Community Needs Assessment Tool

Household Interview Guide

Date of interview _____________

Questionnaire

Code

Enumerator’s Name _____________________________

District Name ______________ Ward Name ______________

Village Name ______________ Ward Number ____________

Natural region Area Type

1=I 2=IIa 3=IIb 1=Urban

4=III 5=IV 6=V 2=Peri Urban

3=Rural

Section 1
Demographics
Q. 1 Household Members

How many family members reside in your home? [Circle number]

1 2 3 4 5 6 7 8 OR MORE

A A2 A3 A4 A5 A6 A7
1
Please give me the Is (NAME) Age a. Is a. Is Has name been very sick for at least 3
First name of each Male or In name’s name’s months for the past 12 months? Very
Member, starting Female? year natural natural sick means that name was too sick to
with s mother father work or do normal activities around the
the household 1=male alive? alive? house for at least 3 of the past
head 2=femal 1months?
e 0=No 0=No 0=No
1=Yes 1=Yes 1=Yes
2=Don’t 2=Don’t 2=Don’t know
know know
1
2
3
4
5
6
7
8
9
1
0
1
1
1
2

Q.2 Details of Head of HH. Is household head 1=male or 2=female

Name ___________________________________________

Q.3 Details of head of HH (Head who has been living in the HH for the
past 3months.
Highest formal education level of head of HH
Circle the option
0=none
1=grades 1-3
2=grades 4-7
3=forms 1-2
4=forms 3-4
5=forms 5&6
6=any tertiary

Note: Sub A=grade 1, sub B=grade 2, std 1=grade 3

Q4. Marital status

1=married 2=single 3=divorced 4=widowed

5. What are the household head vulnerability characteristics? (Check all that
apply)

1=Chronically ill hh head 2=Child headed 3=Elderly headed

4=Disabled hh head 5=Single parent 8=None

6. Indicate the number of chronically ill members in the household

A. <5 years ..... B. 5-18 years….. C. 19-60 years ….. D. >60 years …..
E. Total ….

7. Indicate number of orphans in the household

0-4 years 5-14 years 15-17 years Total

A. Male …...... ……… ……… ………

B. Female ……… ……… ……… ………
8. How many years have you lived in this community? [Circle number]

1=0-3 YEARS 4=11-15 YEARS

2=4-6 YEARS 5=16-25 YEARS

3=7-10 YEARS 6=OVER 25 YEARS ___

9. Are you renting or staying at your own home? [Circle number]

1=RENTING 2=OWN

10. Which category best represents the age of the head of household? [Circle
number]

1=18-24 4=45-54

2=25-34 5=55-64

3=35-44 6=65 OR OLDER

Section 2
Living conditions
11. Which materials did you use to construct your house?

1=poles, mud, grass 2=poles, mud, grass cement, bricks 3=asbestos, bricks,
gum treated poles, cement

Sources of energy

12. What source of energy do you use for illumination?

1=paraffin 2=diesel 3=candle 4=wood 5=electricity

13. What source of energy do you use for cooking?

1=LP gas 2=paraffin 3=firewood 4=electricity

Water sources

14. What is the main source of drinking-water for members of your

household?

1=Piped water into dwelling 2=Public tap 3=borehole 4=Protected dug well
5=Unprotected dug well 6=Protected spring 7=Unprotected spring 8=Rainwater collection
9=Surface water (river, dam, lake,pond, stream, canal, irrigation 10=Other (specify)
15. What is the main source of water used by your household for other
purposes, such as cooking and hand washing?
1=Piped water into dwelling 2=Public tap 3=borehole 4=Protected dug well
5=Unprotected dug well 6=Protected spring 7=Unprotected spring 8=Rainwater collection
9=Surface water (river, dam, lake,pond, stream, canal, irrigation 10=Other
(specify)______________________________________________________________________

16. How much water do you use in your household per day?

1= < 150 litres 2= 150 - 200 litres 3= 250 -300litres 4= >300 litres

17. What type of container do you use to store water in the home?

1= plastic containers with lids 2=plastic containers without lids 3= traditional pots with
lids 3=Traditional pots without lids 4=metal containers with lids 5= metal containers
without lids 6=other (specify)……….

18. How far is the main source of water used by your household?
1=0 – 199m 2=200 – 399m 3=400 – 599m 4=600 – 799m 5=800- 999m 6=1000m and
above

19. Who usually goes to this source to fetch the water for your
household?
1=Adult woman 2=Adult man 3=Female child (under 15 years) 4=Male child (under 15
years)

20. Do you treat your water in any way to make it safer to drink?
1=Yes 2=No DK

21. What do you usually do to the water to make it safer to drink?

1=Boil 2=Add bleach/chlorine 3=Strain it through a cloth 4=Use a water filter (sand)
5=Let it stand and settle 6=other (specify) ________________________________
7=DK >>

Sanitation facilities

22. In the household has anyone received training in hygiene?

1=Yes 2=No

23. Has any one died of cholera in the past 12 months?

1= Yes; 2=No

24. What kind of toilet facility do members of your household usually

use?
1=Flush toilet 2=Pit latrine with slab 3=Pit latrine without slab/open pit
4=Ventilated improved pit latrine 5=Bush

25. If a structure is used, do you share this facility with other

households?

