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: