BASELINE SURVEY FORMAT

School name: ………………………………U-DISE code:…...…………………………

Block Name: ……………………………….Class ……….………to.…….……...……

Head Teacher:……………………………Contact no.: ………………………………

Cluster resource center: …………………District: ……………………………………

State:…………………………………………...

SECTION A: GENERAL INFORMATION

  1. No. of teachers
/ Male: / Female:
  1. No. of students
/ Boys: / Girls:
  1. No of Children with Special Needs (CWSN)
/ Total:
  1. Type of school: Boys/Girls/Co-educational:

  1. How many households are there in the village/town/city?

  1. How many households use individual toilets?

  1. Whether the school has electricity
/ A. Yes / B. No
  1. Status of school boundary/compound wall
/
  1. Complete
/
  1. Partial

  1. No boundary wall/ fence

  1. Which of the following student committees does the school have:

A. Child cabinet/Bal Sansad / B. Meenamanch / C. Eco club
D. Science club / E. Other ………….. / F. None
  1. How often does the student committee meet?
(Can refer to the child cabinet meeting register if maintained)
  1. Weekly
/
  1. Monthly
/
  1. Quarterly

  1. Half yearly
/
  1. Annually
/
  1. As and when required

  1. Is not active/doesn’t meet
/
  1. No such committee

SECTION B: WATER

  1. What is the source of drinking water in the school premises?
(Tick against the correct category)
A. Hand pump
B. Well
C. Force lift handpump
D. Tap water
E. Others (Specify): ……………..
F. No source
  1. What is the status of functionality of the source of the drinking water?

  1. Functional
/
  1. Partially functional
/
  1. Non-functional

  1. What methods of water treatment are used before drinking /cooking

A. Sieve water / B. Boiling
C. Using filter with ceramic or other candle / D. Chlorination
E. No treatment / F. Any other methods, please specify: ………………………………………
  1. Does water source need repairs? If yes:

  1. Requires minor repair (Please specify): ……………………………………………….

  1. Requires major repair (Please specify): ……………………………………………….

  1. Whether the school has functioning overhead tank for drinking water storage
/ A. Yes / B. No
  1. If so, how is water lifted to the tank?
/ A. Electric Motor / B. Manual

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SECTION C: TOILETS

  1. Does the school have toilets in the premises?
/
  1. Yes
/
  1. No

  1. How many toilets are there for each of the following: (Number)
/ How many are functional? (Number)
Girls: …………………
Boys: …………………
Teachers: …………….
Common: …………….
  1. Are the toilets clean, odorless and well maintained? (Tick against the correct category)

  1. Toilets are clean with minimal odor

  1. Toilets are dirty and unusable
  2. Toilets are not clean, smelly but are being used

  1. Do the toilets need repairs? (Tick against the correct category)

  1. Minor repairs like fixing doors, latches, broken taps etc

  1. Major repairs like broken pan, adding ventilators, septic tank connection etc

  1. Incomplete toilet construction

  1. Defunct or completely damaged toilets
  1. How is the water provided to toilets/urinals? (Tick against the correct category)

  1. Running water

  1. Water stored in drums inside the toilet block

  1. Any other (Specify): ……………………….

  1. No water

22. Is there a toilet specially for children with special needs (CWSN)? / A. Yes / B. No
  1. If yes, does it have ramp access with handrail
/ A. Yes / B. No
  1. A wide door for wheelchair entry
/ A. Yes / B. No
  1. Handrails inside the toilet for support
/ A. Yes / B. No
  1. Are there cleaning materials available near the toilet for cleaning toilets/ urinals?
  1. YesB.No

  1. Is there handwashing facility attached or close to the toilet?
/ A. Yes / B. No
  1. Is there water provided in the handwashing facility?
/ A. Yes / B. No
  1. Is there soap provided in the handwashing facility?
/ A. Yes / B. No
  1. Who cleans the toilets and urinals?

  1. School authorities
/
  1. Child cabinet
/
  1. Panchayat

  1. Hired worker
/
  1. SMC
/
  1. None

  1. Other (Specify): …………………………………………………

  1. How often are the toilets/urinals cleaned?

  1. Daily
/
  1. Alternate days
/
  1. Twice a week

  1. Weekly
/
  1. Not cleaned

  1. Other (Specify):………………………………………………
  1. Is there adequate and private space for changing and disposal facilities for menstrual wasteincluding dust bins? (only for co-educational upper primary/senior secondary schools)
A. YesB. No
30.Is there any incinerator installed for the disposal of menstrual waste? (only for co-educational upper primary/senior secondary schools)
A. YesB. No

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SECTION D:HYGIENE AND HANDWASHING

(This section is to be answered based on observation)

  1. Is there a group handwashing facility (a place where 6-10 children can wash hands simultaneously) to wash hands before meals? A Yes B. No
  1. Is there soap available at the group handwashing facility? A YesB. No
  1. On the day of your visit, did you observe children washing hands with soap before meals?

A YesB. No

  1. How many children would you say washed hands with soap before meals?

……………………………………………………..

  1. Does the school have washing facilities for cooking & serving?

A. YesB. No

  1. On the day of your visit, did you observe cooks and helpers washing hands with soap before cooking and/or serving meals?

A YesB. No

  1. Is there provision of drainage for wastewater from kitchens and handwashing facilities?

A YesB.No

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SECTION E: BUDGET

Indicative cost required for this school to keep the drinking water, toilets and handwashing facilities functional:

S.No / Component / Description / Indicative Cost (INR)
1 / Drinking Water source
  1. New Source

  1. Repairs

2 / Toilets
  1. Construction

  1. Repairs

3 / Handwashing station
  1. Construction

  1. Repairs

  1. Soap

4 / Maintenance
  1. Attendant wages

  1. Cleaning material

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One Star Norms for School WASH Facilities

  1. There should be atleast one toilet each for boys and girls

Each toilet should have all components below:

a)Access to water by bucket or tap

b)1 ceramic rural squatting pan

c)Toilets must have 1 door in each WC at a height of 2100 mm with child accessible latching arrangement

d)One opening for light/ventilation in each toilet of size 450 -450 mm at a height that allows sunlight to penetrate for self drying

e)Roof cover that provides privacy and protection from sun and rain

f)Bucket and mug in each toilet

  1. Toilets should be available inside the school premises
  2. Toilets must be connected to leach pit/twin pit/septic tank for disposing of wastewater
  3. Toilet complex should be more than 10 meters away from the drinking water well or the hand pump of the school
  4. 2.5 to 5.0 cm size holes in the masonry of the soak-pit at the time of toilet construction must be done so that water and gas collected get absorbed into the soil
  5. School ensures access to water through running water/ stored water containers
  6. Atleast one separate urinal each for boys and girls
  7. There must be a partition at 1500mm height between each urinal especially in case of high schools and above

10. Hand washing and cleaning material like soap, mug, brush, phenyl must always be available in the toilet

  1. School provides handwashing facility with water and soap close to the toilet either as common/separate in girls and boys blocks: Water provided can be running water or through stored water containers
  2. School provides handwashing facility with water and soap close to the dining area either by:

Water provided can be running water or through stored water containers

  1. A minimum of 500 litres wash water storage tank capacity should be available for a school of up to 100 children (Subsequent calculation @ 5 litres per child)
  2. School toilets/urinals must be cleaned by a dedicated person atleast once in two weeks
  3. If water tanks exist, cleaning of water storage tanks atleast twice a year

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