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Appendix B. CHECKLIST FOR CENSUS SURVEY OF BUILDING & CONTAINMENT ASSESSMENT FOR IMIS

Date: _ _/_ _/ _ _ _ _

Name of Surveyor:

Name of Respondent:

Gender (Male/Female/Others):

Contact number of Respondent:

Owner Information

  1. Name of Owner:
  2. Gender (Male/Female/Others):
  3. Contact number of Owner:
  4. Ward:
  5. House Address:
  6. Road Code (XXX):
  7. Road Name:
  8. Tax Code/ Holding ID:

Building Information

1.What is the construction type of the building?

    • RCC
    • Load bearing with cement mortar
    • Load bearing with mud/lime mortar
    • Wooden/Mud/CGI /Temporary
    • teel structure
    • Other (Specify): 
  2. What is construction year of the building (YYYY AD)?
  3. Number of floor (including ground floor):
  4. Is the Building Low Income Household?
    • Yes
    • No
  5. If Q.12 is Yes, Low Income Community Name, if applicable?
  6. What is the use purpose of the building?
    • Residential
    • Commercial
    • Mixed (Residential and Commercial)
    • Offices
    • Educational
    • Hospital/clinic
    • Industrial
    • Assembly
    • Other (Specify):
  7. What business /governmental institutions/offices/educational entities are present in the building? List out names.
  8. How many households (HHs) are living in the building?
  9. How many people are living in the building including all households?
    • Male:
    • Female: 
    • Others:

       If differently abled:

  • Male: 
  • Female:
  •  Others:

Toilet & Containment Information

  1. Do you have a toilet on your premises?

    • Yes
    • No

  2. If Q18 “No”, where do your family go for defecation?

    • Use Community Toilet
    • Open defecation at water bodies/ open ground
    • Others (Specify):

  3. If Q18 “Yes”, how many toilets do you have?

  4. If Q18 “Yes”, how many households have shared toilets?

  5. If Q18 “Yes”, Where does your toilet connection go?

    • Sewer Network
    • Drain Network
    • Septic Tank
    • Pit/ Holding Tank
    • Onsite Treatment (e.g., Anaerobic Digestor/ Biogas, DEWATS)
    • Composting Toilet (e.g., ecosan, UDDT, etc.)
    • Water Body
    • Open Ground ix. Shared Septic Tank

  6. If Q22 “Septic tank”, where does your outlet connection go?

    • Septic Tank connected to Sewer Network
    • Septic Tank connected to Drain Network
    • Septic Tank connected to Soak Pit
    • Septic Tank connected to Water body
    • Septic Tank connected to Open Ground
    • Septic Tank without Outlet Connection
    • Septic Tank with Unknown Outlet Connection

  7. If Q22 “Holding Tank/ Pit”, what type of Pit is it?

    • Double Pit
    • Permeable/ Unlined Pit/Holding Tank
    • Lined Pit

  8. If Q24 “Lined Pit”, where does your outlet connection go?

    • Lined Pit connected to a Soak Pit

    • Lined Pit connected to Water Body

    • Lined Pit connected to Open Ground iv. Lined Pit connected to Sewer Network

    • Lined Pit connected to Drain Network

    • Lined Pit without Outlet

    • Lined Pit with Unknown Outlet Connection

    • If Q 22 “Sewer Network” or Q 23 ”Septic Tank connected to Sewer Network” or Q 25” Lined Pit connected to Sewer Network” then Sewer Code?

    • If Q 22 “Drain Network” or Q 23 ”Septic Tank connected to Drain Network” or Q 25” Lined Pit connected to Drain Network” then Drain Code?

  9. If Q22 “Septic Tank”, does septic tank have at least 2 chambers, outlet at top, sealed/lined base, and walls?

    • Yes
    • No
    • Don’t know

  10. If Q22 “Septic Tank/ Pit/Holding Tank”, When was the containment constructed (YYYY AD)?

  11. If Q22 “Septic Tank/ Pit/Holding Tank”, Where it is located?

    • Inside the building footprint
    • Outside the building footprint
    • Don’t know

  12. If Q22 “Septic Tank/ Pit/Holding Tank”, have you ever emptied your septic tank/holding tank/pit?

    • Yes
    • No

  13. If Q29 “Yes”, when was it last emptied (year)?

  14. If Q22 “Septic Tank/ Pit/Holding Tank”, what is the estimated size of your Septic Tank/ Pit/Holding Tank”?

  15. If Q19 “Use Community Toilet”, then name of Community Toilet?

  16. If Q22 “Shared Septic Tank”, BIN of building that has septic tank pre-connected?

Water Use Information

  1. What is the main source of water for drinking?

    • Municipal/Public Water Supply

    • Dug Well

    • Tube Well

    • Spring/River/Canal/Stone Spout

    • Rainwater

    • Private Tanker Water

    • Jar Water

    • Others

  2. If Q24, “Municipal/Public water supply”, what is your water supply customer ID?
  3. If Q24, “Municipal/Public water supply”, what is your water supply Pipe ID?
  4. Do you have well on your premises?
    • Yes
    • No
  5. If Q27, “Yes”, what is distance of well from the nearest septic tank/holding tank/pit?

Solid waste Information

  1. Do you have a solid waste collection service?
  2. If Q29 “Yes”, what is name of the solid waste service provider?
  3. If Q29 “Yes”, what is your solid waste customer ID
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