HHRD-Water for Life ProgramBase line Pre KAP Survey for Hygiene Situation Analysis

Information on target area:

· Name of province …………………………..· Name of district …………………………….· Name of village …………………………….· Number of households ……………………..· Number of families …………………………· Number of children under 5 year at a household ……………………………..· Number of caregiver for children at a household …………………………….· Number of people suffered from diarrhea at a household for last month

…………………………..· Number of dead cases in the village due to diarrhea in the village for last three months

……………….· Name of village’s leader ………………………………· Total number of family members at a household ……………………....· Name of hygiene educators ……………………Name of interviewer …………………………..Through some questions we will find the hygiene status as follows:

Hygiene status assessment CommentsSafe drinking water and hygiene

From which source people using safe drinkingWater?

TapHand pumpProtected wellProtected springsProtected Karez

From which source people usingUnsafe drinking water?

StreamRiverUnprotected wellUnprotected springUnprotected Karez

How people make drinking water safe fromUnsafe sources?

By boilingBy adding chlorineFiltration

Nothing

Are water sources safe or not?Is the surrounds of safe water source clean? Yes NoIs safe water source protected well? Yes NoIs the damaged/broken water source beingRepaired?

Yes No

Are they keeping water utensils clean?

Are they washing water containers beforeUse?

Yes No

Are they touch the clean water containers withUnclean hands?

Yes No

Are they keep cover drinking waterContainers?

Yes No

Sanitation facilities and hygieneDo they use safe latrine? Yes NoDo they have safe latrine? Yes NoDo they use latrine for defecation? Yes NoAre scattered faeces on the floor/slab ofLatrine?

Yes No

Is the latrine far from the safe water sources?How many meters?

Yes No

Is the household latrine clean/hygienic?Do they wash the floor of latrine? Yes NoIs door for manhole present and closed? Yes NoWill community participate in building of safeHousehold latrine?

Yes No

Can animals and insects get into householdLatrine?

Yes No

Do they wash their hands after defecation?Do they wash their hands after defecationWith soap or ash?

Yes No

Do the mothers wash their hands with soup orAsh after cleaning child faeces?

Yes No

Is their latrine easily emptying from faeces?Do they dispose the night soil in a safePlace (burying or composting)?

Yes No

Do they dispose the night soil in safe placeAway from water sources?

Yes No

Personal & Environmental hygieneDo they wash their hair and body in shortPeriod?

Yes No

Do they take shower regularly? Yes NoAre their hand nails shorter? Yes NoAre their cloths clean? Yes No

Personal Hygiene with children under 5 yearsIs their general appearance look clean? Yes NoDo they walk with bear feet/without shoes? Yes No

Hygiene situation of household and environment?Is waste taken away from your house andStreet and buried or burned in safe places?

Yes No

Food and hygieneDo they prepare safe food? Yes NoDo they wash fruit and vegetable before use? Yes NoDo they wash fruit and vegetable with saltyWater or chlorine before use?

Yes No

Is their food and utensils clean or safe Yes No

For use?Do they wash food utensils with soup orPowder or ash before and after use?

Yes No

Do they cover the food by a clean cloth? Yes NoDo the heat the leftover food before keepingOr after use?

Yes No

Re-hydration for diarrheal patientsDo they know the need for ORS and useOf it?

Yes No

Do they know what is it for? Yes NoDo they know how to prepare it? Yes NoIf there is no ORS what else they will do? Yes NoDo they know how to prepare ORS or WSS? Yes NoDo they know to take their child to doctor ifHe/she is suffering diarrhea?

Yes No

Name of the Team Member: _____________ Designation: ______________

Signature: ________________ Date: _____/____/_____