HOUSEHOLD QUESTIONNAIRE
Urban Water Supply in Cambodia
There should only be one questionnaire filled out
per household. Interview an adult member of the household (either
the head of household or the spouse).
The
surveyors should introduce themselves to the household and explain that we
would like to ask them some questions about their use of water and satisfaction
with water delivery. Explain that the
experiences they share with you will help the people who provide these services
to learn how to better serve households in the future. Explain that there are no right or wrong
answers for any of the questions you will be asking, and that they should
answer the questions as best and honestly as they can, based on their own
perceptions and experiences.
Please
select only one answer for each question.
No multiple answers are allowed, except where specifically mentioned.
Please use the
following codes for unanswered questions:
Not applicable -9
Respondent
did not understand the question -8
Respondent
refused to answer -7
Respondent
did not know -6
Note: There
should be none or only a few unanswered questions.
Name
of the interviewer: _________________________________
Interview: 1. Complete
2.
Incomplete
Note: HG1-HG3 to be filled
in by the surveyor before starting the interview.
HG1 Household identification number
_______________________
HG2 Town:
1.
Banteay
Meanchey
2.
Kampong
Speau
3.
Takeo
4.
Kandal
5.
Battambang
6.
Kampong
Chhang
7.
Svay
Rieng
HG3 Household:
1.
served
by a private water utility
2.
served
by a public water utility
3.
not
served by a water utility
4.
served
by a subcontractor to a water utility
H1 Gender of respondent: 1.
Male 2. Female
H2 Relationship of respondent to the head
of household:
1.
respondent
is the head of household
2.
spouse
3.
daughter
or son
4.
mother
or father
5.
other
relative
6.
other
(please specify) ________________________
H3 How long has your family lived in this house? ___________ years
I am now going to ask some
questions about the head of household:
H5 What is the native language of the head of household (surveyor to determine without asking)?
1.
Khmer
2.
Vietnamese
3.
Chinese
4.
Thai
5.
Laos
6.
French
7.
English
H6 What is the level of education of the head of household?
(check only the highest level obtained)
1.
none
2.
Pagoda
school
3.
primary
school incomplete
4.
primary
school complete
5.
secondary
school incomplete
6.
secondary
school complete
7.
high
school incomplete
8.
high
school complete
9.
vocational
college
10.
university
11.
other
(please specify) ______________________________________
H7 What is the religion of the head of
household?
1.
Buddhist
2.
Muslim
3.
Animist
4.
Christian
5.
Taoist
6.
Other
(please specify) ______________________________________
H8 What is the ethnic group of the head of household (surveyor to determine without asking)?
1.
Khmer
2.
Chinese
3.
Vietnamese
4.
Thai
5.
Laos
6.
Other
(please specify) ___________________________________
H9 Is your household connected to a piped water network?
1.
yes
(move to H46)
2.
no
If no, answer H10-45:
Why are you not connected?
H10 The
water utility does not serve the area where we live 1. yes 2. no
H11 We have another source of
water 1. yes 2. no
H12 We did
not pay our water bills and were disconnected 1.
yes 2. no
H13 Connection
fee is too high 1.
yes 2. no
H14 Piped
water is too expensive 1.
yes 2. no
H15 We
have no reference person 1.
yes 2. no
H16 The
water utility turned us down 1.
yes 2. no
H17 The
quality of piped water is poor 1.
yes 2. no
H18 The
water utility is unreliable 1.
yes 2. no
H19 We
don’t own this house 1.
yes 2. no
H19B Other
(specify)__________________________________ 1.
yes 2. no
H20 Would you be interested
in getting a piped water connection?
1.
yes
(move to H28)
2.
no
If no, answer
H21-27:
Why are you
not interested in getting a piped water connection?
H21 Connection fee is too high 1.
yes 2. no
H22 Piped water is too expensive 1.
yes 2. no
H23 The
quality of piped water is poor 1.
yes 2. no
H24 The water utility is unreliable 1.
yes 2. no
H25 We
don’t own this house 1.
yes 2. no H26 We have no reference person 1.
yes 2. no
H27 Other (specify) __________________ 1. yes 2. no
What is your household’s source of
water?