1=Yes 2=No

26. How many households use this toilet facility?

_______________

NB: [This question should be asked if the household has a child under
the age of 3 years]

27. The last time [name of youngest child] passed stools, what was
done to dispose of the stools?

1=Child used toilet/latrine 2=Put/rinsed into toilet or latrine 3=Put/rinsed into drain or
ditch 4=Thrown into garbage 5=Buried 6=Left in the open 7=other (specify)
__________
8=DK

28. How far is the rubbish pit from the kitchen?

1= 50 metres and below; 2= 51- 100 metres; 3= 101- 150 metres; 4= > 150 meters

Sanitation practices

29.

Hand washing before eating Hand washing after defecation

YES/N With water With water YES/N Soap Mud Ash

O only and soap O
 Section 3
Livelihoods
30. Are there any members of the household that have migrated out in the last
3 months?

1=Yes, 0=No

31. If yes, what are the reasons for migration?

1= Search for employment; 2= Educational pursuit, 3= Resettlement; 4= other specify

32. Which of the following categories best describes your gross total family
income per month in US$?

1. 0 – 9.99

2. 10.00 – 19.99 7. 60.00 – 69.00

3. 20.00 – 29.99 8. 70.00 – 79.00

4. 30.00 – 39.99 9. 80.00 – 89.00

5. 40.00 – 49.00 10. 90.00 – 99.00

6. 50.00 – 59.00 11. 100.00 and above_________

33. Do you have a house hold garden?

1=yes 2=no

34. If yes, what crops do you grow in the garden?

1=leguminous plants (peas, beans); 2=Tubers; 3=Fruits; 4=Vegetables; 5= other

(specify)

35. If yes, do you process crops you grow to add value?

1=Yes; 2=No

36. Did you receive any income or kind assistance in the past 12 months? 1=
Yes 2= No

37. If yes, continue to the table below;

A B C
Income Source 1= Rank the important of the income
Yes,
 2=No (1= Most important, 2=Important 3=
Least important)

38 Informal work (maricho)

39 Formal employment

40 Remittances

41 Child Support Grants

42 Pension Fund from work

43 Selling of field crops

44 Selling of garden Crops

45 Selling of Livestock assets

46. How many months will the 2009/10 harvest last?...........................

47. Are you expecting to sell any of your harvest?

1= Yes 2= No

48. If yes, what are the reasons for selling?

1= no longer needed 2=Pay daily expenses 3=buy groceries 4=Pay debt 5=pay
medical expenses 6=other emergencies 7=Pay social event 8=pay funeral 9=pay
school fees 10=Other (specify)

49. Have any of these cereal grain/food sources been available to the
household for the past month?

A B C D
Food Source 1=Yes 0=No Name of food Rank of importance
items

50 Food handouts from Govt

51 Food handouts from the

NGOs

52 Food donations from

relatives and community

53 Purchase from
neighbours/markets/GMB
54 Food for work

55 Other (specify)

Options for food items: 1=maize 2=small grains 3=bulgur 4=CSB 5=sugar beans
6=vegetable oil 7=matemba 8=vegetables 9=other (specify)……………

56. Asset ownership

ASSETS YE N ASSETS YE N
OWNED S O OWNED S O

Cattle Ox drawn
plough

Chickens Ox drawn
Cart

Donkeys Hoe

Goats Radio

TV Cell phone

57. Do you own land?

1=YES 2=NO

[If yes, proceed to question 28, if NO, proceed to question 30]

58. How many acres of land do you own?

_________acres

59. Of this land how many acres is arable land?

_________acres

60. Which field crops do you grow? (List)

_______________

_______________

_______________

_______________
_______________

_______________

_______________

Instructions: I am going to read some statements to you and I would like you to
tell me two things about the statement: how important it is to you that the
following services are in your community, and how satisfied you are with each
service in your area.

Please circle the appropriate score

using the following scale:
1=completely unimportant
1=completely satisfied
2=unimportant
2=unsatisfied
3=important
3=satisfied
4=very important 4=very
satisfied
How important is
How satisfied

This to you.....
are you with.....

61. Availability of a good grocery store 1 2 3 4 1 2 3

4

62. Availability of a functional clinic 1 2 3 4 1 2 3

4

63. Affordability of prescription drugs 1 2 3 4 1 2 3

4

64. Quality of teaching at schools 1 2 3 4 1 2 3

4
65. Availability of employment opportunities 1 2 3 4 1 2 3
4

for youths

66. Availability of adequate transportation of 1 2 3 4 1

2 3 4

produce to the market

67. Opportunity for you and your family to 1 2 3 4 1 2 3

4

Improve and make decisions that affect the

Community

68. Availability of small business in the 1 2 3 4 1

2 3 4

Community

69. Opportunities available to open small 1 2 3 4 1 2 3

4

Business in the community

70. To have your own household 1 2 3 4 1 2 3

4

Toilet

71. Availability of safe water source near 1 2 3 4 1 2 3

4

your house

Thank you for your time!