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

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

Surveyor Name:

Respondent Name:

Respondent Gender (Male/Female/Others): Respondent Contact Number:

Owner Information
1.    Owner Name:

2.    Owner Gender:
i.    Male
ii.    Female
iii.    Others

3.    Owner Contact Number:
Building Information

4.    Main Building:
i.    Yes
ii.    No

5.    (If Q. 4 is “No”) BIN of Main Building:

6.    Ward Number:

7.    Road Code (RXXXX):

8.    Road Name:

9.    Tax Code/ Holding ID (XX-XXX-XXXX-XX):

10.    House Address:

11.    Structure Type:
i.    RCC
ii.    Load bearing with cement mortar
iii.    Load bearing with mud/lime mortar
iv.    Wooden/Mud/CGI /Temporary
v.    Steel structure
vi.    Other (Specify):

 
12.    Year of Construction (YYYY AD):

13.    Number of Floor (including ground floor):

14.    Functional Use of Building:
i.    Residential
ii.    Commercial
iii.    Mixed (Residential and Commercial)
iv.    Offices
v.    Educational
vi.    Hospital/clinic
vii.    Industrial
viii.    Assembly
ix.    Other (Specify):

15.    Subcategory according to Functional Use:

16.    Office or Business Name (List out names):

17.    Number of Households:

18.    Population of Building:
i.    Male:
ii.    Female:
iii.    Others:

If differently abled:
iv.    Male:
v.    Female:
vi.    Others:

Low Income Community Information
19.    Is Low-Income Household:
i.    Yes
ii.    No

20.    Located in Low Income Community:
iii.    Yes
iv.    No

 
21.    (If Q. 20 is “Yes”) Low Income Community Name:

Water Source Information
22.    Main Drinking Water Source:
i.    Jar Water
ii.    Rainwater
iii.    Spring/River/Canal
iv.    Private Tanker water
v.    Tube well
vi.    Dug well
vii.    Deep boring
viii.    Pond
ix.    Municipal/Public water supply
x.    Others

23.    (If Q. 22 “Municipal/Public water supply”) Water Supply Customer ID:
24.    (If Q. 22 “Municipal/Public water supply”) Water Supply Pipeline Code:

25.    Well in Premises:
i.    Yes
ii.    No

26.    (If Q. Error! Reference source not found., “Yes”) Distance of Well from Closest C ontainment (m):

Solid Waste Management Information
27.    Do you have a solid waste collection service:
iii.    Yes
iv.    No

28.    (If Q. 27 “Yes”) Solid Waste Service Provider:

29.    (If Q. 27 “Yes”) Solid Waste Management Customer ID (if any):
Toilet & Containment Information

30.    Presence of Toilet:
i.    Yes
ii.    No

 
31.    (If Q. 30 “No”) Defecation Place:
i.    Community Toilet
ii.    Open Defecation
iii.    Shared Toilet
iv.    Others (Specify):

32.    (If Q. 31 “Community Toilet”) Community Toilet Name:

33.    (If Q. 30 “Yes”) Number of Toilets:

34.    (If Q. 30 “Yes”) Households with Shared Toilet:

35.    (If Q. 30 “Yes”) Population that uses Shared Toilet:

36.    (If Q. 30 “Yes”) Toilet Connection:
i.    Sewer Network
ii.    Drain Network
iii.    Septic Tank
iv.    Pit/ Holding Tank
v.    Onsite Treatment (e.g., Anaerobic Digestor/ Biogas, DEWATS)
vi.    Composting Toilet (e.g., Ecosan, UDDT, etc.)
vii.    Water Body
viii.    Open Ground
ix.    Community Toilet
x.    Open Defecation
xi.    Shared Containment

37.    (If Q. 36 “Septic Tank”) Containment Type:
i.    Septic Tank connected to Sewer Network
ii.    Septic Tank connected to Drain Network
iii.    Septic Tank connected to Soak Pit
iv.    Septic Tank connected to Water body
v.    Septic Tank connected to Open Ground
vi.    Septic Tank without Outlet Connection
vii.    Septic Tank with Unknown Outlet Connection

38.    (If Q. 36 “Pit / Holding Tank”) Containment Type: 
i.    Double Pit
ii.    Permeable/ Unlined Pit/Holding Tank
iii.    Lined Pit connected to a Soak Pit
iv.    Lined Pit connected to Water Body
v.    Lined Pit connected to Open Ground
vi.    Lined Pit connected to Sewer Network
vii.    Lined Pit connected to Drain Network
viii.    Lined Pit without Outlet
ix.    Lined Pit with Unknown Outlet Connection

39.    (If Q. 36 “Septic Tank” or “Pit/Holding Tank”) Containment Volume (m3):

40.    (If Q. 36    “Septic Tank”) Does septic tank have at least 2 chambers, outlet at top, sealed/lined base, and walls:
i.    Yes
ii.    No
iii.    Don’t know

41.    (If Q. 36 “Septic Tank” or “Pit/Holding Tank”) Containment Construction Date (YYYY AD):

42.    (If Q. 36 “Septic Tank” or “Pit/Holding Tank”) Containment Location?
i.    Inside the building footprint
ii.    Outside the building footprint

43.    (If Q. 36 “Septic Tank” or “Pit/Holding Tank”) Containment Accessible to Desludging Vehicle?
i.    Yes
ii.    No

44.    (If Q. 36 = “Septic Tank” or “Pit/Holding Tank”) Have you ever emptied your “Septic Tank” or “Pit/Holding Tank”:
i.    Yes
ii.    No

45.    (If Q43 is “Yes”) Last emptied date (year):

46.    (If Q. 36 “Sewer Network” or Q. 37 ”Septic Tank connected to Sewer Network” or Q. 38 ”Lined Pit connected to Sewer Network”) Sewer Code:
 
47.    (If Q. 36 “Drain Network” or Q. 37 ”Septic Tank connected to Drain Network” or Q. 38 ”Lined Pit connected to Drain Network”) Drain Code:

48.    (If Q36 “Shared Containment”) BIN of Pre-Connected Building: