Water Usage Questionnaire – Short Form
Water Usage Questionnaire – Short Form
Interviewer Name Date
Parish Subject No.
Zone/Cell Respondent: Male Female Child
Section 1: Water Sources
A: Main Water Source
I would like to learn about the different places you or someone in your family gets water from, NOT INCLUDING RAINWATER AND VENDORS
1. Firstly I Would Like To Know Where You Most Often Get Your Water From?
[If the person says “spring”, ask if it is a protected or unprotected spring. TICK the number of the type of source]
|TYPE OF SOURCE |TICK |
|Spring |Protected |1 |
| |Unprotected |2 |
|Tap | |3 |
|Other | |4 |
2. What Do You Use This Water For?
[If only one use is given say “do you use this water for anything else?” Tick EACH
answer the person gives]
|USE |TICK | |
|Consumption |1 |Drinking, Cooking and food preparation |
|Other domestic use |2 |Bathing, laundry etc |
3. What Kind Of Container Do You Use To Collect Water And How Big Is It?
[Ask person to show you if you are not clear]
Type of container Approximate Litres
4. How Many Jerry Cans (Other Vessel) Of Water Do You Collect From This Source Each Day?
Number of Jerry Can/other container
B: Second Water Source
Often people use more than one place to get their water from
1. Are There Are Any Other Places You Get Water From, NOT INCLUDING RAINWATER AND VENDORS? [IF NO, GO TO SECTION 2 ]
❑ Yes
❑ No
2. Which Is The Place You Get Water From Most Often After (Say Name Of Primary Water Source)
|TYPE OF SOURCE |TICK |
|Spring |Protected |1 |
| |Unprotected |2 |
|Tap | |3 |
|Other | |4 |
3. What Do You Use This Water For?
[If only one use is given say “do you use this water for anything else?” Tick EACH
answer the person gives]
|USE |TICK | |
|Consumption |1 |Drinking, Cooking and food preparation |
|Other domestic use |2 |Bathing, laundry etc |
4. What Kind Of Container Do You Use To Collect Water And How Big Is It?
[Ask person to show you if you are not clear]
Type of container Approximate Litres
5. How Many Jerry Cans (Other Vessel) Of Water Do You Collect From This Source Each Day?
Number of Jerrycan/other container
C: Other sources
Do You Use Any Other Water Sources, NOT INCLUDING RAINWATER AND VENDORS? [IF NO, GO TO SECTION 2]
❑ Yes
❑ No
[More than one source can be ticked, state name of source]
❑ Tap Name
❑ Protected Spring
❑ Unprotected Spring
❑ Other
Section 2: Other water
A: RAINWATER
Do You Ever Collect Rainwater?
❑ Yes
❑ No
Observation: Is There Guttering And Tank/Drum For Rainwater Collection?
❑ Yes
❑ No
B: VENDORS
1. Do You Buy Water From Vendors [IF NO GO TO SECTION 3]
❑ Yes
❑ No
2. How Often Do You Buy Water From A Vendor?
❑ Every day
❑ At least once a week
❑ At least once a month
❑ Very occasionally
3. How Much Water Do You Buy On Each Occasion?
Type of Container Number
Section 3: Socio-demographic Information
Finally I would like to ask you some information about your household
1. How Many People Live In Your Household?
No. Women No. of Men No. of Children
FOR OFFICE USE ONLY:
Total No. SOURCES
No. external SOURCES
Water Usage Questionnaire – Long form
Interviewer Name Date
Parish Subject No.
Zone/Cell Respondent: Male Female Child
Section 1: Water Sources
PART A: Primary Water Source
To start with, I would like to learn about the different places you or someone in your family get water from, NOT INCLUDING RAIN WATER AND VENDORS
5. Firstly I Would Like To Know Where You Most Often Get Your Water From?
[If the person says “spring”, ask if it is a protected or unprotected spring. TICK the number of the type of source]
|TYPE OF SOURCE |TICK |
|Spring |Protected |1 |
| |Unprotected |2 |
|Tap | |3 |
|Other | |4 |
6. Why Do You Choose To Get Water From This Place?
[If only one reason is given say “are there any other reasons why you get water from this place?” TICK EACH answer the person gives]
|TICK |REASONS |TICK |REASON |
|1 |Distance |6 |Only source |
|2 |Cost |7 |Only tap |
|3 |Quality |8 |Personal/family reasons |
|4 |Reliability |9 |Other ………………… |
| | | |…………………………. |
|5 |Available | | |
7. What Do You Use This Water For?
[If only one use is given say “do you use this water for anything else?” Tick EACH
answer the person gives]
|TICK |USE |TICK |USE |
|1 |Bathing |5 |Animals |
|2 |Cooking |6 |Gardening |
|3 |Drinking |7 |Laundry |
|4 |Cleaning house |8 |Other……………………………………….. |
8. What Kind Of Container Do You Use To Collect Water And How Big Is It?
[Ask person to show you if you are not clear]
