Community diagnosis

User Support Form Building
1

COMMUNITY DIAGNOSIS QUESTIONNAIRE
GENERAL INFORMATION
Name of the interviewer …………………………………………………………….
Date ………………………………………………………………………………….

PART 1
A. DEMOGRAPHIC PROFILE
1.Gender.
Male Female
2. Age.
15-24 yrs
25-34 yrs
35-44 yrs
45-54 yrs
Above 55yrs
3. Marital status.
Single
Married
Divorced
Widowed.
4. Occupation.
Employed
Self-employed
Unemployed
5. Level of education
Primary
Secondary
Tetiary
None

  1. Size of household
    1- 5
    8-10
    Above 10

                                     PART 2    
         ENVIRONMENTAL SANITATION

A. HYGIENE.

  1. Do you have a hand washing station?
    Yes
    No

  2. How often do you wash your hands?
    Regular
    Before and after meals
    Never

  3. Do you practice personal hygiene?
    Yes
    No

                           B. WATER.

  4. What is your main source of water?
    Rainwater
    River
    Borehole/well
    Others……………………………….

  5. Do you treat water?
    Yes
    No

  6. How do you treat water?
    Boiling
    Chlorination
    Sieving
    Filtration
    3 pot system

4.How do you store your water?
Tank
Pot
Jerrycan
Bucket

                          C. WASTE

  1. How do you dispose your waste?
    Burning
    Composting
    Burying
    Others

  2. Where do you dispose your human waste?
    Toilet
    Pit latrine
    Bush
    Other specify……………………………

  3. Does your toilet have a lid?
    Yes
    No

                              HEALTH
                 Health Seeking Behaviour

  4. Do you seek health services?
    Yes
    No

  5. If yes, where do you go?
    Hospital
    Spiritual places/ordinances
    Traditional healers/dieties
    If no, specify………………………………………………….

  6. Do you deworm?
    Yes
    No

  7. How often do you deworm?
    After 3 months
    After 6 months
    After 1 year
    Never

E. NUTRITION

  1. How many meals do you take per day?
    1
    2
    3
    Other specify………………………………………………………….
  2. Sources of nutrient for your family.
    Farm products
    Market products
    Others specify…………………………………………………………
  3. How long does your child exclusively breastfeed?
    0-3 months
    3-6 months

6 months

2

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