Response Solicited Preferably from Wife of Well Owner, Then Sister/Sister in Law

A. Well ID from SS plate: [1234] (no tag: [lost], moved well: [shift], removed: [gone]) ***if lost/shift/gone: ask 1-9 and 10c, put new plate in lost/shift/gone duct tape pocket

B. Well status based on new plate: unsafe [0], safe [1]

C. Well status (visible on well): none [0], [1] CU plate, [2] red paint,

[3] green paint

D. Does the well function? No [0], yes [1]

Response solicited preferably from wife of well owner, then sister/sister in law

1. What is your relation to the owner? [1] close family, [2] same bari, [3] neighbor

2. Are you or a member of your close family in any community association?

[0] no, [1] informal savings/micro-credit, [2] bazaar samiti, [3] other

3. How many years of education have you completed? [#]

4. Do you use this well for drinking or cooking? [0] no, [1] sometimes, [2] drink, [3] cook, [23] both

5. What is the status of this well? [0] Unsafe, [1] safe, [2] don’t know

6. How do you know the status of this well?

[1] CU result, [2] paint, [3] other testing, [4] told by someone,

[X] if don’t know for number 5

7. Does anyone in your family have a CU medical card? [0] No, [1] yes, [2] lost

8. Have you responded to a questionnaire that asked how much money you spent on food

in the last week? [0] No, [1] yes, [2] don’t know

9. Did you change the well you drink from or shift your well in the past 3 years?

No: [0]

Yes change: [11#] to CW for arsenic reasons, [10#] to CW for other reasons,

[21#] to PW for arsenic reasons, [20#] to PW for other reasons

(e.g., if they switched to a community well 1.5 years ago for arsenic reasons: 1130)

Yes shifted: 30#

(e.g., if they shifted their well to a new location last month, enter 3001. If they shifted 2 years ago, enter 3024. Zero after the 3 is a blank to make the answer 4 digits long)

Look at the answers for questions B, 5 and 4 before asking ONE question

Enter ‘x’ for any questions you do not ask

Remember, if LOST/SHIFT/GONE only ask 10c.

SAFE/KNOW SAFE

10a. By how many has the number of household using this well increased in the past three years? [#]

UNSAFE/KNOW UNSAFE

10b. Why are you still using this well? Don’t care [1], CW too far [2], not allowed at CW [3], PW too far [4], not allowed at PW [5], don’t know of safe well [6]

SAFE/DON’T KNOW SAFE

If the person drinks from the well ask 10d and 10e:

10c. Why didn’t you switch to a well known to be safe? Don’t care [1], CW too far [2], not allowed at CW [3], PW too far [4], not allowed at PW [5], don’t know of safe well [6]

10d. Now that you know this well is safe, by how many is the number of households using this well likely to increase? [#]

If the person does not drink from the well:

10e. Will you use this well now that you know it is safe? [0] No, [1] Yes

UNSAFE/DON’T KNOW UNSAFE

10f. Will you switch to a safe well now that you know this well is unsafe?

No: Don’t care [1], CW too far [2], not allowed at CW [3], PW too far [4], not allowed at PW [5], don’t know of safe well [6]

Yes: CW [7], PW [8]

11. Complete? [0] No, [1] Yes