H28 own
well 1.
Yes 2. No
H29 public
well 1.
Yes 2. No
H30 neighbor’s
well 1.
Yes 2. No
H31 rain
water collection 1.
Yes 2. No
H32 water
vendors/tanker truck 1.
Yes 2. No
H33 metered
purchase from neighbor’s connection 1.
Yes 2. No
H34 non-metered
purchase from neighbor’s connection 1.
Yes 2. No
H35 river,
lake, spring, pond 1.
Yes 2. No
H36 purchase
from a subcontractor to the water utility 1.
Yes 2. No
H36B other
(specify)________________ 1.
Yes 2. No
In addition, would any of the
following water services be available to you in this area?
H37 public
well 1.
Yes 2. No
H38 public
standpost 1.
Yes 2. No
H39 rain
water collection 1.
Yes 2. No
H40 water
vendors/tanker truck 1.
Yes 2. No
H41 metered
purchase from neighbor’s connection 1.
Yes 2. No
H42 non-metered
purchase from neighbor’s connection 1.
Yes 2. No
H43 river,
lake, spring, pond 1.
Yes 2. No
H44 purchase
from a subcontractor to the water utility 1.
Yes 2. No
H44B other
(specify)________________ 1.
Yes 2. No
H45 How
satisfied are you with your current main source of water?
1.
very
satisfied
2.
satisfied
3.
slightly
satisfied
4.
slightly
dissatisfied
5.
very
dissatisfied
6.
I
have no other choice
Move to H164 if interviewing
a household NOT connected to the piped network.
If the household is
connected to the piped network, ask questions H46 onwards:
H46 For how many years has your household had
a piped water connection? _________ years
H47 Is the network managed by
1.
a
private water utility
2.
a
public water utility
3.
a
subcontractor to the water utility
4.
I
don’t know
Prior
to this service provider, what was your household’s source of water?
H48 piped connection served by a public water
utility 1. Yes 2. No
H49 piped connection served by a private water
utility 1. Yes 2. No
H50 own well 1.
Yes 2. No
H51 neighbor’s well 1. Yes 2. No
H52 public well 1.
Yes 2. No
H53 rain water collection 1.
Yes 2. No
H54 water vendors/tanker truck 1.
Yes 2. No
H55 purchased from a neighbor 1.
Yes 2. No
H56 river, lake, spring, pond 1.
Yes 2. No
H57 other (specify) _________________ 1. Yes 2. No
I now want to ask questions
about your CURRENT piped water connection.
H58 Do you share piped water from this connection with your neighbors?
1.
yes
2.
no
H59 Do you sell piped water from this
connection to your neighbors?
1.
yes
2.
no
Cost of
Connection
H60 Did you pay a fee (including labor and other charges) to the
water utility to get a piped water connection?
1.
yes
2.
no
(move to H65)
If yes, answer questions
H61-64 about the connection fee:
How much did you pay for the piped water connection?
H61a as a
connection fee _________
Riels
H61b as
labor charges _________
Riels
H61c as
other charges (specify)_____________ _________
Riels
H62 Did
you receive a receipt for this payment for the connection?
1.
yes
2.
no
H63 Did
you pay for the connection in lump sump or in step-by-step payments?
1.
In
lump sum
2.
In
step-by-step payments
H64 Did
somebody help you to pay for the connection?
1.
no
2.
yes,
relatives
3.
yes,
an NGO
4.
yes,
other (please specify) ______________________________
H65 Did you also have to pay a
“commission”/additional money to get a connection?
1.
yes
2.
no
(move to H67)
If yes, answer H66:
H66 How
much did you pay? ______________Riels
H67 How long did it take to get a connection (from the day you requested till the day you got the connection)? __________days
H68 Did you pay additional money to speed it up?
1. yes
2. no
Cost of Service
H69 Is your household’s consumption of water
currently metered?
