MIC-6
Questionnaire for water quality testing
Name and year of survey
Your logo here
Water quality testing information panel: WQ
WQ1. Cluster number: _ _ _
WQ2. Household number: _ _
WQ3. Measurer's name and number:
Name ____ _ _ _
WQ4. Interviewer's name and number
Name ____ _ _ _
WQ5. Day/month/year:
_ _ / _ _ / 201 _
WQ6. Check HH10 in the household information panel in the household questionnaire: is the household selected for blank testing?
[] 1 Yes
[] 2 No
[] 2 No
WQ7. Name of the respondent to water quality testing questionnaire
Name ____
WQ8. Check HH44. Is permission given to test water?
[] 1 Yes, permission is given [Go to WQ10]
[] 2 No, permission is not given [Go to WQ31]
[] 2 No, permission is not given [Go to WQ31]
WQ31. Result of water quality testing questionnaire.
Discuss any result not completed with supervisor.
[] 01 Completed
[] 02 Permission not given
[] 03 Glass of water not given
[] 04 Partly completed
[] 96 Other (specify) ____
[] 02 Permission not given
[] 03 Glass of water not given
[] 04 Partly completed
[] 96 Other (specify) ____
[p. 2]
Water quality testing
WQ10. Record the time:
_ _ Hours
_ _ Minutes
_ _ Minutes
WQ11. Could you please provide me with a glass of the water that members of your household usually drink?
[] 1 Yes
[] 2 No [Go to WQ31 and record '03']
[] 2 No [Go to WQ31 and record '03']
WQ12. Observe and record whether the water was collected directly from the source or from a separate storage container.
[] 1 Direct from source
[] 2 Covered container
[] 3 Uncovered container
[] 8 Unable to observe
[] 2 Covered container
[] 3 Uncovered container
[] 8 Unable to observe
WQ13. Label sample H-XXX-YY, where XXX is the cluster number (WQ1) and YY is the household number (WQ2).
WQ14. Have you or any other member of this household done anything to this water to make it safer to drink?
[] 1 Yes
[] 2 No [Go to WQ17]
[] 8 DK [Go to WQ17]
[] 2 No [Go to WQ17]
[] 8 DK [Go to WQ17]
WQ15. What has been done to the water to make it safer to drink?
Probe: Anything else?
Record all items mentioned.
[] A Boiled it
[] B Added bleach/chlorine
[] C Strained it through a cloth
[] D Used a water filter (ceramic, sand, composite, etc.)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK
[] B Added bleach/chlorine
[] C Strained it through a cloth
[] D Used a water filter (ceramic, sand, composite, etc.)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK
[p. 3]
WQ17. What source was this water collected from?
Piped water
[] 11 Piped into dwelling
[] 12 Piped to yard/plot
[] 13 Piped to neighbour
[] 14 Public tap/standpipe
[] 12 Piped to yard/plot
[] 13 Piped to neighbour
[] 14 Public tap/standpipe
[] 21 Tube well/borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
[] 32 Unprotected well
Spring
[] 41 Protected spring
[] 42 Unprotected spring
[] 42 Unprotected spring
[] 51 Rainwater
[] 61 Tanker-truck
[] 71 Cart with small tank
[] 72 Water kiosk
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel)
[] 61 Tanker-truck
[] 71 Cart with small tank
[] 72 Water kiosk
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel)
Packaged water
[] 91 Bottled water
[] 92 Sachet water
[] 92 Sachet water
[] 96 Other (specify) ____
WQ18. Can you please show me the source of the glass of drinking water so that I can take a sample from there as well?
If 'No' probe to find out why this is not possible?
[] 1 Yes, shown
No
No
[] 2 Water source was not functional [Go to WQ20]
[] 3 Water source too far [Go to WQ20]
[] 4 Unable to access source [Go to WQ20]
[] 5 Do not know where source is located [Go to WQ20]
[] 3 Water source too far [Go to WQ20]
[] 4 Unable to access source [Go to WQ20]
[] 5 Do not know where source is located [Go to WQ20]
[] 6 Other reason (specify) ____ [Go to WQ20]
WQ19. Record whether source water sample collected.
Label sample S-XXX-YY, where XXX is the cluster number (WQ1) and YY is the household number (WQ2).
[] 1 Source water collected
[] 2 Source water not collected (specify) ____
[] 2 Source water not collected (specify) ____
WQ20. Check WQ6: Is the household selected for blank testing?
[] 1 Yes
[] 2 No [Go to WQ22]
[] 2 No [Go to WQ22]
[p. 4]
WQ21. Take out the sample of sterile/mineral water that you got from your supervisor.
Label B-XXX-YY, where XXX is the cluster number (WQ1) and YY is the household number (WQ2).
Record whether the sample is available.
[] 1 Blank water sample available
[] 2 Blank water sample not available (specify) ____
[] 2 Blank water sample not available (specify) ____
WQ22. Conduct test within 30 minutes of collecting sample. Record the results following 24-48 hours of incubation.
WQ23. Record the time
Hours and minutes _ _ : _ _
[p. 5]
Water quality testing results
Following 24-48 hours of incubation the results from the water quality tests should be recorded.
WQ24. Day / Month / Year of recording test results:
_ _ / _ _ / 201 _
WQ25. Record the time:
Hour and minutes _ _ : _ _
WQ26. Household water test (100ml):
Record 3-digit count of colonies.
If 101 or more colonies are counted, record '101'
If it is not possible to read results, record '991'
If the results are lost, record '992'
Number of blue colonies _ _ _
WQ26A. Check WQ19: Was a source water sample collected?
[] 1 Yes, WQ19=1
[] 2 No, WQ19=2 or blank [Go to WQ28]
[] 2 No, WQ19=2 or blank [Go to WQ28]
WQ27. Source water test (100ml):
Number of blue colonies _ _ _
WQ28. Check WQ21: Was a blank water sample available?
[] 1 Yes, WQ21=1
[] 2 No, WQ21=2 or blank [Go to WQ31]
[] 2 No, WQ21=2 or blank [Go to WQ31]
WQ29. Blank water test (100ml):
Number of blue colonies _ _ _ [Go to WQ31]
[p. 6]
Measurer's observations ________
Supervisor's observations ________