MBI Sample CRC Questionnaire PAC PDF
MBI Sample CRC Questionnaire PAC PDF
MBI Sample CRC Questionnaire PAC PDF
Investigator Introduction:
Hello, my name is ______________, and I work for ____________, a Social Science Survey Agency
that is collecting information on drinking water services in ____________. May I speak to an adult
member of your household? (Modify the introduction to sound as natural as possible.)
Instruction to investigator: please use pencils and circle the code where applicable and write the
answers in legible handwriting in the spaces provided for responses.
This document is the Intellectual Property of Public Affairs Centre (PAC). Any quotation from it should duly
acknowledge PAC.
11 What is your main source of water? Single response 1- Bore well/ hand pump (skip to q. 12)
2- Public tap (skip to q.18)
3- Open well (skip to q.28)
4- Household water supply/ piped (skip
to q. 32)
5- Other specify ------------------ (skip to
Q36)
12 How far (in meters) is the bore well/ hand pump that
you use?
13 How long (in minutes) does it take to fetch water
and return home?
14 Who fetches water most often ? 1- Adult male
2- Adult female
3- Male child
4- Female child
15 Has the bore well / hand pump broken down in the 1- Yes
past one year? 2- No (skip to q. 36)
16 How frequently has the bore well/ hand pump 1. Once a week
broken down during the past one year? 2. Once a fortnight
3. Once a quarter
4. Once in six months
5. Once a year
17 Is the bore well/ hand pump fixed promptly when it 1- Yes
breaks down? 2- No
GO TO QUESTION 36
Public tap
18 How far (in meters) is the public tap that you use?
This document is the Intellectual Property of Public Affairs Centre (PAC). Any quotation from it should duly
acknowledge PAC.
25 Has the public tap broken down in the past one 1- Yes
year? 2- No (skip to q. 36)
GO TO QUESTION 36
Open well
28 How far (in meters) is the open well from which you
get water?
29 How long (in minutes) does it take to fetch water
and return home?
30 Who fetches water most often? 1- Adult male
2- Adult female
3- Male child
4- Female child
31 What is the frequency of cleaning the well? 1- Once in a quarter
2- Once in six months
3- Once a year
4- Not cleaned in the last year
GO TO QUESTION 36
Household water supply (piped)
CONTINUE TO QUESTION 36
Common Questions
This document is the Intellectual Property of Public Affairs Centre (PAC). Any quotation from it should duly
acknowledge PAC.
response 2- February
3- March
4- April
5- May
6- June
7- July
8- August
9- September
10- October
11- November
12- December
39 Generally, how does the water smell? 1- No smell
2- Foul smell
40 Generally, does the water have a taste? 1- Yes
2- No (tasteless)
41 Generally, what does the water look like? 1- Clear
2- Cloudy/ dirty
42 Do you pay for water? 1- Yes
2- No (skip to q. 45)
43 How much do you pay a month?
44 Are the bills that you receive accurate? 1- Yes
2- No
45 Have you made a complaint related to your drinking 1- Yes
water service in the past one year? 2- No (skip to q. 48 )
46 To whom did you complain?
54 Was the bribe demanded (or did you pay on your 1- Demanded
own) 2- Paid on my own
55 Did the work get done after paying the bribe? 1- Yes
2- No
(Interview Complete)
This document is the Intellectual Property of Public Affairs Centre (PAC). Any quotation from it should duly
acknowledge PAC.