Type of container Approximate Litres
9. How Many Jerry Cans (Other Vessel) Of Water Do You Collect From This Source Each Day?
Number of Jerry Can/other container
10. Do you pay for the water from this source? [IF NO GO TO QUESTION 8]
❑ Yes
❑ No
11. How much do you pay for a Jerry Can?
12. Are there times when you find no water at this source? [IF NO GO TO PART B]
❑ Yes
❑ No
13. How often is there no water at this place?
❑ At least every day
❑ At least once a week
❑ At least once a month
❑ In the dry season
❑ Only occasionally
PART B: Second Water Source
Often people use more than one place to get their water from
I Would Like To Know If There Are Any Other Places You Get Water From, NOT INCLUDING RAINWATER AND VENDORS? [IF NO, GO TO PART D]
❑ Yes
❑ No
Which Is The Place You Get Water From Most Often After (Say Name Of Primary Water Source)
|TYPE OF SOURCE |TICK |
|Spring |Protected |1 |
| |Unprotected |2 |
|Tap | |3 |
|Other | |4 |
Why Do You Choose To Get Water From This Place?
[If only one reason is given say “are there any other reasons why you get water from this place?” TICK EACH answer the person gives]
|TICK |REASONS |TICK |REASON |
|1 |Distance |6 |Only source |
|2 |Cost |7 |Only tap |
|3 |Quality |8 |Personal/family reasons |
|4 |Reliability |9 |Other …………………… |
| | | |…………………………. |
|5 |Available | | |
What Do You Use This Water For?
[If only one use is given say “do you use this water for anything else?” Tick EACH
answer the person gives]
|TICK |USE |TICK |USE |
|1 |Bathing |5 |Animals |
|2 |Cooking |6 |Gardening |
|3 |Drinking |7 |Laundry |
|4 |Cleaning house |8 |Other……………………. ………………………….. |
What Kind Of Container Do You Use To Collect Water And How Big Is It?
[Ask person to show you if you are not clear]
Type of container Approximate Litres
How Many Jerry Cans (Other Vessel) Of Water Do You Collect From This Source Each Day?
Number of Jerry Can/other container
Do You Pay For The Water From This Source? [IF NO, GO TO QUESTION 9]
❑ Yes
❑ No
How Much Do You Pay For A Jerry Can?
Are There Times When You Find No Water At This Source? [IF NO, GO TO PART C]
❑ Yes
❑ No
How Often Is There No Water At This Place?
❑ At least every day
❑ At least once a week
❑ At least once a month
❑ In the dry season
❑ Only occasionally
Part C: Other sources
Do You Use Any Other Water Sources, NOT INCLUDING RAINWATER AND VENDORS? [IF NO, GO TO PART D]
❑ Yes
❑ No
[More than one source can be ticked, state name of source]
❑ Tap Name
❑ Protected Spring
❑ Unprotected Spring
❑ Other
Part D: Rainwater
Do You Ever Collect Rainwater?
❑ Yes
❑ No
Observation: Is There Guttering And Tank/Drum For Rainwater Collection?
❑ Yes
❑ No
Part E: Proximity
1. Which Of The Source You Have Mentioned Is Nearest To Your Home, Which Is The Next Nearest And Which Is The Furthest?
[Write type of source and name]
Nearest Second Nearest
Furthest
Section 2: Vendors
I would now like to ask you about whether you ever buy water from a vendor.
Do You Buy Water From Vendors [IF NO GO TO SECTION 3]
❑ Yes
❑ No
How Often Do You Buy Water From A Vendor?
❑ Every day
❑ At least once a week
❑ At least once a month
❑ Very occasionally
How Much Water Do You Buy On Each Occasion?
Type of Container Number
How Much Do You Pay Per Container?
Why Do You Buy From The Vendor?
[If give only one reason, ask “is there any other reason?”. Tick EACH answer given]
|TICK |REASON |TICK |REASON |
|1 |Lack of assistance in the home |5 |No other source/restricted access |
|2 |Proximity/Time |6 |Personal/family/health problems |
|3 |Cost |7 |Quality |
|4 |Inadequacy |8 | |
Section 3: Water Collection and Storage
I would now like to ask you about how you collect and store your water
1. Which People Collect Water In Your Family?
❑ Children
❑ Women
❑ Men
2. Where Do You Keep Or Store Your Water?
[Type of container and place]
3. Do You Do Anything To Your Water Before You Drink It?
❑ Yes
❑ No
If yes what do you do to it?
Section 4: Socio-demographic Information
Finally I would like to ask you some information about your household
2. How Many People Live In Your Household?
No. Women No. of Men No. of Children
How Many Rooms Do You And Your Family Live In?
3. Has Anyone In Your Family Had Diarrhea Within The Last Week?
❑ Yes
❑ No
Section 5: Observations by Health Worker
Floor Material
❑ Earth
❑ Wood/Stone
❑ Cement Screed
❑ Concrete/Brick
Roof Material
❑ Tile/Concrete
❑ Iron Sheet
❑ Asbestos
❑ Papyrus/Grass
Wall Material
❑ Concrete
❑ Burnt brick
❑ Unburnt bricks
❑ Pole and Mud
❑ Stone/Cement Block/Wood
FOR OFFICE USE ONLY: Total No. SOURCES
No. external SOURCES
-----------------------
/ /
NAME OF SOURCE:
NAME OF SOURCE:
/ /
NAME OF SOURCE:
USh.
NAME OF SOURCE:
USh:
Ush ……………… per container
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