Multi-sectors Initial Rapid Assessment Form

This regular assessment/monitoring form is intended to provide all humanitarian actors with an
sectoraloverview of conditions and needs in crisis affected areas on regular basis. Please complete
camp/village/site visited. Leave forms behind if a camp management exists to enable regular monitoring and
changes.Returnhardcopies of the form as soon as possible to OCHA field offices, OCHA Yangon or
ochamyanmar@un.org!
Please enter information in the light gray fields or mark tick boxes

immediate, multione form for each

therefore tracking of
scan and send to

where it applies (double click on tick box).

Module I : Identification
1. Surveying General Information
Monitoring Team
Responsible Name :

Assessment
Date(dd/mm/yyyy) :

Responsible Organizations :

Phone 1 :

E-mail :

Phone 2 :

2. Geographic Information
State :

Township :

Village Tract/Town :

Village/Ward Name :

P-code :

Site Name :

Latitude :

Longitude :

(dd.ddddd) or (dd mm ss)

(dd.ddddd) or (dd mm ss)

3. Access

Travel by:

No access because of
(main reason)

1.

Boat

2.

Car

3.

Truck

4.

Motorbike

5.

Foot

1.
3.

Broken bridge 2. River crossing

General remoteness 4. other

Travel time
(minutes):

(_______)

Nearest town
name :

(_____________)

Module II : Population
1. Population Data
1.1 Affected population (count)
Number of displaced people in evacuation site

Affected people non-displaced

Number of returned population

People in host community

1.2 How long is the majority of population displaced/

returned/ affected?

1.
4.

1 week
1 month

2.
5.

2 weeks
more than 1 month

3.

3 weeks

1.3 Affected population (count)

# of HH

Under 6 mths
(M/F)

1-2 yrs (M/F)

5-11 yrs (M/F)

18-59 yrs (M/F)

Total (M/F)

6 mths - 1 yrs
(M/F)

2-4 yrs (M/F)

12-17 yrs (M/F)

60 yrs and over

(M/F)

1.4 Vulnerable Groups (count)

Child or
Adolescent at
/
risk (M/F)
Older person at
risk

Women at risk

Single headed
household

Latest version, OCHA Myanmar in Aug 2015 - Floods

Pregnant Women

Extremely food
insecure
individuals

Lactating Women

Chronically ill

Multi-sectors Initial Rapid Assessment Form

Serious
Medical condition

Persons with
mental disabilities

Persons with
physical
disabilities

Specific legal
and physical
protection needs

Module III : General Key Informant

1. Communication with communities
Since the disaster [amend according to context], what are your main ways of finding information here? DO NOT READ
Mobile phone SMS

From another person religious

leader

program on this station do you listen to

most? --------------------------

Posters

From another person government

officia

Newspapers

Leaflets

From another person army/police

Magazines

Loudspeakers/megaphone announcements

From another person aid worker

Facebook

Community events

Other (WRITE In) _____________

Internet other (WRITE IN) ________

From another person friends/family

Dont know

Email

From another person community leader

Refused

Television
Radio Which station? ___ASK What

Mobile phone call

Note: This question is sometimes difficult for respondents to understand and results in answers about general needs. Ask if there is anything
they are confused about, or feel like they dont have enough information on.
To triangulate data, ask local key informants what questions Members of the community have been asking
frequently.
There are many different things people are confused about or feel they need to know about. What is the main thing
you need to know about right now? DO NOT READ CATEGORIES. MARK THEN ASK Is there anything else?

MAIN
ISSUE

SECOND
ISSUE

News
General news on what is happening here
News on what is happening at home
The weather
Dont Know
Refused
Security
The security situation here
The security situation at home
How to get help after attack or harassment
How to stay safe to prevent attack/harassment
Dont Know
Refused
How to access aid, essential items and healthcare
How to register for aid
Finding missing people
How to get water
How to get food
How to get shelter/accommodation or shelter materials
Information about nutrition
How to get cooking fuel/firewood
How to get healthcare/medical attention
How to replace personal documentation (e.g. ID, birth certificate)
How to get access to education
How to get transport
Dont Know
Refused
Communication
Communicating with people who are in a different place
How to communicate with aid agencies
Other (WRITE IN)____________________________________________________
Dont Know

Latest version, OCHA Myanmar in Aug 2015 - Floods

THIRD
ISSUE

Multi-sectors Initial Rapid Assessment Form

Refused

2. Humanitarian Assistance
2.1. Has any organization provided assistance recently in this location?
Type of assistance

Name of Organization

Contact

3. Non-Food Items/ Shelter

No. of households with partially damaged houses

No. of households in other temporary shelter:

No. of households with destroyed houses

No. of households in others specify (_________________):

Households with sufficient: (tick appropriate boxes)

2. Plastic Sheeting

1.

