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Base line Pre KAP Survey for Hygiene Situation Analysis
Information on target area:

—c ×ame of province ««««««««««..

—c ×ame of district «««««««««««.
—c ×ame of village «««««««««««.
—c ×umber of households ««««««««..
—c ×umber of families ««««««««««
—c ×umber of children under 5 year at a household «««««««««««..
—c ×umber of caregiver for children at a household «««««««««««.
—c ×umber of people suffered from diarrhea at a household for last month
««««««««««..
—c ×umber of dead cases in the village due to diarrhea in the village for last three months
««««««.
—c ×ame of village¶s leader ««««««««««««
—c ½otal number of family members at a household ««««««««....
—c ×ame of hygiene educators ««««««««
×ame of interviewer ««««««««««..
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0rom which source people using safe drinking ½ap
Water? Hand pump
Protected well
Protected springs
Protected Karez
0rom which source people using Stream
Unsafe drinking water? River
Unprotected well
Unprotected spring
Unprotected Karez
How people make drinking water safe from By boiling
Unsafe sources? By adding chlorine
0iltration
×othing
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Is the surrounds of safe water source clean? Yes ×o
Is safe water source protected well? Yes ×o
Is the damaged/broken water source being Yes ×o
Repaired?
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Are they washing water containers before Yes ×o
Use?
Are they touch the clean water containers with Yes ×o
Unclean hands?
Are they keep cover drinking water Yes ×o
Containers?

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Do they use safe latrine? Yes ×o
Do they have safe latrine? Yes ×o
Do they use latrine for defecation? Yes ×o
Are scattered faeces on the floor/slab of Yes ×o
Latrine?
Is the latrine far from the safe water sources? Yes ×o
How many meters?
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Do they wash the floor of latrine? Yes ×o
Is door for manhole present and closed? Yes ×o
Will community participate in building of safe Yes ×o
Household latrine?
Can animals and insects get into household Yes ×o
Latrine?

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Do they wash their hands after defecation Yes ×o
With soap or ash?
Do the mothers wash their hands with soup or Yes ×o
Ash after cleaning child faeces?
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Do they dispose the night soil in a safe Yes ×o
Place (burying or composting)?
Do they dispose the night soil in safe place Yes ×o
Away from water sources?

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Do they wash their hair and body in short Yes ×o
Period?
Do they take shower regularly? Yes ×o
Are their hand nails shorter? Yes ×o
Are their cloths clean? Yes ×o

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Is their general appearance look clean? Yes ×o
Do they walk with bear feet/without shoes? Yes ×o

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Is waste taken away from your house and Yes ×o
Street and buried or burned in safe places?
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Do they prepare safe food? Yes ×o
Do they wash fruit and vegetable before use? Yes ×o
Do they wash fruit and vegetable with salty Yes ×o
Water or chlorine before use?
Is their food and utensils clean or safe Yes ×o
 0or use?
Do they wash food utensils with soup or Yes ×o
Powder or ash before and after use?
Do they cover the food by a clean cloth? Yes ×o
Do the heat the leftover food before keeping Yes ×o
Or after use?



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Do they know the need for ORS and use Yes ×o
Of it?
Do they know what is it for? Yes ×o
Do they know how to prepare it? Yes ×o
If there is no ORS what else they will do? Yes ×o
Do they know how to prepare ORS or WSS? Yes ×o
Do they know to take their child to doctor if Yes ×o
He/she is suffering diarrhea?
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×ame of the ½eam Member: _____________ Designation: ______________

Signature: ________________ Date: _____/____/_____