To nominate a village, please answer to the best of your ability the questions listed below.
Name of Village
Location
Size
Population
Language(s)
Does the village have a primary school?
yes no
If the village does not have a primary school, what is the approximate distance to the closest school?
Less than 2 km (approximately 1.2 miles)
2 km—5 km (approximately 1.2—3 miles)
5 km + (approximately 3 miles +)
Does the village have a secondary school?
If the village does not have a secondary school, what is the approximate distance to the closest school?
In this village, how likely is a girl to attend school?
Most likely
Less likely
Does the village have electricity?
What medium is regularly used for cooking? (please check all that are relevant)
Wood burning Coal Gas Solar Power Animal waste/dung
Does the village use renewable energies?
Where do men work?
mostly agriculture other, please specify
Where do women work?
Where do villagers get most of their water?
Nearby well Nearby river Nearby lake Nearby pool of water This village does not have water in its surroundings
Is the drinking water safe?
Yes --most of the time Yes --sometimes No
List the crops grown in the village (if none a grown, enter “none”)
Are irrigation systems available in this village?
What type of animals does this village have? (please check all that are relevant)
Bull Calf Cat Chicken Colt Cow Donkey Duck Goat Goose Hen Horse Lamb Pig Rooster Sheep Turkey No Animals
What is the distance to the closet clinic/hospital?
Less than 2 km (approximately 1.2 miles) 2km—5km (approximately 1.2—3 miles) 5-10 km (approximately 3—6.2 miles) 10km+ (approximately 6.2 miles +)
Is HIV/AIDS common in this village?
Is malaria common in this village?
Is tuberculosis common in this village?
What type of housing is most common in this village?
Brick Mud Stone Wood other, please specify
Are roads leading to this village paved?
Mostly Partially None
Are any of the following within the villagers’ reach?
Telephone - landline Telephone - cell The Internet
Does the village have facilities with running water?
None More than one More than 2 Enough for most villagers
Describe the village’s sanitary condition:
Flush Pour-flush Ventilated improved pit latrine (VIP) Pit latrine with slab Composting toilet Bucket Hanging toilet or latrine Bush or Field
Is there a public bath near the village?
What method is most commonly used for disposing of trash?
Designated area close to the village Designated area far from the village Anywhere Composting Recycling
What is the common mode of transportation?
Bicycle Vehicle - private Public Transportation Walking
Does the village benefit from government aid?
Frequently; please specify Sometimes; please specify Never
Does the village receive other forms aid?
Do the villagers have access to credit?
Frequently Sometimes Never
Please list the items that this village urgently needs
