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Household Template 55 -Form Fill
Identifiers
Q01
Name of State
Q02
Code of State
Q03
Name of District
Q04
Code of District
Q05
Name of the block
Q06
Code of the block
Q07
Name of PSU
Q08
Code of PSU
Q09
Structure number
Q10
Household Number
Q11
Name of the head of the household
Q12
Name of the respondent
Q13
Relation to head of household
Q14
Age of the respondent
Survey Information (To be filled by the enumerator)
A01
Interviewer name
A02
Interviewer code
A03
Supervisor Name
A04
Supervisor Code
A05
Date of the interview
A06
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)
A07
TIME STARTED
A08
TIME FINISHED
Family Details
B01
Number of members in the HH
B02
What is your religion?
Hindu
Muslim
Christian
Sikh
Buddhist/Neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No Religion
Other (Specify)
B03
Which caste category do you belong to?
Scheduled Caste
Scheduled Tribe
Other Backward Caste
General
Other (Specify)
B04
Which of the following cards does your household possess?
Apl
Bpl
Annapurna
Antyodaya
Single Card
No Card
Don’t Know
B05
Interviewer to check bpl card
Yes, Card Seen
Yes, Card Not Seen
No
B06
Can you read and write ?
Can Read
Can Write
Both Read And Write
None
B07
What is the highest standard or class you completed?
Never Attended School
Did Not Complete Primary
Completed Primary
Completed Upper Primary/ Middle
Completed Secondary
Completed Higher Secondary
Diploma/Certificate Course (Below Graduate Level)
Graduate
Postgraduate and Above.
B08
What kinds of work (household main occupation) do you do?
Farming (Crops)
Agricultural Day Labor
Herding Animals
Non-Agricultural Day Labor
Maid Servant/Cleaning
Cook
Child Care Provider
Service/Salaried Worker
Small/Cottage Industry
Petty Business/Shop
Business/Trader
Other Self-Employment
Skilled Worker
Other (Specify)
HOUSEHOLD CHARACTERISTICS (ALL CATEGORIES)
C01
Do you/your family own this house or any other house?
Yes
No
C02
What is the type of house?
Kutcha
Semi Pucca
Pucca
C03
What type of fuel does your household mainly use for cooking?
Electricity
LPG/Natural Gas
Biogas
Kerosene
Coal/Lignite
Charcoal
Wood
Straw/Shrubs/Grass
Agricultural Crop Waste
Dung Cakes
Other (Specify)
C04
What is the main source of lighting in this household?
Lantern
Kerosene Lamp
Candle
Electric
LPG/Battery
Solar Energy
None
Others (Specify)
C05
What is the source of drinking water for members of your household in dry season?
Piped into Dwelling
Piped To Yard/Plot
Public Tap/Standpipe
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/Well At Home
Neighbour’s Hand
Other (Specify)
C06
How far from home is the main source of drinking water located in dry season?
C07
How long on average does it take to go to the water source, get water, and come back in dry season?
C08
What is the source of drinking water for members of your household in non-dry season?
Piped into Dwelling
Piped To Yard/Plot
Public Tap/Standpipe
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/Well At Home
Neighbour’s Hand
Other (Specify)
C09
How far from home is the main source of drinking water located in non-dry season?
C10
How long on average does it take to go to the water source, get water, and come back in non-dry season?
Details of the toilet in the house
D01
Does your household have a toilet?
Yes
No
D02
In which month and year was the toilet constructed?
D03
Who paid for construction of toilet?
HH Paid for It Entirely On Its Own
Partly Subsidized by The Government
Completely Paid by Government
Partly Subsidized by NGO/CBO
Completely Paid by NGO/CBO
Given/Offered by Relative or Friend
Already Existed in The House
Loan
Don’t Know
Others (Please Specify)
D04
Who was involved in the decision making regarding the construction of the toilet?
All family members/collective decision
Head of HH
Eldest male member of the household
Eldest female member of the household
Respondent
Already Existed in The House
Don’t Know
Others (please specify)
D05
What were the reason because of which you/your HH decided to build a toilet?
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 hygiene
Daughter attained puberty
Neighbours got a toilet
We would like to appear modern
Status Symbol
Already Existed in The House
Other (please specify)
D06
Who usually makes decisions about who all in the family will use the toilet for defecation?
Respondent
Wife/Mother
Respondent and Wife/Mother Jointly
Other Household Members
Wife/Mother and Other Household Members Jointly
All Household Members Jointly
Each Member Decides For
Other
D07
How many toilets does your household have?
D08
What kind of toilet facilities does your household have?
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)
D09
Is this toilet located within the premise of the household?
Yes
No
D10
Is there a door in the toilet?
Yes
No
D11
Can it be locked from inside?
Yes
No
D12
Is there a source of light in the toilet?
Yes
No
D13
Is/Are there window(s) in the toilet?
Yes
No
D14
Does the household have soap near (within 2 meters) or inside the toilet facility?
Yes
No
D15
Is sufficient water available in the toilet throughout the year?
Yes
No
D16
For how many months sufficient water i.e. as much required for sanitation activities of the HH is available throughout the year?
