Spreadsheet: 121094d1315842344-countif-over-multiple-worksheets-100-questionnaire-latest
Sheet: Start

General | Organization: |  | RIRP |  |  |  |  | Name of Surveyor: |  |  |  |  |  |  |  |  |  | Date of assessment:
 | Head of household name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Assessment no:
 | Beneficiary group: |  |  |  | IDP returnee |  |  | Refugee returnee |  |  |  | IDP |  |  | Other |  |  | Respondant sex: |  |  | Male |  |  | Female
 | Civil Status ID no: |  |  |  |  |  |  | MoDM Registration: |  |  |  | Yes |  |  | No |  |  | Telephone no:
 | Year of displacement: |  |  |  |  | Location of displacement: |  |  |  |  |  |  |  |  |  |  |  | Year of return:
 | Location of house: District: |  |  |  |  |  |  | Sub District: |  |  |  |  |  |  |  |  |  | Town/village:
 | GPS coordinates of the house: |  |  |  |  | GPS Latitude: |  |  |  |  |  |  |  |  |  |  |  | GPS Longitude:
Household Profile | No of families occupying the house (if more than 1): |  |  |  |  |  |  |  |  |  |  | No of individuals occupying the house/shelter:
 | Female |  | Under 4 |  |  |  |  |  |  |  |  | Male |  |  |  |  |  | Under 4
 |  |  | Between 5 and 11 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Between 5 and 11
 |  |  | Between 12 and 17 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Between 12 and 17
 |  |  | Between 18 and 59 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Between 18 and 59
 |  |  | Over 60 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Over 60
Household Vulnerability | Head of household name under 16 years old: |  |  |  |  |  |  |  | Yes |  | No |  | Victims of violence (indicate number and type ) |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Elderly head of house (with no other adult member) |  |  |  |  |  |  |  | Yes |  | No |  | Victims of trafficking: type |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Female head of house (with no male adult member) |  |  |  |  |  |  |  | Yes |  | No |  | [NAME]: |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Unaccompanied/separated children (indicate #) |  |  |  |  |  |  |  | Yes |  | No |  | Large families (more than 10 family members): |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Disabled family members (how many): |  |  |  |  |  |  | # | Yes |  | No |  | Deported: |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Chronically ill indicate number & type: |  |  |  |  |  |  | # | Yes |  | No |  | Any orphans: |  |  |  |  |  |  |  |  |  |  | Yes |  | No
Income Insecurity | Unemployed (no income sources) |  |  |  |  |  |  |  | Yes |  | No |  | Daily unskilled labour |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Other unstable or poorly paid income activity: |  |  |  |  |  |  |  | yes |  | No |  | Daily skilled labour |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Home based female labour: |  |  |  |  |  |  |  | yes |  | No |  | Child labour |  |  |  |  |  |  |  |  |  |  | Yes |  | No
 | Average household monthly income: |  |  |  |  |  |  |  |  |  |  |  | Other: (specify)
Meet at least 1 of the vulnerability or income insecurity criteria? |  |  |  |  |  |  |  |  |  | Yes |  | No |  | If the answer is NO, there is no need to fill in the below sections
Status of Accommodation | Living in own house on own land (with proof of ownership) |  |  |  |  |  |  |  |  |  |  |  |  | Living in improvised shelter on public land
 | Living in rented accommodation |  |  |  |  |  |  |  |  |  |  |  |  | Living in improvised shelter on private land
 | Living in improvised shelter on own land (with proof of ownership) |  |  |  |  |  |  |  |  |  |  |  |  | Illegally occupying public places (precise building type)
 | Collocating with Iraqi relatives or friends |  |  |  |  |  |  |  |  |  |  |  |  | Illegally occupying private premises (not renting)
 | Year of arrival in current accommodation? |  |  |  |  |  |  |  |  |  |  |  |  | Other, specify
Current Living Conditions | Shelter Security |  | Shelter conditions: |  |  |  |  |  |  | Good  Undamaged |  |  |  | Minor damages (broken windows/doors etc) |  |  |  |  |  | Moderate damages (30% of walls, roof or floor) |  |  |  | Severe Damage