All

2.

Most

3.

Few

4.

None

3. Clothing

1.

All

2.

Most

3.

Few

4.

None

4. Blankets & Bedding

1.

All

2.

Most

3.

Few

4.

None

5. Mosquito Nets

1.

All

2.

Most

3.

Few

4.

None

6. Cooking Utensils

1.

All

2.

Most

3.

Few

4.

None

7. Cooking Fuel

1.

All

2.

Most

3.

Few

4.

None

8. Jerry Cans

1.

All

2.

Most

3.

Few

4.

None

4. Food
How many families in the village have food stock that will last:
4.1 Food Stock:

Less than 1 week

(______)

1 to 2 weeks

(______)

2 to 4 weeks

(______)

(______) More than 4 weeks

How many families in the village have lost:

4.2 Loss of Livestock:

Less than half of their livestock (______)

More than half of their livestock

(______)

All their livestock

(______)

How many farmers in the village have:

4.3 Loss of crops:

Partially lost their crops

4.4 Fishing/ Casual

labour :

How many fishermen/ casual labour in the village are able to fish/work?
More than half
Less than half
None

4.5 Market:

(______) Totally lost their crops

(______)

Do villagers have access to Market?

Yes

No

Is the nearest market functioning?

Yes

No

Not lost anything

(______)

5. Nutrition
5.1 - Has infant formula (dried or ready to use) or other milk products (e.g., dried whole, semi-skimmed or
skimmed milk powder, ready to use milk)) and/or baby bottles/teats been distributed since the emergency started?
If YES, what products,

(___________________________)

and by whom?

5.2 - Has the community/health staff/parents/caregivers identified any problems in feeding children under 2 years
since the crisis started?
If YES, what problems?

1.

Yes

2.

No

(__________________________)
1.

Yes

2.

No

(______________________________________________________________________________________)

Latest version, OCHA Myanmar in Aug 2015 - Floods

Multi-sectors Initial Rapid Assessment Form

5.3 - What are the priorities expressed by parents and caregivers regarding
infant and young child feeding?

(___________________________________________________)

6. Water Supply
Daily amount of Drinking Water available (3 l/person/day):
Daily amount of Water for
1. Sufficient 2.
Not sufficient
Cooking available:

1. Sufficient
2.
Not sufficient
Daily amount of Water for
1. Sufficient
Bathing available:

Primary water source at the site:

1.
4.

Rain water/pond
Borehole/Pump

Do people boil water before drinking?

1.

Yes

If no, why they dont boil?

Are water purification methods/tablets
available?
Condition of man-made water infrastructure:

1.

Lack of firewood

1.

Yes 2.

1.

Working

2.

2.
5.

Natural spring
Piped water system

3.
6.

2.

Not sufficient

River/Stream
Open/shallow well

No
2.

Lack of knowledge
Is water considered safe for
drinking?

No
2.

Not working

Community water storage last for how many days for all community members

3.

1.

Yes

2.

No

Destroyed

)days

7. Sanitary and Hygiene conditions

How many affected people have access to functioning latrines?

1.

All

2.

Most

3.

Few

4.

None

How many latrines have been damaged?

1.

All

2.

Most

3.

Few

4.

None

Percentage of households with sufficient: (tick appropriate boxes)

1. Soap

1.

All

2.

Most

3.

Few

4.

None

2. Sanitary Pads

1.

All

2.

Most

3.

Few

4.

None

8. Education Access
8.1. Children
Approx. # children attending schools or
learning spaces before and after the
new emergency:

Is there any specific group of children

who do not have access to education
due to the new emergency? (and so
require special attention)

Edu level (Preschool, Primary,

Secondary)

# children
now

# children before

1.

Girls

2.

Children with disability

3.

Working children

What are children's edu needs? (in priority order 1-4)

1.

Stationery (pens, paper, notebooks)

2.

Textbooks

3.

Recreation materials & activities

4.

Psychosocial support

5.

Other (or additional info): _________________

4.
5.

Separated / orphaned children

IDP / Stateless children

6.

Child-headed households

7.

Other:

Are there schools functional?

1.

Functional

2.

Partially functional 3.

Non-functional

Is there any health facility damaged?

Are there schools damaged?

1.

No-damaged 2.

Partially damaged 3.

Completely damaged

Is there any health facility damaged?