D17
Who usually cleans the toilet?
Male HH Member
Female HH Member
Not Fixed, Could Be Male Or Female
Pay Someone to Clean It
Other (Specify)
D18
Do you think there is any disadvantage of having a toilet?
Yes
No
D19
What are the disadvantages of having a toilet?
Takes Up Space in The House
Construction Cost is High
Maintenance Cost ss High
It Is Not Hygienic to Have the Toilet Inside
Requires Sewerage System
Requires Water Facility
It Is Against Our Traditions
It Is Unnecessary
It smells
Others
D20
How satisfied are you with your toilet facility?
Very Satisfied
Satisfied
Unsatisfied
Very Unsatisfied
Don’t Know/Can’t Say
D21
What are the main reasons for the dissatisfaction?
No Water Supply
Gives Bad odour
It Is Wet All the Time
Sludge Overflows in The Toilet
Vermin Infestation
Toilet Has No Roof
Pit Gets Full
Improper Sewerage System
Number Of Toilets Is Not Sufficient
No one to clean the toilet
Don’t Know
Others
D22
Do you think there are any ill effects of open defecation?
Yes
No
D23
What are the ill effects of defecating in open?
Spreads Diseases
Spoils Environment
Not Safe for Girls And Women
Can Fall Ill/Get Disease
Takes Time
Other (Specify)
Details of Toilet usage
E01
Under normal conditions, where do you urinate?
E01A
Before construction of toilet
Own toilet
Community toilet
Neighbour’s toilet
Street
Park
Railway track
Near Sewage line
Open field
Open space near home
Bathroom
E01B
After construction of toilet
Own toilet
Community toilet
Neighbour’s toilet
Street
Park
Railway track
Near Sewage line
Open field
Open space near home
Bathroom
E02
Under normal conditions, at what time of the day do you defecate?
E02A
Before construction of toilet
Early morning
In the evening
In afternoon
At night (complete dark)
Any time during the day
E02B
After construction of toilet
Early morning
In the evening
In afternoon
At night (complete dark)
Any time during the day
E03
Under normal conditions, where do you defecate?
E03A
Before construction of toilet
Own toilet
Community toilet
Neighbour’s toilet
Street
Park
Railway track
Near Sewage line
Open field
Open space near home
E03B
After construction of toilet
Own toilet
Community toilet
Neighbour’s toilet
Street
Park
Railway track
Near Sewage line
Open field
Open space near home
E04
Is there any specific reason for always not using the toilet?
E04A
Before construction of toilet
Limited/No water
Pit is small so gets filled up frequently
Water stagnation in the toilet
High cost of getting the pit cleaned 4
Do not like using the toilet
Not accustomed to the toilet/not habituated
Like to go for a walk
Consider healthier to go in open
Afraid to use toilet
Difficult for all HH members to manage with one toilet
No toilet in HH
Child is too young to use toilet
Community toilet has a queue
Do not want to share toilet with women
Other (specify)
E04B
After construction of toilet
Limited/No water
Pit is small so gets filled up frequently
Water stagnation in the toilet
High cost of getting the pit cleaned 4
Do not like using the toilet
Not accustomed to the toilet/not habituated
Like to go for a walk
Consider healthier to go in open
Afraid to use toilet
Difficult for all HH members to manage with one toilet
No toilet in HH
Child is too young to use toilet
Community toilet has a queue
Do not want to share toilet with women
Other (specify)
E05
How far is the place of defecation?
E05A
Before construction of toilet
E05B
After construction of toilet
E06
What is the average total time spent to travel to and from the place of defecation?
E06A
Before construction of toilet
E06B
After construction of toilet
E07
After getting the toilet at home, what do you do with the time you spent to travel to place of defecation?
Sleep
Household work/chores
Eat
Occupation related work
Leisure
Other (specify)
PSYCHOLOGICAL STRESS AND COPING MECHANISM
F01
How frequently have you faced the below challenge while performing any sanitation activity?
F01_1
Travelling long distance
Never
Sometimes
Often
Always
F01_2
Crossing difficult obstacles (like walls, ditches etc.)
Never
Sometimes
Often
Always
F01_3
Discomfort at the site due to mosquitoes or other insects
Never
Sometimes
Often
Always
F01_4
Fear of encountering snakes or other animals at site
Never
Sometimes
Often
Always
F01_5
Discomfort at the site due to stones or other sharp objects
Never
Sometimes
Often
Always
F01_6
Due to muddy ground at the site, during rainy season
Never
Sometimes
Often
Always
F01_7
Poor condition of common latrines
Never
Sometimes
Often
Always
F01_8
Fear of being seen while performing sanitation activities
Never
Sometimes
Often
Always
F01_9
Social restrictions like who you should be seen with or who you should talk to etc.
Never
Sometimes
Often
Always
F01_10
Conflicts within family due to long time spent for sanitation activities
Never
Sometimes
Often
Always
F01_11
Conflict at sanitation site due to limited space and resources
Never
Sometimes
Often
Always
F02
Do you do anything to cope with the urge to urinate/defecate under normal conditions
F03
what do you do to cope with urge to urinate/defecate?
