Please Wait...
Household Template 30 -Form Fill
DESCRIPTIVE IDENTIFICATION OF SAMPLE HOUSEHOLD
Q01
STATE/U.T
Q02
DISTRICT
Q03
Village Code
Q04
VILLAGE NAME
Q05
NAME OF HEAD OF HOUSEHOLD
Q06
HH S. NO
Q07
DATE
Q08
Name of the enumerator
Q09
Enumerator Code
Q10
Supervisor Code
Screening Questions
A01
Does this household contain only one toilet?
Yes
No
A02
Was this toilet constructed after October 2014?
Yes
No
A03
Is it possible for you to let us know the month and year of toilet construction?
A04
Is the toilet construction complete?
Yes
No
A05
Is an eligible male respondent, one who is above the age of 18 and has all information about toilet usage and construction, present at home ?
Yes
No
A06
What is the name of the male respondent?
A07
What is the age of the male respondent?
A08
Is an eligible female respondent, one who is above the age of 18 and has all information about toilet usage and construction, present at home?
Yes
No
A09
What is the name of the female respondent?
A10
What is the age of the female respondent?
HOUSEHOLD CHARACTERISTICS
B01
Household size/Number of members in the HH
B02
Highest level of education among the male members of the household (code)(Above 18 years)
not literate
literate without formal schooling
literate: below primary
primary
upper primary/ middle
secondary
higher secondary
diploma/certificate course (below graduate level)
graduate
postgraduate and above
B03
Highest level of education among the female members of the household (code)
not literate
literate without formal schooling
literate: below primary
primary
upper primary/ middle
secondary
higher secondary
diploma/certificate course (below graduate level)
graduate
postgraduate and above
B04
What is the principal occupation of the head of the household?
Farmer (Crops)
Agricultural day labor
Non Agricultural day labor
Service/Salaried worker
Small/cottage industry
Business/Traders
Skilled worker
Other Self-employment
House Work /Housewife
Migrant labor
Jobless
Retired/Old age
Physically challenged
small trader/petty shop
Other
B05
Religion
Hinduism
Islam
Christianity
Sikhism
Jainism
Buddhism
others
B06
Social group
scheduled tribe
scheduled caste
other backward class
General
others
Exposure to IEC/BCC activities (Motivations & reasons for building a toilet)
C01
Can you tell us from where did you/ any HH member got to hear about constructing toilet for the first time?
SHG member
Sarpanch/ PRI
Neighbor
TV ad
Wall painting
Health worker(Asha, AWW, ANM etc)
Representatives from School (Teacher/Principal)
Swacchata Doot/Swacchata Prerak
Govt Official
No one
Any other( please specify)
C02
Were you ever counselled by any person (NGO workers, Panchayat members, ASHA, AWW, ANM, School Teacher, School Principal, Govt officials etc.) about benefits of construction / usage of toilets or ill effects of Open defecation?’
Yes
No
C03
If Yes, by whom?
Panchayat members
Health workers (ASHA, AWW, ANM, doctor)
NGO workers
Govt Officials
Swatchta Doot/Prerak
Other
C04
Was the importance of issues of toilet construction and usage discussed in Gram Sabha, Panchayat meetings or other village level meetings?
Yes
No
C05
Are there any hoardings or posters or wall paintings in your gram panchayat, which mention the importance of toilet construction and usage?
Yes
No
C06
Were there any special events conducted in your gram panchayat, which focused on toilet construction and toilet usage?
Yes
No
C07
If Yes, what were they?
Nukkad Natak
Processions for toilet usage awareness
Video Screening
Special meetings with community members for toilet usage
Any Other
C08
Do you think such events (IEC activities, including counselling) encouraged/motivated you to construct toilets?
Yes
No
C09
If Yes, which of the events?
Nukkad Natak
Processions for toilet usage awareness
Video Screening
Special meetings with community members for toilet usage
Poster/wall painting/hoardings
Counselling
Any Other
DECISION TO BUILD THE TOILET
D01
What kind of toilet facilityis currently present in your house?
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
No Facility/Uses Open Space Or Field
Other (Specify)
D02
Who all did you discuss with before deciding to construct the toilet?
Family members
Neighbors
Health worker
Households which already had toilet
Sarpanch
Representatives from School
Swacchata Doot/Swacchata Prerak
Govt Official
None
Any Other(please specify)
D03
Who was it who took the final decision of construction of the toilet?
All family members/collective decision
Himself
Eldest male member of the household
Eldest female member of the household
Wife of the respondent/Chief wage earner
Others(please specify)
D04A
Who helped you decide the size of the toilet to construct?
Local NGO worker
Sarpanch
Neighbor who already had a toilet
Retailer who sold the toileteries
Mason
Government Officials
No one helped
Any other
D04B
Who helped you decide the size of the pit to be constructed?
Local NGO worker
Sarpanch
Neighbor who already had a toilet
Retailer who sold the toiletries
Mason
Government Officials
No one helped
Any other
D04C
Who helped you decide the type of the pit to be constructed?
Local NGO worker
Sarpanch
Neighbor who already had a toilet
Retailer who sold the toileteries
Mason
Government Officials
No one helped
Any other
D04D
Who helped you decide the type of pan to be constructed?
Local NGO worker
Sarpanch
Neighbor who already had a toilet
Retailer who sold the toileteries
Mason
Government Officials
No one helped
Any other
D05
Did you face any resistance from anyone when you told them about your decision to build a toilet?
Yes
No
D06
If Yes, from whom?
Family members
Neighbors
People from your caste
People from your religion
Any Other (please specify)
D07
What are the main reasons why this household constructed a toilet?
Avail the benefits of the scheme
Pressure from Panchayat
Self-motivation-Realising the benefits of toilet construction
Others
Financial Information/Fund Availability
E01
How much time did it take to construct the toilet?
E02
How much did the construction of the toilet cost you?
E03
At the time of construction where did you arrange the money from?
Sarpanch / PRI MemberPanchayat
Relative
Local Moneylender
Local SHG
Bank
Others(please specify)
E04
Were you charged any interest?
Yes
No
E05A
Till date have you received the compensation /incentive for toilet consruction as mandated under the SBM guidelines?
Yes
No
E05B
If yes, what is the amount received so far?
E06
In case yes, how many days after construction did you receivethe amount?
E07
Were you satisfied with the financial compensation received from the government?
Yes
No
E08
If government aid received, ask this question.
Yes
No
E09
If answered Yes above What were the reasons?
Did not know how to submit the application for completion of toilet construction
The amount was disbursed after a very long time of toilet construction
Nobody to direct/guide
Did not get the promised amount
Others
E10A
Did you hire/contract someone for construction/fitting of the toilet?
E10A_1
Mason
Yes
No
E10A_2
Labourer for digging the pit
Yes
No
E10A_3
Plumber
Yes
No
E10A_4
Others
Yes
No
E10B
If Yes,Amount (in Rs.)
E10B_1
Mason
E10B_2
Labourer for digging the pit
E10B_3
Plumber
E10B_4
Others
E11
Did you also contribute in construction of the toilet, by means of physical labour?
Yes
No
E12
If yes, then how much would you have earned, had you worked the same amount?
E13A
Did you buy or receive the following material for the construction of toilet?
E13A_1
Bricks/Stone
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_2
Cement/sand
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_3
Toilet pan
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_4
Door
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_5
Asbestos Sheet
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_6
Pipe
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13A_7
Other material(specify)
Neither bought nor received from government
Buy
Received from Govt/ Panchayat
E13B
How much did it cost you?
E13B_1
Bricks/Stone
E13B_2
Cement/sand
E13B_3
Toilet pan
E13B_4
Door
E13B_5
Asbestos Sheet
E13B_6
Pipe
E13B_7
Other material(specify)
Cost of maintenance
F01
Do you spend any money for water consumption for toilet usage?
Yes
No
F02
How much money do you spend for water every month?
F03
Do you face any water scarcity for toilet usage?
Yes
No
Knowledge and Attitude towards toilet usage
G01
According to you, what are the important benefits of going to toilet for defecation?
Safety from being bitten by reptiles, snakes etc.
Safety of women in the household’
Controls spreading of diseases
Comfort for the older members of the household
Good for sanitation and hygine
Ensures Privacy
Any other (please specify)
G02
Do you think there is any harm to health of others in going out for defecation in open?
Yes
No
G03A
By defecating in the open, what are the various diseases which could be spread?
Some deadly disease
Diarrhea
Dysentery
Cholera
Any other (please specify)
Don’t know/Can’t say
G03B
In the last two years, has any member in the household contacted any disease/ailment linked to open defecation - like diarrhea, dysentery or cholera?
Yes
No
G04
We will read out some statements which people like you have made about sanitation and toilet construction. We would like to know to what extent do you agree/disagree to these statements.
G04_1
Going out in open for defecation is good for health
Agree
Disagree
G04_2
Defecating in the open is good for the soil; improving its quality
Agree
Disagree
G04_3
Defecating in the open lead to spread of any diseases.
Agree
Disagree
G04_4
Taking a stroll in the open is an important benefit of going for open air defecation
Agree
Disagree
G04_5
The family’s prestige is hampered if the women go for open defecation
Agree
Disagree
G04_6
The daughter in law and father in law should not use the same latrine
Agree
Disagree
G04_7
I use the latrine because I am afraid of being bitten by snakes, leeches and other kinds of insects
Agree
Disagree
G04_8
While defecating in the open, I get the opportunity to chit-chat with my friends and discuss household issues with them
Agree
Disagree
G04_9
It is impure to have a toilet within the household premises
Agree
Disagree
G04_10
There are too many people in the household for just one latrine
Agree
Disagree
G04_11
It is inconvenient to get the water needed to defecate in the toilet
Agree
Disagree
G04_12
At night, it is convenient to use the latrine for defecation rather than going out
Agree
Disagree
HANDWASHING
H01
On what occasions do you wash your hands usually?
Before cooking
After handling food
Before eating
Before feeding the infant
After cleaning infant faeces
Before Prayer
After Work
After washing dishes
After defecating
After urinating
Others (Specify)
H02
Whether or not soap is used while washing hands during this instance?
H02_1
Before cooking
Yes
No
H02_2
After handling food
Yes
No
H02_3
Before eating
Yes
No
H02_4
Before feeding the infant
Yes
No
H02_5
After cleaning infant faeces
Yes
No
H02_6
Before Prayer
Yes
No
H02_7
After Work
Yes
No
H02_8
After washing dishes
Yes
No
H02_9
After defecating
Yes
No
H02_10
After urinating
Yes
No
H02_11
Others (Specify)
Yes
No
Asset Index
I01
Does your household own this house or any other house?
Yes
No
I02
Observe roof, wall and floor and record
Pucca
Semi Pucca
Kuccha
I02A
What is the main material of which the floor is made of?
Natural floor (mud/clay/sand/dung)
Rudimentary floor (raw wooden planks/ bamboo/stone/brick)
Finished floor (Marble/cement/tiles/polished wood or stone)
I02B
What is the main material of which the roof is made of?
Natural roof (no roof/thatch/grass/mud/plastic or polythene sheet)
Rudimentary roof ((Mat/Bamboo/Unburnt Brick/raw wooden planks/stones)
Finished roof (Metal/cement/wood/asbestos sheets/tiles/concrete/burnt bricks)
I02C
What is the main material of which the exterior walls are made of?
Natural wall (no wall/thatch/grass/mud/cane /bamboo)
Rudimentary wall ((Mat/Bamboo/Unburnt Brick/raw wooden planks/stones)
Finished wall (Metal/cement/wood/asbestos sheets/tiles/concrete/burnt bricks)
I02D
Do you have any window at home?
Yes
No
I02E
How many rooms in this house are used for sleeping?
I03
What is the main source of drinkingwater for members of your household?
Piped water in residence/yard/plot
Hand pump in residence/yard/plot
Well water in residence/yard/plot
Public hand pump
Public tap
Public well
Bore well
Canal
Other source (specify)
I04
What is the main source of lighting for your household?
Electricity
Kerosene lamp nhid
Gas lamp /nhid
Candle
Solar energy
Other (specify)
I05
What type of fuel does your household commonly use for cooking?
