Survey

Baseline StudyMonitorting Report

Borehole Name/ID:
village/Community:
GPS Coordinates (optional):
Borehole Location Description / Building type
HouseholdSchoolReligious buildingCommunity Centre

Name:
Phone:
Household Size:
Distance from Borehole (in minutes or kilometers):

1.What is your primary water source? (Select one):

This boreholeAnother protected boreholeUnprotected boreholePiped water systemRiver/StreamLake/Pond
Other (specify):

2. Do you use this borehole year-round? (Yes/No):

YesNo

If no, why not?

3. How much water does your household fetch from this borehole daily

Less than 20 liters20–50 litersMore than 50 liters

4.Do you treat the water before use?

YesNo

If yes, how? (Boiling/Filtration/Chemical treatment/Other):

5. Do you experience water shortages at this borehole?

YesNo

If yes, during which months or seasons?

6. What challenges do you face when using this borehole? (Select all that apply):

Long waiting timesWater quality concernsFrequent breakdownsDistanceNo challenges

Other (specify):

1. What type(s) of stoves do you use for cooking or boiling water? (Select all that apply):

Traditional three-stone fireImproved cookstoveGas stoveElectric stove
Other (specify):

2. How many stoves do you have in your household?:
Traditional:
Improved:
Gas:
Electric:

3a. How often do you boil water for drinking before the repair of the borehole?

NeverOccasionallySometimeMostlyAlways

3b. How often do you boil water after the repair of the borehole?

NeverOccasionallySometimeMostlyAlways

1.What types of fuel do you use for cooking or boiling water? (Select all that apply):

FirewoodCharcoalLPGElectricityAgricultural residuesNone of the above
Other (specify):

2. What is the approximate amount of fuel used per week for boiling water?:

Firewood: Kg
Charcoal: Kg
LPG: Liters
Electricity: Kwh

3. Do you collect or purchase your fuel? (Select one for each type):

Firewood: CollectPurchaseNot Applicable

Charcoal: CollectPurchaseNot Applicable

LPG: PurchaseNot Applicable

Other (specify):

4. Has the availability of alternative water solutions reduced your dependence on forest resources? (Select one)

YesNo

1. Which stove(s) do you primarily use to boil water?

Traditional fireImproved cookstoveGas stoveElectric stove

2. On average, how long does it take to boil a liter of water using your primary stove?:

Less than 5 minutes5–10 minutesMore than 10 minutes

3. How often do you boil water for drinking in a day? (Select one):

Once2–3 timesMore than 3 timesNever

4. Do you mix methods to boil water (e.g., use multiple stove types)?

YesNo

If yes, explain:

5.If cost weren’t a concern, would you use more wood or fuel for boiling water

YesNo

If Yes, how much more would you buy: Kgs

1. Are you satisfied with the water quality from this borehole?

YesNo

If no, why not? :

2. What improvements would you recommend for this borehole? (Select all that apply):

Faster repairsBetter water qualityReduced waiting timesMore boreholes in the areaNo recommendations
Other (specify):

3. Do you prefer using this borehole over other water sources? (Yes/No):

YesNo

If no, why not? :

1. Waterborne Diseases:

In the past month, has any member of your household experienced waterborne illnesses? (Select all that apply):

NoYes, diarrheaYes, choleraYes, other
Other (specify):

2. Respiratory Conditions:

Has anyone in your household experienced respiratory conditions caused by unclean cooking or water boiling methods? (Select one):

NoYes, mild respiratory issuesYes, severe respiratory issues

3. Burns from Unsafe Practices:

Have there been cases of burns or accidents related to water heating in your household in the past year? (Select one):

NoYes, Minor BurnsYes,Major Burns

1. Type of Toilet Facility:

What kind of toilet facility does your household usually use? (Select one):

Flush/pour flush to sewerFlush/pour flush to septic tankPit latrine with slabPit latrine without slabNo facility (bush/field)

2. Shared Toilet Facility

Do you share this facility with others who are not members of your household? (Select one):

NoYes, with 1-2 other householdsYes, with more than 2 households

3. Location of Sanitation Facility:

Where is this toilet facility located? (Select one):

In own dwellingIn own yard/plotElsewhere

4. Emptying of On-Site Sanitation Facilities:

Has your (pit latrine or septic tank) ever been emptied?

No, it has never been emptiedDon’t know

Other (specify):

5. Disposal of Excreta from On-Site Sanitation Facilities:

The last time your (pit latrine or septic tank) was emptied, where were the contents emptied to? (Select one):

Removed by a service provider to a treatment plantRemoved by a service provider but don't know whereEmptied by household and buried in a covered pitEmptied by household to an uncovered pit, open ground, water body, or elsewhereOther (specify)Don't know

1. Handwashing Facilities:

Where do members of your household most often wash their hands? (Select one):

Fixed facility (sink/tap)Mobile object (bucket/jug)No handwashing facility

2. Water Availability:

Is water available at the handwashing place? (Select one):

YesNoNo handwashing facility

3. Soap Availability:

Is soap available at the handwashing place? (Select one):

YesNo

1. How much water does your household collect from this borehole daily? (Liters):
2. What portion of this water is used for drinking? (Liters):
3. Have there been days when the borehole was not operational?:
YesNo

If yes, how many days in the past year? (Approximate number):
4. How much water is typically available from this borehole per day? (Estimated liters)

3. Do you think the current water availability meets your household's needs?

YesNo

If no, why not? :

Name & Signature of employee doing the questionnaire

Signature of respondent