F03_1
Reduce food intake to avoid need to defecate
Yes, Spontaneous
Yes, After Reading
No
F03_2
Reduce water/liquid intake to avoid need to urinate/defecate
Yes, Spontaneous
Yes, After Reading
No
F03_3
Control urge to urinate/defecate
Yes, Spontaneous
Yes, After Reading
No
F04
Under normal conditions, how frequently do you have to do this?
F04_1
Reduce food intake to avoid need to defecate
Never
Rarely
Sometimes
Usually
F04_2
Reduce water/liquid intake to avoid need to urinate/defecate
Never
Rarely
Sometimes
Usually
F04_3
Control urge to urinate/defecate
Never
Rarely
Sometimes
Usually
F05
Do you practice this more during day or night?
F05_1
Reduce food intake to avoid need to defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F05_2
Reduce water/liquid intake to avoid need to urinate/defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F05_3
Control urge to urinate/defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F06
When you have diarrhoea, how frequently do you have to do this?
F06_1
Reduce food intake to avoid need to defecate
Never
Rarely
Sometimes
Usually
F06_2
Reduce water/liquid intake to avoid need to urinate/defecate
Never
Rarely
Sometimes
Usually
F06_3
Control urge to urinate/defecate
Never
Rarely
Sometimes
Usually
F07
If coded 2,3 or 4, Do you practice this more during day or night?
F07_1
Reduce food intake to avoid need to defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F07_2
Reduce water/liquid intake to avoid need to urinate/defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F07_3
Control urge to urinate/defecate
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F08
Do you do anything to cope with the problem of less water available for sanitation activities under normal conditions or during diarrhoea?
F09
what do you do to cope with problem of less water available?
F09_1
Use less water for post defecation cleaning
Yes, Spontaneous
Yes, After Reading
No
F09_2
Do not flush/use less water to flush after using toilet
Yes, Spontaneous
Yes, After Reading
No
F10
Under normal conditions, how frequently do you have to do this?
F10_1
Use less water for post defecation cleaning
Never
Rarely
Sometimes
Usually
F10_2
Do not flush/use less water to flush after using toilet
Never
Rarely
Sometimes
Usually
F11
Do you practice this more during day or night?
F11_1
Use less water for post defecation cleaning
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F11_2
Do not flush/use less water to flush after using toilet
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F12
When you have diarrhoea, how frequently do you have to do this?
F12_1
Use less water for post defecation cleaning
Never
Rarely
Sometimes
Usually
F12_2
Do not flush/use less water to flush after using toilet
Never
Rarely
Sometimes
Usually
F13
If coded 2,3 or 4, Do you practice this more during day or night?
F13_1
Use less water for post defecation cleaning
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F13_2
Do not flush/use less water to flush after using toilet
Only During Day
Only During Night
More During Day
More During Night
Same During Day And Night
F14
Do you do anything to cope with the problem of poor/unsafe/no toilet facility under normal conditions or during diarrhoea?
Yes
No
Experience of Self-respect
G01
Have there been any instances when you felt embarrassed or humiliated due to lack of toilets at your home?
Yes
No
G02
How often do you experience these situations/incidents now after getting a toilet?
Never
Rarely
Sometimes
Usually
G03
Were you afraid of being judged by others due to a lack of toilet at home?
Yes, always
Yes, sometimes
No
G04
In case of any guests or relatives at home, did you feel embarrassed or humiliated due to a lack of toilet?
Yes
No
G05
How often do you experience such situations now, after getting a toilet?
Never
Rarely
Sometimes
Usually
G06
Did you face any situation where you avoided certain guests/relatives due to lack of toilet?
Yes
No
G07
Do you think the people in your community viewed you or your household differently when you did not have a toilet at home?
Yes
No
G08
How do you think did they view you differently?
Think less of you/your household
Think less of you due to other reasons (than no toilet)
Viewed you the same
Thought highly of you regardless of toilet or lack thereof
G09
Did you ever face restrictions in your movement/mobility due to lack of toilets at home?
Yes
No
G10
Did you ever feel embarrassed or awkward to use the toilet at home, in presence of others?
Yes
No
G11
Did you ever feel embarrassed or awkward to use the toilet at home, in presence of family elders?
Yes
No
G12
Did you or your family experience a sense of pride/satisfied after getting a toilet at home?
Yes
No
Community Behaviors
H01
Has there been any change in the community in toilet usage, after the construction of toilets?
Yes
No
H02
Can you tell us what has been the change in community?
All of community members use toilets
Most of the community members use toilets
Some of the community members use toilets
H03
According to you, what are the reasons for non-usage of toilets?
Toilet maintenance is difficult
Lack of Awareness on toilet usage
Traditional norms
Lack of Soap /water in the toilets
Toilets are located too far
Too crowded
Toilets are smelly
Other (specify)
H04
Do you feel embarrassed/awkward watching others defecate in the open?
Yes
No
H05
Have there been any accidents that you know of, due to open defecation practices in the community?
Yes
No
H06
Can you tell us, what kind of accidents have happened due to open defecation?
Individual assault
Harm from animals
Road accidents/train accidents
Health issues/risks
Other (specify)
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