1.
yes
2.
no
(move to H71)
If yes, answer H70:
H70 How
many meters do you have? __________ number
H71 Does your household currently pay for the
water consumed?
1.
Yes (move
to H73)
2.
No
If no, answer H72:
H72 Why
don’t you pay?
1.
there
is no water tariff—water is free
2.
nobody
collects the tariff
3.
we
do not receive water bills
4.
we
bribed officials not to collect from us
5.
we
cannot afford to pay
6.
we
are not satisfied with the service
7.
other
(please specify) _____________________
Move to H86.
H73 Do you receive a water bill on a regular
basis?
1.
yes
2.
no
H74 Do you currently pay based on the meter
reading (volumetric billing) or a flat fee?
1.
A
flat fee (move to H75)
2.
Based
on meter reading (move to H76)
If a flat fee, answer H75:
H75 How
much is the flat fee you pay per month?
________Riels/month
Move to H80.
If the bill is based on
meter reading, answer H76-79:
H76 How much was your last monthly water bill? ____________ Riels
H77 How
much is the unit tariff charged by the water utility? _________Riels/m3
H78 Is there a minimum monthly fee you have to pay (that does not
depend on the meter reading)?
1.
yes
2.
no
(move to H80)
If yes, answer
H79:
H79 What
is the minimum monthly fee?
_______________ Riels/month
H80 What happens if a household does not pay
its water bills?
1.
nothing
happens
2.
that
household is warned that service will be disconnected
3.
that
households negotiates a payment plan with the service provider
4.
that
household must pay a penalty to get to continue use the service
5.
that
household needs to bribe an official to get to continue use the service
H81 Has the unit tariff/flat fee changed in the past two years?
1.
No
(move to H85)
2.
Yes,
once
3.
Yes,
twice
4.
Yes,
more than twice
If yes, answer H82-84:
H82 Has the tariff/fee increased or decreased?
1.
increased
2.
no
change
3.
decreased
H83 Did
the water utility inform you in advance of the tariff/fee change?
1.
yes
2.
no
H84 Did
you understand why the tariff was changed?
1.
Yes
2.
No
H85 Does your household pay now more or less for piped water than two years ago?
1.
Much
more
2.
Somewhat
more
3.
About
the same
4.
Somewhat
less
5.
Much
less
I now want to ask some
questions about the availability of water from your piped connection.
Do
you use piped water for
H86 Drinking 1.
Yes 2. No
H87 Cooking 1.
Yes 2. No
H88 Washing and bathing 1. Yes 2. No
H89 Gardening 1.
Yes 2. No
H90 Animals 1.
Yes 2. No
H91 Commercial purposes 1. Yes 2. No
How
many hours per day is piped water usually available?
H92 During the wet season: __________hours
H93 During the dry season: __________hours
H94 In the past three months, has piped water been available every
day from your connection?
1.
Yes
(move to H101)
2.
No
If no, answer H95-100:
Why has piped water not been available every day?
H95 During
the dry season the piped water supply is scarce 1.
Yes 2. No
H96 During
the wet season the piped water supply is scarce 1.
Yes 2. No
H97 Frequent
breakdowns in water delivery 1.
Yes 2. No
H98 Water
utility rations water consumption 1.
Yes 2. No
H99 Capacity
is inadequate 1.
Yes 2. No
H100 Other
(please specify)___________________ 1.
Yes 2. No
H101 In the dry season, do you get all the water your household needs from this piped connection or do you also use another source of water?
1.
Yes,
we get all water from the piped connection in the dry season (move
to 115)
2.
No,
we also use another source in the dry season
If no, answer H102-114:
Why do you use another source of water in the dry season?
H102 piped water is too expensive—use less expensive water sources when available 1. Yes 2. No
H103 quality
of piped water is not good enough 1.
Yes 2. No
H104 piped
water is not available all the time 1.
Yes 2. No
H105 piped
water is not sufficient in the dry season 1.
Yes 2. No
H105B other
(specify)________________________ 1.
Yes 2. No
What is this other source of water you use in the dry season?
H106 own
well 1.
yes 2. no
H107 neighbor’s
well 1.
yes 2. no
H108 public
well 1.
yes 2. no
H109 public
standpost 1.
yes 2. no
H110 rain
water collection 1.
yes 2. no
H111 river,
lake, pond, or spring 1.
yes 2. no
H112 purchase
from water vendors/tanker truck 1.
yes 2. no
H113 purchase
from neighbor 1.
yes 2. no
H114 other
(please specify) ____________________ 1.
yes 2. no
H115 In the wet season, do you get all the water your household needs from this piped connection or do you also use another source of water?
1. Yes, we get all water from the piped connection in the wet season (move to H129)
2. No, we also use another source in the wet season
If no, answer H116-128:
Why do you use another source of water in the wet season?
H116 piped water is too expensive—use less expensive water sources when available 1. Yes 2. No
H117 quality
of piped water is not good enough 1.
Yes 2. No
H118 piped
water is not available all the time 1.
Yes 2. No
H119 piped
water is not sufficient in the wet season 1.
Yes 2. No
H119B other
(specify) ____________________________ 1.
Yes 2. No
What is this other source of water you use in the wet season?
H120 own
well 1.
yes 2. no
H121 neighbor’s
well 1.
yes 2. no
H122 public well 1.
yes 2. no
H123 public
standpost 1.
yes 2. no
H124 rain
water collection 1.
yes 2. no
H125 river,
lake, pond, or spring 1.
yes 2. no
H126 purchase
from water vendors/tanker truck 1.
yes 2. no
H127 purchase
from a neighbor 1.
yes 2. no
H128 other
(please specify) ____________________ 1.
yes 2. no
H129 Has the availability of piped water (that is, days piped water available and the number of hours piped water available daily) from your connection changed in the past two years?
1.
Increased
a lot
2.
Increased
somewhat
3.
No
change
4.
Decreased
somewhat
5.
Decreased
a lot
H130 Does your household consume now more or less water than two years
ago?
1.
Much
more
2.
Somewhat
more
3.
No
change
4.
Somewhat
less
5.
Much
less
I next want to ask some
questions about the quality of water you get from your piped connection.
H131 Is the piped water you get clear?
1.
yes
2.
no
3.
depends
on season
H132 Does the piped water you get have a taste?
1.
yes
2.
no
3.
depends
on season
4.
I
don’t know
H133 Do you boil the piped water before drinking?
1.
yes
2.
no
3.
we
don’t drink piped water
H134 Do you filter the piped water before
drinking?
1.
yes
2.
no
3.
we
don’t drink piped water
H135 Overall, how would you rate the quality of
piped water?
1.
very
good
2.
good
3.
satisfactory
4.
bad
5.
very
bad
H136 Has the
quality of piped water you get changed in the past two years?
1.
improved
a lot
2.
improved
somewhat
3.
no
change
4.
worsened
somewhat
5.
worsened
a lot
H137 Does your household have sufficient water
pressure?
1.
Yes
(move to H139)
2.
No
(move to H139)
3.
depends
on season
If depends on season, answer
H138:
H138 Is
water pressure typically better in
1.
wet
season
2.
dry
season
H139 In which floor do you live?
1.
ground
floor
2.
2nd
floor
3.
3rd
floor
4.
other
(please specify) ___________________
H140 Has your water pressure changed in the past
two years?
1.
Increased
a lot
2.
Increased
somewhat
3.
No
change
4.
Decreased
somewhat
5.
Decreased
a lot
H141 Is the piped water supply reliable (that is, is water available
every day and when you expect it)?
1.
very
reliable
2.
reliable
3.
somewhat
reliable
4.
not
at all reliable
H142 In the past three months, has the piped water supply to your
house ever been stopped for a day or more?
1.
yes,
several times
2.
yes,
a few times
3.
yes,
once
4.
no
(move to H144)
If yes, answer H143:
H143 How
long were these breakdowns typically?
__________ days
H144 Are there more or less service breakdowns now than two years ago?
1.
Much
more
2.
Somewhat
more
3.
No
change
4.
Somewhat
less
5.
