Household WASH Assessment Form
Please complete the Household WASH Assessment Form to help us understand your household's water, sanitation, and hygiene conditions.
Type of main water source for your household
*
Piped water into dwelling
Public tap/standpipe
Protected well or spring
Unprotected well or spring
Surface water (river/lake/pond)
Other
How often is water available from your main source?
*
Always
Most of the time
Sometimes
Rarely
How do you treat your drinking water at home?
*
Boiling
Filtration
Chlorination
No treatment
Other
Type of sanitation facility used by your household
*
Flush/pour flush toilet
Ventilated improved pit latrine
Pit latrine without slab
Composting toilet
No facility (open defecation)
Other
Please indicate the availability and condition of the following WASH facilities in your household.
*
Rows
Not available
Available, poor condition
Available, good condition
Handwashing station with soap
1
2
3
Toilet/latrine
4
5
6
Bathing/shower facility
7
8
9
Drinking water storage
10
11
12
How satisfied are you with your household's access to safe water?
*
1
2
3
4
5
How satisfied are you with your household's sanitation facilities?
*
1
2
3
4
5
How often do members of your household wash hands with soap at critical times (after toilet use, before eating)?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Please indicate your agreement with the following statements about hygiene practices in your household.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
We have enough soap for regular handwashing
13
14
15
16
17
Children in the household practice good hygiene
18
19
20
21
22
Household members understand the importance of hygiene
23
24
25
26
27
Additional comments or observations (optional)
Submit Assessment
Should be Empty: