WASH ASSESSMENT TOOL
Name of the Village ……………………Parish ……………………Sub-County …..…………………..…
Health Sub-District ……………………………………..District ………………………………………….
Name of WASH assessment officer …………………………………………… Date ……/……/20………
S/N PARAMETERS Code
1. H/H Socio- Demographic Characteristics
Yes (1) or
1.1. Name of Household (H/H) Head ……………………….................................................................. NO (0)
a) Age ………yrs. Sex/Gender : Male Female
b) Marital status: Single Married Separated Widowed
c) Level of Education: None Primary Secondary Tertiary
d) Religion: Islam Catholic Anglican SDA Pentecostal others
e) Tribe: Munyankole/Muhima Mukiga Munyarwanda Mutoro other
1.2. H/H size (Population) ………………M ………F ………No. Children under 5years …………..
2. WATER
Yes (1) or
2.1. Water Availability/Scarcity, Accessibility and Affordability NO (0)
a) Main source of water:
Tap water Protected spring Borehole(B.H) Shallow well
open well Rain water harvesting
b) How far is the water source? < 1km >1km
c) How long does it take to fetch water from the main water source? …………minutes/ hours
d) Does the water source produce enough water needed through the year? ........................................
e) How much Water does your H/H use in a day …..……Estimate Per capita consumption……….
f) Do you buy or pay for water ………If so, How Much? …………… and How often? ……………
Yes (1) or
2.2. Water Quality, Safety & Hygiene NO (0)
a) How do you store water for domestics use? Tank/Drums Jerry Can/Pots Others
b) State of water storage facility? Clean Dirty± algal growth
c) Observed physical appearance of water:
o Color: Colorless Turbid/colored/Dirty
o Odor: Odorless Smelly (Fishy Ammonium//Fecal/chlorine….)
o Taste: Tasteless Salty Others
d) Has the District/Town council water department//NWSC ever sampled & tested your water source
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for water quality? ……….I don’t know…… If Yes (1), did they inform the community on the
water quality levels of the water source? …………I don’t Know……..If yes (1), what was the state
of the water source where you fetch water? ..............................................
Activity: After Home visit, Go to the Water Source and conduct a water source sanitary inspection;
observe water quality at source, any source contamination, nearness to latrines, open defecation,
animal contamination, water source fencing, human activity around the source, WUC& state of repair.
Yes (1) or
NO (0)
2.3.Drinking water & Water Treatment
a) How many liters of water do you consume in a day …………………( versus recommended )
b) How do you treat drinking water? Boiling add Chemicals Filtration others
c) How do you store drinking water? Refrigerator/water dispenser Jerry Can/Pot Others
d) State of Drinking water Storage facility? Clean Dirty± algal growth
3. SANITATION
Yes (1) or
3.1. H/H has a Latrine/Toilet ………. If Yes (1), Latrine is Newly constructed ……….. If No (0), NO (0)
Latrine under construction…………
3.2. Type of Latrine: Traditional Pit Latrine Improved Pit Latrine/VIP
ECOSAN/Compost Flush Toilets Others
3.3. Latrine is shared ……………………………….. (Estimated Improved latrines that are shared)
3.4. Latrine has: Door shutter/Curtain wall for Privacy Washable floor,
Anal cleansing materials Fly Proof/ Squat hole Cover
3.5. Has a separate Urinal for male use ……………………
3.6. State of latrine:
o Clean Dirty/Soiled & Smelly
o Good state of repair Dilapidated Filled Up
3.7. Sign of open defecation …………..
3.8. H/H has a Refuse /manure Pit …...or has Storage facility for refuse before collection& disposal….
4. HYGIENE
Yes (1) or
4.1. H/H has a; NO (0)
o Hand washing facility (HWF) at Latrine ………… If Yes (1), With Water only…….. Or
water & Soap …………… Any sign/Evidence of Use …………
o Bathroom …………….. With a soak away pit for waste water drainage………………
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o Drying Rack ………………with a soak away pit for waste water drainage ……………..
o A well-drained Laundry space …………………with Drying Lines ……………………
o A well-drained spacious clean compound with trimmed grass ………………………..
4.2. How many times do bath in a day: One time Two times Three or more times
4.3. When do you Brush your teeth? In the morning Every after a meal Before bed time
4.4. Do you have a flat iron/ iron box? ………….
4.5. Do Physical exercises/activity? ........... If Yes (1), how many Minutes/hours do you exercise in a
day………… and how many days in a week ……………
4.6. How many hours do you sleep in a day ………….……..
4.7. Others …………………………………………………………………………………………….
5. WASH Associated Diseases
Yes (1) or
5.1. Is there any one at home currently/previously(within last month) suffering from; NO (0)
o Diarrheal diseases/ worms/Typhoid? ………If Yes (1), was it a child under 5 years? ……
o Malaria? ………If Yes (1), was it a child under 5 years? …… or a pregnant mother? ............
o Trachoma/Scabies/skin fungal infections/Pediculosis?.........If Yes (1), was it a child? ...........
o UTI or Vulvo-Vaginal Candidiasis (VVC)? ..... If yes (1) was it WCBA or Pregnant mothers
o Dental Caries/Periodontal/Gum disease? ........ If yes (1), did it lead to a dental extraction? …
5.2. Others ………………………………………………………………………………………….
6. Summary of observed WASH Challenges of the Village [ Share with VHT/ L.C1 Chairperson]
NB: Remember to note them done and include them in your COBERMS report
7. Recommendations [ Propose practical solutions to cited WASH challenges]
NB: Remember to note them done and include them in your COBERMS report
8. Plan with the Community Leadership an Evidence Based Health Intervention and work with
them to conduct social mobilization on set date and selected venue.
NB: Remember to note them done and include them in your COBERMS report
9. Compiled by:
Name: ……………………………. Signature ………………… Date …………………..
WASH Assessment Team Leader
Endorsed by
1. Name (VHT) ………………………………….. Signature ……………….Date ………………..
2. Name: ……………………………….... Signature ………………..Date …………………
Chairperson L.C1 [STAMP]
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LIST OF WASH ASSESSMENT TEAM MEMBERS
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Approved by
Name: ……………………………………… Signature ……………………. Date ………………………..
COBERMS I Field Supervisor
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