 |  |  | Protection from elements |  |  | Yes |  | No |  | Safety of the shelter: |  |  |  | Safe |  | Risk |  |  |  |  |  | privacy: |  | Yes |  | No
 |  |  | # of persons sleeping in 1 room: |  |  |  |  | less than 5 |  |  |  |  | between 5 and 9 |  |  |  |  | between 10 and 19 |  |  |  |  |  | More than 20
 | Sanitary facilities |  | Type and no of facilities: |  |  |  |  | Flush in toilets |  |  |  |  | Oriental toilets |  |  |  |  | Communal latrines |  |  |  |  |  | other
 |  |  | Number of persons sharing one toilet: |  |  |  |  | less than 5 |  |  |  |  | Between 5 and 9 |  |  |  |  | Between 10 and 19 |  |  |  |  |  | more than 20
 |  |  | Conditions of facilities: |  |  |  |  | Good |  |  |  |  | Poor |  |  |  |  | Very Poor |  |  |  |  |  | Unusable
 |  |  | Other available facilities: |  |  |  |  | septic tank |  |  |  |  | shower |  |  |  |  | [NAME] |  |  |  |  |  | garbage container
 | Water system |  | Source: |  |  |  |  | Public network |  |  |  |  | Communal RO unit |  |  |  |  | Household RO |  |  |  |  |  | Surface water
 |  |  |  |  |  |  |  | Rain water |  |  |  |  | Private arrangement |  |  |  |  | Water tanker |  |  |  |  |  | Other:
 |  |  | # of litres per person / day: |  |  |  |  | less than 10 |  |  |  |  | between 10 and 19 |  |  |  |  | between 20 and 49 |  |  |  |  |  | more than 51
 |  |  | Working conditions: |  |  |  |  | Working |  |  |  |  | Damaged |  |  |  |  | [NAME] |  |  |  |  |  | Unusable
 |  |  | Perceived quality of water: |  |  |  |  | Potable |  |  |  |  | Good for cooking / washing |  |  |  |  | Non potable but clean |  |  |  |  |  | Unusable
 | Electricity: |  |  |  |  |  |  | available |  |  |  |  | Public network |  |  |  |  | Private arrangement |  |  |  |  |  | Not available
Previous assistance provided: |  |  |  | Shelter,date |  |  |  |  |  |  | NFI,date |  |  |  |  |  |  | IGA, date |  |  |  |  |  | Other
Meet the living conditions criteria? |  |  |  |  |  |  |  | Yes |  | No |  | If YES what living condition critteria:
Living conditions criteria | Living conditions criteria |  | Shelter: |  |  |  |  |  |  | Water: |  |  |  |  |  |  |  | Sanitation:
 |  |  | Not protected from elements or structural hazards: |  |  |  |  |  |  | Less than 20 litres of water per person per day: |  |  |  |  |  |  |  | More than 20 persons share a toilet:
 |  |  | More than 10 persons sleep in one room: |  |  |  |  |  |  | Water source contaminated / at risk from contamination: |  |  |  |  |  |  |  | Sanitation or washing facilities inadequate:
 |  |  | Privacy inadequate: |  |  |  |  |  |  | Water source pr system inadequate: |  |  |  |  |  |  |  | Other:
Eligibilty (at least 1 vulnerability and 1 living condition criteria met) and recommendation to the BSC for shelter and/or watsan assistance
YES | Structural element: |  |  |  | Openings: |  |  |  |  | Water: |  |  |  |  | Sanitation: |  |  |  |  |  |  |  |  | Other:
 | repair roof/ceiling |  |  |  | Repair external doors |  |  |  |  | Install water storage tank |  |  |  |  | Repair/install toilet |  |  |  |  | Repair/install shower |  |  |  | Electricity work
 | repair floor |  |  |  | Repair internal doors |  |  |  |  | Install RO unit/filters |  |  |  |  | Repair/install septic tank |  |  |  |  | Repair pipes |  |  |  | Painting
 | repair walls |  |  |  | Repair/install windows |  |  |  |  | Install/repair water pump |  |  |  |  | Provide garbage containers |  |  |  |  | Install handwash basin |  |  |  | Specify
NO | current shelter & watsan in good condition |  |  |  |  |  |  |  |  |  |  |  |  |  | Imminent threat of eviction
 | family appears to be able to afford repair costs |  |  |  |  |  |  |  |  |  |  |  |  |  | Family does not want any repairs/work conducted in their shelter
 | Family does not own the land / cannot provide paperwork |  |  |  |  |  |  |  |  |  |  |  |  |  | Family cannot document their return/displacement status
Additional remarks/comments: