BASELINE QUESTIONNAIRE/REGISTRATION FORM:

ORPHANS PROJECT
Enumerator name
Date of assessment
District
Village
GPS Cordinates

1. Orphan Child Information

Reference Number
Surname
First Name & Middle Name
Birth date
Place of birth
Gender [ ] Male [ ] Female
Picture of the orphan child

2. Biological parent (Mother)

Status [ ] Alive & present [ ] Alive & Absent [ ]
Dead
Surname
First Name& Middle name
Profession / Occupation
Salary/income (in USD)
Date of death
Cause of death [ ] Accident
[ ] Illness
[ ] War
[ ] Killed
[ ] Natural disaster
[ ] Natural death
[ ] Wrecked
[ ] Other________________
Cause of Absence(not staying at the HH [ ] Married
currently) [ ] Divorced
[ ] Other

If dead, is the death certificate available? [ ] Yes [ ] No

If available take photo
 3. Biological parent (Father)
Status [ ] Alive [ ] Dead
Surname
First Name
Profession / occupation
Salary/Income (in USD)
Date of death
Cause of death [ ] Accident
[ ] Illness
[ ] War
[ ] Killed
[ ] Natural disaster
[ ] Natural death
[ ] Wrecked
[ ] Other________________
If dead, is the death certificate available? [ ] Yes [ ] No
If available take photo

4. Health
Child health status [ ] Healthy
[ ] unhealthy
Does the orphan need to regularly visit a [ ] Yes [ ] No
doctor?
Frequency of the visit [ ] Daily
[ ] Fortnightly
[ ] Weekly
[ ] Monthly
[ ] Bi-monthly
[ ] Quarterly
[ ] Yearly
Who gives Consultation to sick child [ ] A doctor
[ ] NGO
[ ] Pharmacist
[ ] local/traditional medicines
Does the child need to be hospitalized [ ] Yes [ ] No
regularly?
Does the child have special needs/disability ? [ ] Yes [ ] No
If YES which need? [ ] blind
[ ] Deaf or partially deaf
[ ] Down Syndrome
[ ] Learning Disability
[ ] Mental Retardation
 [ ] Paralyzed
[ ] Severe or multiple disabilities
[ ] Traumatized
[ ] Autistic
[ ] Other
Does the child suffer from diseases? [ ] yes [ ] No
If YES which disease? [ ] Anemia
[ ] Arthritis
[ ] Asthma
[ ] Autism
[ ] Bilharzia
[ ] Blindness
[ ] Brain tumor
[ ] Bronchitis
[ ] Cancer
[ ] Chickenpox
[ ] Depression
[ ] Diabetes
[ ] Epilepsy
[ ] Heart Problem
[ ] HIV
[ ] Kidney Problem
[ ] Malaria
[ ] Measles
[ ] Meningitis
[ ] mumps
[ ] Rubella
[ ] Tetanus
[ ] panic attack
[ ] phobias
[ ] pneumonia
[ ] Tuberculosis
[ ] worms
[ ] Other
Has the child received the following [ ] NONE
vaccines? [ ] Cholera
[ ] Diphtheria
[ ] Hepatitis B
[ ] Measles
[ ] meningitis
[ ] mumps
[ ] polio
[ ] rubella
[ ] tetanus
[ ] yellow fever
[ ] pertussis (whooping cough)
 [ ] DTP
[ ] MMR
[ ] BSG(TB)
[ ] Other

5. Schooling
Does the orphan child attending a school [ ] Yes [ ] No
program?
If NO, why is the orphan child not attending [ ] lack of money
school? [ ] Child is working to support family income
[ ] Other
If working ,which kind of job? [ ] construction site
[ ] shoe shinning business
[ ] laundry
[ ] begging in town
[ ] Other Specify__________

