil
Ash
D06_4
After eating
Water
Soap
Soil
Ash
D06_5
Before serving food
Water
Soap
Soil
Ash
D06_6
After serving food
Water
Soap
Soil
Ash
D06_7
Before feeding children
Water
Soap
Soil
Ash
D06_8
After changing baby/handling child’s feces
Water
Soap
Soil
Ash
D06_9
After defecation
Water
Soap
Soil
Ash
D06_10
After attending cattle
Water
Soap
Soil
Ash
D06_11
After cleaning house/cattle shed
Water
Soap
Soil
Ash
D06_12
After returning from work/outside visit
Water
Soap
Soil
Ash
Household Sanitation
E01
Is it possible for your household to defecate in [LOCATION]?
E01_1
Community toilet
Yes
No
E01_2
Neighbor’s toilet
Yes
No
E01_3
Private toilet (IHL)
Yes
No
E02
Does your household ever use [LOCATION] for defecation?
E02_1
Open defecation
Yes
No
E02_2
Community toilet
Yes
No
E02_3
Neighbor’s toilet
Yes
No
E02_4
Private toilet (IHL)
Yes
No
E03
Could you please tell me why your household does NOT have / use [LOCATION]?
E03_1
Open defecation
No health benefits
Lack of privacy
Lack of safety
Too expensive
Don’t know how (e.g., to install, use)
Government should provide toilets
Inconvenient
Other (specify: _______)
E03_2
Community toilet
No health benefits
Lack of privacy
Lack of safety
Too expensive
Don’t know how (e.g., to install, use)
Government should provide toilets
Inconvenient
Other (specify: _______)
E03_3
Neighbor’s toilet
No health benefits
Lack of privacy
Lack of safety
Too expensive
Don’t know how (e.g., to install, use)
Government should provide toilets
Inconvenient
Other (specify: _______)
E03_4
Private toilet (IHL)
No health benefits
Lack of privacy
Lack of safety
Too expensive
Don’t know how (e.g., to install, use)
Government should provide toilets
Inconvenient
Other (specify: _______)
E04
What are the main reasons for using this [LOCATION]?
E04_1
Open defecation
No choice/nothing else available
Health benefits
Privacy
Safety
Reasonable cost
Know how (e.g., received health to install toilet)
Government provided
Convenient
Other (specify: _______)
E04_2
Community toilet
No choice/nothing else available
Health benefits
Privacy
Safety
Reasonable cost
Know how (e.g., received health to install toilet)
Government provided
Convenient
Other (specify: _______)
E04_3
Neighbor’s toilet
No choice/nothing else available
Health benefits
Privacy
Safety
Reasonable cost
Know how (e.g., received health to install toilet)
Government provided
Convenient
Other (specify: _______)
E04_4
Private toilet (IHL)
No choice/nothing else available
Health benefits
Privacy
Safety
Reasonable cost
Know how (e.g., received health to install toilet)
Government provided
Convenient
Other (specify: _______)
E05
What kind of [TOILET] is it? (Read all the answers. Circle 1.)
E05_1
Community toilet
On-pit (drop) latrine
Flush toilet using septic
Flush toilet using off-set pit
Other (specify: _____)
Don’t’ know/not sure
E05_2
Neighbor’s toilet
On-pit (drop) latrine
Flush toilet using septic
Flush toilet using off-set pit
Other (specify: _____)
Don’t’ know/not sure
E06
How frequently do the men, women, and children in your family use [TOILET] during the day and at night?
E06_1
Open defecation
Daily/usually
Occasionally
Seasonally
Never
E06_2
Community toilet
Daily/usually
Occasionally
Seasonally
Never
E06_3
Neighbor’s toilet
Daily/usually
Occasionally
Seasonally
Never
E06_4
Private toilet (IHL)
Daily/usually
Occasionally
Seasonally
Never
E07
During the busiest time of the day, how long do you have to wait to use [TOILET]?
E08
Do you pay to use the [TOILET]?
Yes
No
E08A
What amount do you pay?
E08B
What is the time period for the charge?
Per use
Per day
Per week
Per fortnight
Per month
Other, specify
E09
About how many people use this [TOILET] on a regular basis (Record -9 if don’t know/not sure)
E10
When was this [TOILET] last cleaned?
