Nepal Gorkha District Assessment Form IDENTIFICATION AND LOCATION I2 DATE OF ASSESSMENT * I3 ENUMERATOR NAME * yyyy­mm­dd I4 DISTRICT * I5 VDC/MUNICIPALITY * I5 VDC/MUNICIPALITY * Please specify Gorkha Bihi Chhaikampar Chumchet Lho Prok Samagaun Sirdibas Uhya Other (specify) I6 WARD * I7 VILLAGE NAME * 1 2 3 4 5 6 7 8 9 Do not know I8 GPS COORDINATES GPS coordinates can only be collected when outside. latitude (x.y °) longitude (x.y °) altitude (m) accuracy (m) I9 SOURCE(S) FOR THIS ASSESSMENT None 1 2 3 or more Select the number of people you spoke to for each category . * Official (administrative) . * Village representative . * Religious leader . * Army or police . * Health worker . * Social worker . * International NGO / development partner . * Teacher . * Other local person I10 HOW MANY OF THOSE KEY INFORMANTS WERE WOMEN? * COMMUNITY PROFILE » Total population P1 ENTER THE PERCENTAGE OF THE OVERALL POPULATION WHO ARE IN THE FOLLOWING CATEGORIES. Needs to add up to 100% * * * % in normal situation % requiring assistance % requiring immediate assistance » Male P2 ENTER THE PERCENTAGE OF THE MALE POPULATION WHO ARE IN THE FOLLOWING CATEGORIES. Needs to add up to 100% * * * % in normal situation % requiring assistance % requiring immediate assistance » Female P3 ENTER THE PERCENTAGE OF THE FEMALE POPULATION WHO ARE IN THE FOLLOWING CATEGORIES. Needs to add up to 100% * * * % in normal situation % requiring assistance % requiring immediate assistance » Children P4 ENTER THE PERCENTAGE OF CHILDREN WHO ARE IN THE FOLLOWING CATEGORIES. Needs to add up to 100% * * * % in normal situation % requiring assistance % requiring immediate assistance P5 ENTER THE PERCENTAGE OF CHILDREN WHO ARE IN THE * * FOLLOWING CATEGORIES (SHOULD ADD UP TO 100%) Over 5 Under 5 CASELOADS C1 FOR THIS VDC, ENTER THE NUMBER OF PEOPLE WHO DIED, ARE MISSING, OR ARE INJURED BY GENDER * * * * Men ­ Dead Women ­ Dead Men ­ Missing Women ­ Missing * * Men ­ Injured Women ­ Injured COMMUNITY BUILDINGS B1 STATUS OF VDC BUILDING * No damage Some damage Destroyed, debris cleaned up Destroyed, debris NOT cleaned up Do not know B2 NUMBER AND STATUS OF SERVICE CENTRES, COMMUNITY OR COOPERATIVE BUILDINGS? Number of buildings * * No damage Some damage Destroyed, debris cleaned up Destroyed, debris NOT cleaned up » Household Buildings B3 NUMBER AND STATUS OF MAIN HOUSEHOLD BUILDINGS? Number of buildings * * No damage Some damage Destroyed, debris cleaned up Destroyed, debris NOT cleaned up VULNERABLE GROUPS V1 ENTER THE PERCENTAGE OF HOUSEHOLDS THAT FALL INTO THE FOLLOWING CATEGORIES %, Write 0 if none * * * * * % Single headed % Female headed % Child headed % Elderly headed % with pregnant/lactating women * * * * % with disabled persons % with chronically ill persons % with % of marginalized ethnicity or separated/unaccompanied caste children V2 IN THIS AREA, WHAT ARE THE THREE MOST VULNERABLE GROUPS? Rank up to 3 * Rank 1 Single headed Female headed Child headed Elderly headed with pregnant/lactating women with disabled persons with chronically ill persons with separated/unaccompanied Of marginalised caste or ethnic children group NONE Do not know * Rank 2 Single headed Female headed Child headed Elderly headed with pregnant/lactating women with disabled persons with chronically ill persons with separated/unaccompanied Of marginalised caste or ethnic children group NONE Do not know * Rank 3 Single headed Female headed Child headed Elderly headed with pregnant/lactating women with disabled persons with chronically ill persons with separated/unaccompanied Of marginalised caste or ethnic children group NONE Do not know INCIDENTS SINCE EVENT R1 INCREASE OF OBSERVED INCIDENTS SINCE EARTHQUAKE * * Describe the other incident You can select more than one Inter­community Related to presence of Child trafficking tension/violence security forces Discrimination by caste Any disease outbreak Other (specify below) or ethnicity or unusual increase in cases / deaths NONE Do not know ACCESS A1 ROAD ACCESS AVAILABLE BEFORE AND AFTER Pre earthquake Post earthquake Do not know THE EARTHQUAKE . * Motorbike . * Foot . * Horse . * Yak . * Helicopter A2 HOW LONG DOES IT TAKE FOR YOUR COMMUNITY TO REACH THE FOLLOWING PLACES? (walking distance in hrs) * * * * * Primary School High School College Nearest market / shops Road head with transport services * * * * Health post / hospital VDC office PCO Police Station A3 ARE MEMBER OF THE COMMUNITY USING ALTERNATIVE TRAILS SINCE THE EARTHQUAKE? * Yes No Do not know A4 ACCESS PROBLEMS High Medium Low None Do not know . * Physical access by relief work . * Aid delivery interference . * Aid worker safety . * Lack of aid provision . * Fear of accessing aid . * Denial of aid because of lack of documentation . * Denial of aid due to ethnicity or caste SANITATION S1 ENTER THE PERCENTAGE OF HOUSEHOLDS WHO ARE IN THE FOLLOWING CATEGORIES WITH REGARDS TO SANITATION. Needs to add up to 100% * * * % in normal situation % of people requiring assistance % of people requiring immediate assistance S2 BEFORE THE EARTHQUAKE, WHAT WAS THE MOST COMMON TYPE OF TOILET? Flush toilet household Flush toilet community Pit toilet household Open defecation Do not know S3 % OF TOTAL POPULATION PRACTICING OPEN DEFECATION * * After earthquake (%) Before earthquake (%) S4 % OF TOTAL POPULATION USING SHARED, NON­ * * EMERGENCY TOILETS After earthquake (%) Before earthquake (%) S5 % OF POPULATION USING * S6 % OF HOUSEHOLDS WITH * S7 % OF HOUSEHOLDS WITH TOILET FACILITIES DAMAGED * EMERGENCY TOILETS TOILET FACILITIES WITH ABOVE AND BELOW GROUND DAMAGED After earthquake (%) WALLS/ROOF/DOORS ONLY After earthquake (%) After earthquake (%) S7 WHAT ARE THE COMMUNITY'S THREE MOST PRESSING PROBLEMS RELATED TO SANITATION IN THIS COMMUNITY? FIRST * * Why hasn't this been addressed yet sufficiently? SECOND * * Why hasn't this been addressed yet sufficiently? THIRD * * Why hasn't this been addressed yet sufficiently? S9 WHAT LEVEL OF CONFIDENCE DO YOU HAVE IN THIS INFORMATION FOR THE SANITATION SECTION? * Do not read Very high High Acceptable Low HYGIENE HY1 ENTER THE PERCENTAGE OF HOUSEHOLDS WHO ARE IN THE FOLLOWING CATEGORIES WITH REGARDS TO HYGIENE. Needs to add up to 100% * * * % in normal situation % of people requiring assistance % of people requiring immediate assistance HY2 % OF POPULATION ABLE TO ACCESS HANDWASHING * * SOAP LOCALLY After earthquake (%) Before earthquake (%) HY3 % OF WOMEN AND GIRLS WITH ACCESS TO MENSTRUAL * * HYGIENE MATERIALS After earthquake (%) Before earthquake (%) HY4 % OF POPULATION WITH WATER CONTAINER WITH LID * * After earthquake (%) Before earthquake (%) HY5 WHAT ARE THE COMMUNITY'S THREE MOST PRESSING PROBLEMS RELATED TO HYGIENE MATERIALS IN THIS COMMUNITY? FIRST * * Why hasn't this been addressed yet sufficiently? SECOND * * Why hasn't this been addressed yet sufficiently? THIRD * * Why hasn't this been addressed yet sufficiently? HY6 WHAT LEVEL OF CONFIDENCE DO YOU HAVE IN THIS INFORMATION FOR THE HYGIENE SECTION? * Do not read Very high High Acceptable Low WATER W1 ENTER THE PERCENTAGE OF HOUSEHOLDS WHO ARE IN THE FOLLOWING CATEGORIES Needs to add up to 100% * * * % in normal situation % of people requiring assistance % of people requiring immediate assistance W2 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: OPEN WELL / DUG WELL After earthquake (%) Before earthquake (%) W3 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: TUBE WELL/HAND PUMP After earthquake (%) Before earthquake (%) W4 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: SPRING After earthquake (%) Before earthquake (%) W5 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: POND After earthquake (%) Before earthquake (%) W6 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: STREAM/RIVER After earthquake (%) Before earthquake (%) W7 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: PIPED WATER SYSTEM After earthquake (%) Before earthquake (%) W8 % OF POPULATION ACCESSING AS PRIMARY DRINKING * * WATER SOURCE: OTHER After earthquake (%) Before earthquake (%) W9 % OF HOUSEHOLDS IN THE SERVICE AREA OF WATER * * SYSTEMS IN NEED OF REPAIR After earthquake (%) Before earthquake (%) W10 % OF HOUSEHOLDS PRACTICING HOUSEHOLD WATER * * TREATMENT After earthquake (%) Before earthquake (%) W11 HAS THE QUALITY OF THE WATER CHANGED SINCE THE * W12 HAS THE QUANTITY OF THE WATER CHANGED SINCE THE * EARTHQUAKE? EARTHQUAKE? Less turbid same more Less Same More turbid Do not know Do not know W13 ARE THE FAMILIES THAT HAVE MOVED AWAY FROM THEIR PROPERTY LIVING IN A CAMP (ASSUME MORE THAN 10HH)? IF SO DESCRIBE THE WASH CONDITIONS AT THESE SITES. W14 PLEASE DESCRIBE THE CONDITION OF WASH AT THE HEALTH FACILITIES. W15 PLEASE DESCRIBE THE CONDITION OF WASH AT THE SCHOOLS AND/OR TEMPORARY LEARNING SPACES. W16 WHAT ARE THE COMMUNITY'S THREE MOST PRESSING PROBLEMS RELATED TO WATER IN THIS COMMUNITY? FIRST * * Why hasn't this been addressed yet sufficiently? SECOND * * Why hasn't this been addressed yet sufficiently? THIRD * * Why hasn't this been addressed yet sufficiently? W17 WHAT LEVEL OF CONFIDENCE DO YOU HAVE IN THIS INFORMATION FOR THE WATER SECTION? * Do not read Very high High Acceptable Low HEALTH AND NUTRITION H1 ENTER THE PERCENTAGE OF HOUSEHOLDS WHO ARE IN THE FOLLOWING CATEGORIES WITH REGARDS TO HEALTH / NUTRITION. Needs to add up to 100% * * * % in normal situation % of people requiring assistance % of people requiring immediate assistance H2 IS THERE A HEALTH FACILITY IN THIS AREA? * Yes No Do not know H3 WHAT IS