Wood
Crop residues
Dung cakes
Coal/ charcoal
Kerosene
Electricity
Liquified petroleum gas
Bio-gas
Other (specify)
I06
Does your household own any of the following items:
I06_1
Electric connection
Yes
No
I06_2
Pressure cooker
Yes
No
I06_3
Mixer/grinder
Yes
No
I06_4
Motorcycle/scooter
Yes
No
I06_5
Car/Jeep
Yes
No
I06_6
Tractor
Yes
No
I06_7
Bicycle
Yes
No
I06_8
Animal-drawn cart
Yes
No
I06_9
Chair
Yes
No
I06_10
Table
Yes
No
I06_11
Cot/ Bed
Yes
No
I06_12
Mattress
Yes
No
I06_13
Clock or watch
Yes
No
I06_14
Electric fan
Yes
No
I06_15
Water pump
Yes
No
I06_16
Thresher
Yes
No
I06_17
Radio/Transistor
Yes
No
I06_18
Sewing machine
Yes
No
I06_19
Refrigerator
Yes
No
I06_20
B & W television
Yes
No
I06_21
Colour television
Yes
No
I06_22
Telephone
Yes
No
I06_23
Computer
Yes
No
I06_24
Mobile
Yes
No
I07
Does your household have a bank account or post-office account?
Yes, bank account
Yes, post office account
Both Bank and Post Office account
None
I08
Does your household own livestock?
Yes
No
I09
What all does livestock include
I09_1
Bullocks
Yes
No
I09_2
Cow
Yes
No
I09_3
Cross bred cow
Yes
No
I09_4
Buffalo
Yes
No
I09_5
Goats/Lambs
Yes
No
I09_6
Poultry
Yes
No
I09_7
Other (Specify)
Yes
No
I10
Does this household own any agricultural land?
Yes
No
I11
How much agricultural land does this household own?
I12
Out of this land, how much is irrigated?
I13
Please specify whether you belong to APL/BPL?
I13A
Card Observed and filled
APL
BPL
Antodyaya Anna Yojana
Don’t know/cant say
I13B
Card not available with the respondent. Filled as per respondent’s answer
APL
BPL
Antodyaya Anna Yojana
Don’t know/cant say
TOILET OBSERVATIONS
J01
Is there a pan fitted in the toilet?
Cement
Porcelain
Steel
Not present
Any other (please specify)
J02
What are the walls made of?
Mud/Bamboo
Bricks/Stones joined with mud
Bricks/Stones joined with cement
Any other (please specify)
J03
Is there a roof in the toilet?
No roof
Thatched
Cemented
Asbestos sheet
Plastic sheet
Any other (please specify)
J04
Is there water available in the toilet
Yes
No
J05
What is the source of water in the toilet?
Container/Tumbler
Tap
Any other (please specify)
J06
Is there any water stagnated around the toilet?
Yes
No
J07
Is there a flush tank in the toilet
Yes
No
J08
Is the flush tank working
Yes
No
J09
Is there electric bulb in the toilet
Yes
No
J10
Is there proper ventilation/windows in the toilet
Yes
No
J11
Is there a door?
Yes
No
J12
Can it be locked from inside?
Yes
No
J13
Can it be locked from outside?
Yes
No
J14
Was there a handwashing facility near or inside the toilet?
Yes
No
J15
Was there soap available near the handwashing facility?
Yes
No
J16
Where is the toilet constructed?
At a podium
At ground level
Below ground level
J17
Where is the toilet located
Attached to the main structure of the house
Very close to the main structure of the house and within the house premises
Outside the house premises
Women Section: To be administered to the adult female of the family
K01
Name
K02
Age
K03
Educational Qualification
not literate
literate without formal schooling
literate: below primary
primary
upper primary/ middle
secondary
higher secondary
diploma/certificate course (below graduate level)
graduate
postgraduate and above
K04
Relationship to the Household head
WIFE
OWN DAUGHTER
STEP DAUGHTER
GRANDCHILD
SISTER
PARENT
PARENT-IN-LAW
NEPHEW
DAUGHTER IN LAW
SISTER IN LAW
OTHER, SPECIFY
Exposure to IEC/BCC activities (Motivations & reasons for building a toilet) - Women
L01
Can you tell us from where did you/ any HH member got to hear about constructing toilet for the first time?
SHG member
Sarpanch/ PRI
Neighbor
TV ad
Wall painting
Health worker(Asha, AWW, ANM etc)
Representatives from School (Teacher/Principal)
Swacchata Doot/Swacchata Prerak
Govt Official
No one
Any other( please specify)
L02
Were you ever counselled by any person (NGO workers, Panchayat members, ASHA, AWW, ANM, School Teacher, School Principal, Govt officials etc.) about benefits of construction / usage of toilets or ill effects of Open defecation?
Yes
No
L03
If yes, by whom?
Panchayat members
Health workers (ASHA, AWW, ANM, doctor)
NGO workers
Govt Officials
Swatchta Doot/Prerak
Other
L04
Was the importance of issues of toilet construction and usage discussed in Gram Sabha, Panchayat meetings or other village level meetings?
Yes
No
L05
Are there any hoardings or posters or wall paintings in your gram panchayat, which mention the importance of toilet construction and usage?
Yes
No
L06
Were there any special events conducted in your gram panchayat, which focused on toilet construction and toilet usage?
Yes
No
L07
If yes, what were they?
Nukkad Natak
Processions for toilet usage awareness
Video Screening
Special meetings with community members for toilet usage
Any Other
L08
Do you think such events (IEC activities, including counselling) encouraged/motivated you to construct toilets?
Yes
No
L09
If yes, which of the events?
Nukkad Natak
Processions for toilet usage awareness
Video Screening
Special meetings with community members for toilet usage
Poster/wall painting/hoardings
Counselling
Any Other
Knowledge and Attitude towards toilet usage _ Women
M01
According to you, what are the important benefits of going to toilet for defecation?
Safety from being bitten by reptiles, snakes etc.
Safety of women in the household
Controls spreading of diseases
Comfort for the older members of the household
Good for sanitation and hygine
Ensures Privacy
Any Other
M02
Do you think there is any harm to health of others in going out for defecation in open?
Yes
No
M03A
By defecating in the open, what are the various diseases which could be spread?
Some deadly disease
Diarrhea
Dysentery
Cholera
Any other (please specify)
Don’t know/Can’t say
M03B
In the last two years, has any member in the household contacted any disease/ailment linked to open defecation - like diarrhea, dysentery or cholera?
Yes
No
M04
We will read out some statements which people like you have made about sanitation and toilet construction. We would like to know to what extent do you agree/disagree to these statements.
M04_1
Going out in open for defecation is good for health
agree
Disagree
M04_2
Defecating in the open is good for the soil; improving its quality
agree
Disagree
M04_3
Defecating in the open lead to spread of any diseases.
agree
Disagree
M04_4
Taking a stroll in the open is an important benefit of going for open air defecation
agree
Disagree
M04_5
The family’s prestige is hampered if the women go for open defecation
agree
Disagree
M04_6
The daughter in law and father in law should not use the same latrine
agree
Disagree
M04_7
I use the latrine because I am afraid of being bitten by snakes, leeches and other kinds of insects
agree
Disagree
M04_8
While defecating in the open, I get the opportunity to chit-chat with my friends and discuss household issues with them
agree
Disagree
M04_9
It is impure to have a toilet within the household premises
agree
Disagree
M04_10
There are too many people in the household for just one latrine
agree
Disagree
M04_11
It is inconvenient to get the water needed to defecate in the toilet
agree
Disagree
M04_12
At night, it is convenient to use the latrine for defecation rather than going out
agree
Disagree
M05
Is there any member in the family who does not use the toilet regularly/defecates in the open?
Yes
No
M06
If yes, then why?
Limited water
Water stagnation in the toilet
Pit is small so gets filled up frequently
Consider defecating in open better
High cost of getting the pit claeaned
Does not think toilet is properly constructed
Other (specify)
M07
Where did majority of the household members defecate before construction of this toilet?
Open defecation
Neighbour’s toilet
Community toilet
Others
Don’t know
M08
What problems did you/ other members of the household faced while you were using Community or neighbour’s toilet?
Cleanliness issue
Uncomfortable to use/privacy issues
Lower and upper caste all use the same toilets
Water scarcity
Long waiting time
Inconvenience at night
Others
Dear user, please upgrade your plan to access this feature
See Plans
Please Wait