One week or less
One week to two months
Never
Other, specify: __________
Don’t know/not sure
E11
When practicing open defecation, where do men, women, and children under 16 years old in this household usually go to defecate?
E11A
Men
E11A_1
Field/bush
Yes
No
E11A_2
Vacant land/pasture
Yes
No
E11A_3
Roadside/surface drain
Yes
No
E11A_4
Drain/gutter/ditch
Yes
No
E11A_5
Compound/yard
Yes
No
E11A_6
River/pond
Yes
No
E11B
Women
E11B_1
Field/bush
Yes
No
E11B_2
Vacant land/pasture
Yes
No
E11B_3
Roadside/surface drain
Yes
No
E11B_4
Drain/gutter/ditch
Yes
No
E11B_5
Compound/yard
Yes
No
E11B_6
River/pond
Yes
No
E11C
Male children under 16
E11C_1
Field/bush
Yes
No
E11C_2
Vacant land/pasture
Yes
No
E11C_3
Roadside/surface drain
Yes
No
E11C_4
Drain/gutter/ditch
Yes
No
E11C_5
Compound/yard
Yes
No
E11C_6
River/pond
Yes
No
E11D
Female children under 16
E11D_1
Field/bush
Yes
No
E11D_2
Vacant land/pasture
Yes
No
E11D_3
Roadside/surface drain
Yes
No
E11D_4
Drain/gutter/ditch
Yes
No
E11D_5
Compound/yard
Yes
No
E11D_6
River/pond
Yes
No
E12
Usually how long does it take to walk (one way from your house) to where you defecate? Need to ask only for relevant household members,for example if a household only has male children don’t ask for female child of the family
E12_1
Men
E12_2
Women
E12_3
Male children under 16
E12_4
Female children under 16
E13
Do you usually defecate within the village or outside the village?
E13_1
Men
Outside the village
Within the village
Don’t know/not sure
E13_2
Women
Outside the village
Within the village
Don’t know/not sure
E13_3
Male children under 16
Outside the village
Within the village
Don’t know/not sure
E13_4
Female children under 16
Outside the village
Within the village
Don’t know/not sure
E14
Does your household own a latrine even if it is not in use/not functional?
Yes
No
E15
How many latrines does your household own?
E18
When was the LATRINE built
E19
Was this LATRINE built before your village had electricity?
After
Before
No electricity
E20
Was this LATRINE built before your village started having mobile phones?
After
Before
No electricity
E21
Was this LATRINE built before your village had upgraded the main road?
After
Before
No electricity
E22
Where did you obtain materials for building this LATRINE?
Within the village
Outside the village
E23
Whose idea was it to build this LATRINE?
Head of household
Other household member
Other community member
Government/ NGO
Other (specify: _______)
Don’t know/ not sure
E24
Is this latrine functional now?
Yes
No
E25
For how long was this latrine functional?
E25A
unit
Months
Years
E26
Why is the latrine not functional?
No superstructure
Filled
Structural problem
Dirty
Other (specify: ___________________)
E27
Does your household still use this latrine?
Yes
No
E28
Why does your household no longer use this latrine?
It was poorly built and broke quickly
It filled and I did not empty it
Open defecation is more convenient
Other (specify: ___________________)
E29
Why did you not empty the latrine?
Too
No one available to empty
Not safe yet
E30
Do your neighbors use this latrine?
Yes
No
E31
Do your neighbors pay to use this latrine?
Yes
No
E32
How much do your neighbors pay to use this latrine?
per use
per day
per week
per fortnight
per month
Other (specify: _______________)
E33
How much did it cost to construct this LATRINE?
E34
How much of this cost was subsidized by the government?
E35
How much would it cost to have a LATRINE like your built today?
E36
How much of this cost would be subsidized by the government?
E37
What type of pit latrines do you have?
Single pit
Double pit
E38
Structure
No structure
Temporary slab or structure
Pucca (permanent) slab or structure
E39
Ventilation
Ventilation by pipes
Not ventilated
Window/sky light/exit fan
Other (specify: ____________________)
E40
May I see your LATRINE?
Yes
No
E41
Walls and doors around LATRINE?
Not present
Temporary
Permanent: good condition
Permanent: bad condition
E42
Roof over LATRINE?
Not present
Temporary
Permanent: good condition
Permanent: bad condition
E43
Raised slab for squatting?