How many days per week does he/she work? Days_______________

How much does he/she earn per month? ________________USD
If YES, what type of school? [ ] Public [ ] private [ ] informal
School Name
At which level
[ ] Pre-primary
[ ] Primary
[ ] Secondary
[ ] Vocational training
Which grade _________________
How would you gauge the child school [ ] Excellent
progress [ ] Good
[ ] Average
[ ] poor
How much is the school fee per term? _____________________USD
How would you define average attendance of [ ] Every day
the orphan going to school? [ ] Half-week
[ ] Regular attendance
[ ] Very irregular attendance
Does the orphan have a school uniform? [ ] Yes [ ] No
What is the state of the uniform? [ ] In Good condition
[ ] Slightly worn out
[ ] Fully Worn out
If YES, how much did you purchase the __________________USD
uniform?
Does the child have schools KIT? [ ] yes, school kit with all items
 [ ] Yes, school kit with some items missing
[ ] Don’t have school kit
How do you describe Child home study Area [ ] Fully equipped
(check for table, chair, lighting equipment’s [ ] Fairly equipped
etc) [ ] not-equipped

How many sisters or brothers of the orphan

child are attending school too?

6. Guardian
Guardian Name
Gender [ ] Male [ ] Female
Relationship with orphan child [ ] Mother
[ ] Father
[ ] Sister
[ ] Brother
[ ] Aunt
[ ] Uncle
[ ] Other specify____
Does the guardian have any disability [ ] Yes [ ] No
If Yes what kind of disability? [ ] Motor/Physical
[ ] Mental
[ ] Other
Degree of literacy of the head of household [ ] Can’t read or write
[ ] Can read but not write
[ ] can read and write

7. Household
Household size total Males________________
Females______________
Ages Under 5 years____________________
6-18 years___________________
18-59 years__________________
60 & Above__________________

Family members (List all family members)

Name Relationship Birth date Job/income Salary in USD
 with orphan activity
child
[ ] Mother
[ ] Father
[ ] Sister
[ ] Brother
[ ] Aunt
[ ] Uncle
[ ] cousin
[ ] Other

8. Household well being

8.1 household income

What is your household monthly income _____________________________________
I would like to know the amount of household Food ____________
monthly income spending’s on the following Water___________
Shelter/non-food items_________
Health________________
Education_____________
Other________________

8.2 Food security

 (a) How many meals per day did your
household eat for the last 7 days?

(b) (i) Does each person of the HH have the [ ] Yes [ ] No

same number of meals per day?
(ii) if NO in (Q8b.i) how many meals (on
average) have your HH members eaten per
day?
Adult Male______________
Adult Female____________
Children below 5 years
Children between 6-12 years________

(c) How many weeks your current household [ ] One week

food stock can last. [ ] Two weeks
[ ] Three Weeks
[ ] One month
[ ] More than one Month
[ ] No Food stock

8.3 water, sanitation and hygiene

What is your family level of Full Partial NO
access to clean and safe water Access Access Access
for the following essential
purposes Drinking & Cooking [ ] [ ] [ ]

Hand-washing [ ] [ ] [ ]

Bathing [ ] [ ] [ ]

Household cleaning & [ ] [ ] [ ]

Hygiene

Livelihoods (irrigation [ ] [ ] [ ]
&Livestock etc)

How affordable are the Fully Partially Not

following hygiene products to Affordable Affordable Affordable
your household currently
Bathing soap [ ] [ ] [ ]

Girls Menstrual pads [ ] [ ] [ ]

8.4 Shelter
(a) Type of dwelling place [ ] House
[ ] hut
[ ] shack/paper-
bags/old clothes
[ ] plastic sheets
[ ] tent
[ ] other
(b) What is the main concern of your household shelter currently? tick where appropriate

Concern Tick
Walls materials are damaged/rotten - wind/rain is coming through
Roof is damaged- wind/rain is coming through
Floor not cemented
Shelter gets flooded/wet when it rains
Ventilation in the shelter is bad
Congestion/no enough space
No privacy for women and girls
Shelters are too close together (risk of fire)
Other______________________________________
None