9. Protection

9.1. Are people able to move freely in and around the community?

1.

No

2.

Yes

999.

Dont know

9.2.a. Are there any security concerns affecting the community?

1.

No

2.

Yes

999.

Dont know

9.2.b. If yes, what types of concerns do you have?

1. Fighting between different community groups

6. Forced recruitment

2. Criminal acts/ theft/ robbery/ injury /physical

assault/extortion

7. Violence against women (rape and harassment)

3. Threat/ extortion/ harassment by official armed actors

8. Kidnapping/ abductions/ disappearances

4. Presence of mine / UXOs incidents

9. Other

5. Violence against boys and girls

999. Dont know

Latest version, OCHA Myanmar in Aug 2015 - Floods

Multi-sectors Initial Rapid Assessment Form

9.3. When there is a security concern, who do you go to?

1.

Police

4.

Political leaders

2.

Military

5.

Religious leaders

3.

Community leaders

6.

No one

999.

Dont know

9.4. What are known situations in this community where children are at increased risk of violence or harassment?
1. In camps/ settlements

6. At school

2. At assistance/distribution points
3. At water collection points

7. At home
8. While moving in the area (e.g. firewood collection,
playing)

4. At bathing facilities

9. Nowhere

5. At health facilities

999. Dont know

9.5. What are the most significant safety and security concerns facing women in this community? (Select all that apply.)
1. No safe place in the community

6. Being forced to have sex to pay for food or shelter

2. Sexual violence/abuse

7. Unable to access services and resources

3. Violence in the home

8. Other If other, please pecify:________________

4. Risk of attack when traveling outside the community

999. Dont Know

5. Risk of attack when going to latrines, local markets, etc.

9.6.a. Are there places in, or near, the camp or village where women and girls and boys might feel
1.
No
2.
Yes
concerned for their safety?
1.
When collecting firewood
4.
In their shelters (day or night)
9.6.b. If yes, what are some of these places?
2.
At latrines
5.
At assistance distribution points
(check all that apply)
3.
At water points
6.
Near large groups of men

9.8. Are there persons with disabilities/ older persons in the community facing neglect, marginalization
or abandonment?
9.9. How many unaccompanied children (not attended by anybody) have been identified?

Dont know

7.

Other

#______

9.7.a. How many families are missing children?

9.7.b. Total number of children missing:

999.

#______ girls
1.

No

2.

#______boys
Yes

999.

Dont know

#____ girls

#_____ boys

9.10. How many separated children have been identified (without parents, grandparents, aunt/uncle or
adult brothers/sisters)?
#____ girls

#_____ boys

Latest version, OCHA Myanmar in Aug 2015 - Floods

Multi-sectors Initial Rapid Assessment Form

Module IV : Specialist Key Informant
1. Health Access
Is there Health Care provided at the site?

1.

Yes

How often:

1.

Daily 2.

2.

No
Twice a week

3.

Once a week 4.

Once every two weeks

What are the main health concerns that occurred during the last two weeks: (to be answered by the health staff)
1. Malaria

7. Trauma

2. Tuberculosis

8. Acute Respiratory Tract infection

3. Diarrhea (watery and/or with visible blood)

9. Dengue Hemorrhagic Fever

4. Skin infections

10.Measles

5. Sexually Transmitted Disease

11.HIV/AIDS

6. Hepatitis

12.Others ____________________________

Are there enough medicine supplies available to cover the needs of the population accessing services?
When there is no Health Care provided,
What is the walking time (hours and minutes)to the next Health Centre?

1.

Is there any health facility functional?

1.

Functional

2.

Partially functional 3.

Non-functional

Is there any health facility damaged?

Is there any health facility damaged?

1.

No-damaged 2.

Partially damaged 3.

Completely damaged

Yes

2.

No

hours

minutes

Is there any health facility damaged?

Module V : Direct Observation

1. Nutrition
Are there young children who are very thin or skinny?

1.

Yes

If yes:

1.

Hardly any

2.

No
2.

Some

3.

Many

2. Hygiene and Sanitation

How many functioning latrines are there?

___________

Are there any sign of open defection?

1.

Yes

2.

Is there stagnant water (large puddles) at the site?

1.

Yes

2.

No

Is there a common waste dump in the site?

1.

Yes

2.

No

Is there livestock at the site?

1.

Yes

2.

No

Is livestock roaming freely at the site?

1.

Yes

2.

No

No

3. List the three most important needs for the community, based on the observations made while assessing/ monitoring.

1.

2.

3.

Latest version, OCHA Myanmar in Aug 2015 - Floods