Not present
Temporary
Permanent: good condition
Permanent: bad condition
E44
Feces in LATRINE?
Not present
Present
E45
Bad smell
Not present
Present
E46
Flies in LATRINE?
Not present
Present
E47
Stagnant water
Not present
Present
E48
Soap or ash
Not present
Present
E49
Cobwebs
Not present
Present
E50
When your pit latrine fills up, do you plan to empty it or replace it?
Empty
Replace
E51
How much would it cost you to empty your pit today?
E52
In how many years do you plan to replace your pit latrine?
E53
Have you ever had your pit latrine emptied?
Yes
No
E54
When was the last time the pit was emptied?
< every 5 years
5 years ago
10 years ago
> 10 years ago
Other, specify: _____________________
Don’t know/not sure
E55
How much did you spend on emptying your pit?
E56
Who emptied the pit?
Sweeper from the same village
Sweeper from different village
We emptied the pit ourselves
Other, specify: ________________
Don’t know/not sure
E57
Please rank the benefits of latrines for each of the following groups in your household
E57A
Privacy/Dignity
E57A_1
Men
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57A_2
Women
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57A_3
Male children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57A_4
Female children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57B
Safety
E57B_1
Men
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57B_2
Women
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57B_3
Male children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57B_4
Female children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57C
Health
E57C_1
Men
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57C_2
Women
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57C_3
Male children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57C_4
Female children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57D
Other
E57D_1
Men
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57D_2
Women
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57D_3
Male children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E57D_4
Female children under 16
most important benefit to
least important benefit; select
if respondent does not think it is a benefit or prefers not to answer
E58
Are you planning on building or have you starting building a new IHL?
No
Yes, eventually
Yes, in the next year
Yes, in the next six months
Yes, in the next month
Yes, we have already started
E59
What type of toilet are you planning to build?
On-pit without superstructure
On-pit with superstructure
Flush toilet with offset pit
Flush toilet with septic tank
E60A
How much will it cost?
E60B
How much of the cost will be subsidized by the government?
E60C
How much will you pay?
E61
Are you aware of the Swachh Bharat mission?
Yes
No
E62
Have you received any subsidies from the Swachh Bharat mission?
Yes
No
E63
Have any of your friends/family received subsidies from the Swachh Bharat mission?
Yes
No
E64
Has anyone in your community received subsidies from the Swachh Bharat mission?
Yes
No
E65
Does the Swachh Bharat mission have any influence on your decision to build a latrine?
No
Yes, subsidy helped me build a latrine
Yes, waiting to receive approved subsidy to build latrine
Yes, will not build latrine until I receive subsidy
Other, specify: _______________________________________________________
E66
How strongly do you agree or disagree with the following statements?
E66_1
Latrines are safer than open defecation for [group] in my household
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_2
Latrines provide privacy benefits for [group] in my household
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_3
[Group] in my household is less likely to be harassed if they use latrines compared to open defecation
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_4
When my household members use latrines, it provides health benefits for [group] in my household
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_5
When my neighbors use latrines, it provides health benefits for [group] in my household
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_6
[Group] in my household prefer using latrines to defecating in the open
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_7
There are sanctions or penalties (including social stigma) for people in [Group] who do not use latrines in this village
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_8
Owning a latrine is a sign of prestige or status in this village
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_9
The norm in the village is for people to use latrines and not practice open defecation
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E66_10
Open defecation can only be eliminated if some else (e.g., government, NGO) pays for or provides other sanitation options
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
E67
Observe, does the neighbor’s wastewater or garbage currently spill into your household’s area or yard?
Yes
No
E68
Observe, does the household’s wastewater or garbage currently spill into the neighbor’s area or yard?
Yes
No
E69
How would you rate your village cleanliness on a 5-point scale?
Very clean
Clean
Somewhat clean/somewhat dirty
Dirty
Very dirty
Don’t know/not sure
E70
How would you rate the cleanliness of your immediate neighborhood or surroundings on a 5-point scale?
Very clean
Clean
Somewhat clean/somewhat dirty
Dirty
Very dirty
Don’t know/not sure
E71
Overall, how satisfied are you with your main sanitation facilities?
Very satisfied
Somewhat satisfied
Less than satisfied/somewhat dissatisfied
Completely dissatisfied
Don’t know/not sure
E72
What would you like to change about your current sanitation situation?