Much
less
H145 As far as you are aware, are there currently
leaking pipes in your household?
1.
yes
2.
no
3.
I
don’t know
H146 As far as you are aware, are there currently
leaking pipes outside in this town?
1.
yes
2.
no
3.
I
don’t know
H147 In your view, how well has the water network
outside been maintained?
1.
very
well
2.
well
3.
satisfactorily
4.
poorly
5.
very
poorly
H148 In your view, has the overall maintenance of the water network
outside changed in the past two years?
1.
improved
a lot
2.
improved
somewhat
3.
no
change
4.
worsened
somewhat
5.
worsened
a lot
H149 In addition to your water bill, do you have to pay additional
money to the water utility staff to keep the water flowing to your household?
1.
Yes
2.
No
H150 If you have inquiries about the service or billing, can you
contact the water utility and get assistance?
1.
yes
2.
no
3.
we
never have inquiries
H151 Does the staff of the utility take customer complaints and
inquiries seriously and attempt to improve service?
1.
all
the time
2.
most
of the time
3.
sometimes
4.
never
5.
we
have never had complaints or made inquiries
H152 Have you ever had a problem with billing with your current service provider?
1.
yes
2.
no
(move to H155)
If yes, answer H153-154:
H153 Was the
problem resolved to your satisfaction?
1.
yes
2.
no
H154 How long did it take to resolve the problem (from the day you
contacted the utility till the day the matter was resolved)?
____________ days
H155 Has the operation of the water utility
improved in the past two years?
1.
yes
2.
no
(move to H161)
If yes, answer H156-160:
H161 How satisfied are you with the quality of
piped water?
1.
very
satisfied
2.
satisfied
3.
somewhat
dissatisfied
4.
dissatisfied
5.
very
dissatisfied
H162 Overall, how satisfied are you with the
piped water service you get?
1.
very
satisfied
2.
satisfied
3.
somewhat
dissatisfied
4.
dissatisfied
5.
very
dissatisfied
H163 Are you more or less satisfied with piped water delivery than two years ago?
1. Much more satisfied
2. Somewhat more satisfied
3. No change
4. Somewhat more dissatisfied
5. Much more dissatisfied
H164 Has anyone in your household suffered from diarrhea in the past month?
1. yes
2. no (move to H166)
If yes, answer H165:
H165 How many members of your household suffered from diarrhea in the
past month? _______ number
H166 Has anyone in your household suffered from typhoid in the past 3 months?
1.
yes
2.
no
(move to H168)
If yes, answer H167:
H167 How many members of your household have suffered from typhoid in the past 3 months? ___________ number
H168 How many people live in this household?
_______________ number
Which
of the following assets does your household own?
H169 Color television 1. Yes 2.
No
H170 Telephone 1.
Yes 2. No
H171 Motorcycle 1.
Yes 2. No
H172 Rimo 1.
Yes 2. No
H173 Car 1.
Yes 2. No
H174 Computer 1.
Yes 2. No
H175 Refrigerator 1.
Yes 2. No
H176 This house 1.
Yes 2. No
H177 Rented property 1. Yes 2. No
H178 In this household, how many people are
earning income? ___________ number
H179 What is your household’s approximate TOTAL monthly income? ________ Riels/month
H180 How much are your household’s TOTAL monthly
expenditures? ________ Riels/month
H181 Surveyor
observe: To what income group does the household belong?
1.
high-income
2.
middle-income
3.
low-income
H182 In many towns there are associations such as cooperatives, credit
groups, sport, music, women’s, and youth groups. Of how many associations in total are you or any member of your
household a member? _______________ number
H183 Does your household have electricity?
1.
yes
2.
no
(move to H185)
If yes, answer H184a-d:
Is the electricity provided by
H184a a
private supplier 1.
yes 2. no
H184b a public
electric utility 1.
yes 2. no
H184c own
generator 1.
yes 2. no
H184d using a
battery 1.
yes 2. no
H185 Name of respondent?
______________________________
H186 Length of interview: ____________ minutes
Comments:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________