DRINKING WATER

1) Main Source of drinking water/WASHING/BATHING/COOKING?

2) Access to the principal source of drinking water
3) Distance to the principal source of drinking water
4) How do you store your drinking water?
5) Do you treat your water in any way to make it safer to drink? (if yes mention it)
6) Is quantity/quantity of water available is sufficient ?

Availability and usage of Toilet Facility

1) Do you have toilet in your home? (Make sure that it is referring to a toilet and not a bathroom)?
2) What is the source of water in the toilet?(If ans is no skip to ques 6)
3) What Kind of toilet it is?
4) Have you encountered problems with your toilet (with its maintenance, its design)? Overflow,
smell?
5) What kind of drainage facility does your latrine have?(black water)
6) Why do not you have a toilet?
7) Where you go for toilet?(open field,farmlands,outskirt vegetated areas)
8) How much is open defecation area is away from village dwelling?

Waste water management

1) How is wastewater(grey) from kitchen and bathroom is disposed?(drainage facility)

2) Where does waste water is drained ? (some pond in village/decentralized facility etc)
3) What kind of drains are present in and around village?( underground 1, covered pucca 2,
open pucca 3, open katcha 4, no drainage 5)
4) Is there any treatment facility available?
5) If yes what is it?

Solid Waste Management

1) Arrangement made for collection of garbage from the household? (by panchayet/municipality
/corporation 1, by resident/group of residents 2, others 3, no arrangement 4)
2) Site where garbage is deposited after removal from the household? (To bio-gas plant or manure
pit-1, to community dumping spot-2, to households individual dumping spot(s)-3, No
designated area 4, others-5, not known-6)
3) Is that place covered?
4) How frequently garbage is cleared?(Daily-1, not daily but at least once in a week-2, not even
once in a week-3, not known-4)
5) Disposal of animal/poultry Excreta (To bio-gas plant-1, manure pit-2, used as fuel- 3, others-9,
not known-4)
6) Do you believe that the garbage has caused disease(s) in your household?
7) If yes, what disease(s)? Diarrhea : 1 : 1 skin diseases: 2 : 2 typhoid: 3 : 3 giardia :
4respiratory problem: 5 stomach ache: 6 : 4 Dont know:7
 8) What problems are caused by garbage lying in open ground generally? it brings germs 1, it has
a bad smell 2, it attracts mosquitoes 3, it spreads diarrhea 4, Others 5 dont know

Self sanitation (not compulsory)

1) How regularly is the house cleaned?

2) What do you use to wash your hands after defecating?
3) Do you wash your hands always before eating?
4) Do you wash your hands always before eating?
5) Do you wash your hands always after dealing with animals?
6) Where do you dispose the stools of children/ babies?
7) If children of 5 or below are present measure their height in cm

A short note on overall sanitation and hygenine of village should be made marking the
uniqueness of problem or goodness of sanitation facilities available.
 Village Level Information Survey

To interview Head Panchayat, or Vice Head Panchayat

Serial Question Answer
No
1 Village Name
2 GP Name

3 Block Name

4 Approximate number of households

5 Dominated by which caste? General caste 1, SC 2,

ST 3, Muslim 4, Others
99 (specify)
6 Does it have a Primary school within the village? Yes 1 No 0

7 Does it have a Primary health Centre or Sub centre within Yes 1 No 0

the village?
8 ANM (Auxiliary Nurse Mid-wife) available there? [with Yes 1 No 0
pink saree]
9 How many ASHAs (Accredited Social Health Activist)
cater to the village? [with purple saree]

10 How many AWC (Anganwadi centre) are there within the Yes 1 No 0
village?
11 How far is the Block HQ? (in KM)

12 How far is the GP HQ? (in KM)

13 Is there all weather motorable road connectivity to GP Yes 1 No 0

HQ?
14 Has the village received a Nirmal Gram Puraskar? Yes 1 No 0

15 If yes, which year?

16 Has the GP received NGP? Yes 1 No 0

17 If yes, which year?

How many only primary schools (1st to 5th standard)

How many middle schools (6th to 8th )
How many secondary schools (9th -10th )
 How many higher-secondary schools (11th -12th )
18 How many Schools have functioning toilets? Yes 1 No 0

19 AWC have functioning toilets? Yes 1 No 0

20 No of Gram Sabha Members from the village

21 All of them have toilets in their houses? Yes 1 No 0

22 Any community toilet maintained by Panchayat? Yes 1 No 0

23 If yes, is it regularly cleaned (at least once a week)? Yes 1 No 0