Build a private latrine
Help in building a community latrine
Request government assistance for improving sanitation
Other, specify
Don’t know/not sure/ no change
E73
Why haven’t you made this change yet?
Not many personal benefits (privacy, health, safety)
Too expensive
Don’t know how/lack expertise
Government should provide/not my job
Don’t know/not sure
E74
Who should pay the costs of improving your family’s health, hygiene, and sanitation?
My family working with government staff and social workers
My family
The government
Community organizations, NGOs, and social workers
E75
What percent would you cost share?
Social Interactions
F01
How many households in your village have latrines?
F02
How many households in your immediate neighborhood or surroundings have latrines?
F03
When did households first start building latrines in your village?
No households have latrines
In the last year
1-3 years ago
3-5 years ago
5-10 years ago
>10 years ago
Don’t know/not sure
F04
Imagine a time when you learned about a new technology (i.e., a latrine). How many households in your village owned this technology before you also obtained it?
I have never invested
Almost all households in village invested before my own
About half the households in village invested before my own
Only a few of the households in the village invested before my own
I was among the first households to invest
Don’t know/not sure
F05
Imagine a time when you learned about a new technology (i.e., a latrine). How many households in your immediate neighborhood or surroundings owned this technology before you also obtained it?
I have never invested
Almost all households in village invested before my own
About half the households in village invested before my own
Only a few of the households in the village invested before my own
I was among the first households to invest
Don’t know/not sure
F06
Are there households that often invest in new technologies (i.e., latrines) before others in this community?
Yes
No
F07
Do you know these households?
Yes, family
Yes, close friends/interact frequently
Yes, interact infrequently
No, know by name only
F08
Where do these households live in the village?
My immediate neighborhood
Center of village
Outskirts of village
Near market
Near shared community resource
Other, specify
Don’t know/not sure
F09
Do you talk with others in your village about health and decisions to invest in technologies such as latrines or cookstoves?
Yes
No
F10
Please list five others in your village that you talk to about health and decisions to invest in technologies such as latrines or cookstoves.
F10A
Household head name
F10B
Relation
Family
Friend
F10C
Household location
Inside immediate neighborhood
Outside immediate neighborhood
F10D
Frequency
Every day
Once a week
A few times a month
Once a month
Once a year
Other, specify
F10E
Did this household have a latrine before your household?
No, my household had a latrine first
Yes, other household had a latrine first
Both households got latrines at the same time
Neither household has a latrine
Don’t know/ not sure
F11
Do you talk with others outside your village about health and decisions to invest in technologies such as latrines or cookstoves?
Yes
No
F12
Please indicated how strongly you agree with the following statements
F12_1
Most people I know wash hands with soap after defecating
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
F12_2
Most people I know wash hands with soap before cooking/eating/handling food.
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
F12_3
Most people I know always use latrines.
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
F12_4
Most people I know sometimes defecate in the open.
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
F12_5
Most people I know always defecate in the open.
Strongly agree
Agree
No opinion
Disagree
Strongly disagree
Socioeconomic Profile
G01
Are you below poverty line (BPL) or above poverty line (APL)?
Below poverty line (BPL)
Above poverty line (APL)
Don’t know/not sure
G02
record based on observation, do not ask. Circle only ONE answer. What is the material used for the floor of the house?
Mosaic/floor tiles
Cement concrete
Stone
Brick
Wood/bamboo
Earth/mud
Other, specify
G03
record based on observation, do not ask. Circle only ONE answer. What is the material used for the walls of the house?
Cement concrete
Stone
Burnt red bricks
GI/metal/asbestos sheets
Wood
Raw bricks/mud
Plastic/polythene
Grass/thatch/bamboo/etc.
Other, specify
G04
record based on observation, do not ask. Circle only ONE answer. What is the material used for the roof of the house?
Cement concrete
Stone
Burnt red bricks
GI/metal/asbestos sheets
Slate
Tiles
Plastic/polythene
Grass/thatch/bamboo/etc
Other, specify
G05A
How many total rooms are there in your house ?
G05B
How many rooms are used for sleeping and living?
G06
Is there a separate room used as the bathroom?
Yes
No
G07
Is there a separate room used as the kitchen?
Yes
No
G08
Is there a separate room used for livestock?
Yes
No
G09
How many rooms do you rent out?
G10
Does your family own this house?
Yes
No
G11
What do you think would be the market value of your house today
G12
How many rooms do you rent, and how much do you pay each month for rent?
G12A
Number of rooms
G12B
Rupees per month
G13
Now I want to ask about total consumption of the household. Please exclude from your answer any purchasing for processing or resale in a household enterprise. About how much money does your household spend per month on…?
G13_1
Cereal or substitutes
G13_2
Rice
G13_3
Gram/pulses
G13_4
Milk/dairy products
G13_5
Edible oils
G13_6
Meat
G13_7
Fish
G13_8
Eggs
G13_9
Vegetables (greens) and roots
G13_10
Fruits and nuts
G13_11
Sugar, salts, spices
G13_12
Beverages
G13_13
Cooking fuel
G13_14
Electricity
G13_15
Health expenses
G13_16
Education
G13_17
Clothing and footwear
G13_18
Transport
G13_19
Mobile phone
G13_20
Liquor and tobacco
G13_21
Soap
G13_22
Other major expenses
G14
Has your household taken a loan from any of the following sources in the last year?
None
Small loan giving group (microfinance)
Family or friends
Agricultural cooperative
Money lender, employer, landlord
Commercial bank
Self-help groups (SHG)
Other, specify
G15
Roughly how much did your household borrow from all of the loan sources in the last year?
G16
How many of the following does your household own?
G16_1
Refrigerator
G16_2
Washing machine
G16_3
Sewing machine
G16_4
Generator (electricity/power)
G16_5
Electric fan
G16_6
Television
G16_7
Bicycle
G16_8
Motorcycle/scooter/moped
G16_9
Car or truck
G16_10
Telephone (land line)
G16_11
Cell phone
G16_12
Mosquito net
G16_13
Improved cookstove
G16_14
Traditional cookstove
G16_15
Mattress
G16_16
Beds/cots
G16_17
Cattle
G16_18
Goats
G16_19
Sheep
G16_20
Chicken
G17
In approximately what year did the following come to your village?
G17_1
Electricity
G17_2
Mobile phones (in the village, not necessarily owned by the household)
G17_3
Upgraded main road to the village
G17_4
Rural jobs program (NREGA)
G17_5
The most recent improvements to the primary school in your village
Community Participation
H01
Do you or any members in your household participate in any activities for cleaning your neighborhood and community?
Yes
No
H02
Please list all village-cleaning activities for community welfare household members participated in. (Spontaneous response. Note in table.) For each of the activities mentioned by you, was this a one-time activity or a repetitive activity?
H02_1
Sweeping streets
Never
One time
Repetitive
H02_2
Cleaning drains
Never
One time
Repetitive
H02_3
Cleaning water sources
Never
One time
Repetitive
H02_4
Cleaning school area
Never
One time
Repetitive
H02_5
Removing garbage
Never
One time
Repetitive
H02_6
Planting trees
Never
One time
Repetitive
H02_7
Cleaning community latrines
Never
One time
Repetitive
H03
When was the last time anyone from your household attended a Gram Sabha meeting?
Never attended
This week
Past two weeks
Within the last month
Within the last 6 months
Within the last year
Other, specify
Don’t know/not sure
H04A
Is this group existing and active in the village?
H04A_1
Cooperative association/ committee
Yes
No
H04A_2
Credit/finance group/SHG
Yes
No
H04A_3
Women’s club
Yes
No
H04A_4
Youth club
Yes
No
H04A_5
Water users’ association (irrigation)
Yes
No
H04A_6
Village education committee
Yes
No
H04A_7
Water and sanitation committee (WSC)
Yes
No
H04B
Do your household members participate in this committee?
H04B_1
Cooperative association/ committee
Yes
No
H04B_2
Credit/finance group/SHG
Yes
No
H04B_3
Women’s club
Yes
No
H04B_4
Youth club
Yes
No
H04B_5
Water users’ association (irrigation)
Yes
No
H04B_6
Village education committee
Yes
No
H04B_7
Water and sanitation committee (WSC)
Yes
No
Enumerator Observations
I01
How well do you think the respondent understood the questionnaire?
Very well
Moderately well
Not very well
Poorly
Very poorly
I02
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