Sociological and Environmental study of the community

of .........................................GN division in Walallavita Divisional

Secretariat Area of Kalutara District.
Date: ……………………….. Serial number: ……………

1. Basic Information

1. Name of household:……………………………………………………………………………………………………………………..

2. Address:……………………………………………………………………………………………………………………………………….

3.Nationality:…………………………………………… 4.Religion:………………………………………………………………….

4. Information of family members:

Seria Name of the Age Gender Marital Disability Occupation Education NCD Languages of
l no: member status level Can be
Spoken

A. Diabetes B. Blood pressure C. .Heart disease D. Cancer E. Stroke F. Cholesterol G. Other

2. Environmental Health

2.1 Type of Latrine:………………………………………………………………………………………………….……………. ( Sanitary / Insanitary)

2.2 Type of water source: ……………………………………...……………..(in/out) ,(private /public),(protected / not protected)

2.3 Methods of Solid Waste Disposal: …………………………………………………………………………………… ( Sanitary / Insanitary)

2.4 Methods of Wastewater Disposal: ………………………………….……………………………………………… ( Sanitary / Insanitary)

2.5 Animal husbandry: (have/haven’t) Type of animal: ………………………………………………………………………………………

2.6 Pets at home:( yes/no), Type of animal: ……………………………………………….….……………….………………………………………

2.7 Mosquito Breading Sites (have/haven’t), details if there: ………………………….……..…………….………….……………………….

2.8 Flies Breading Sites (have/haven’t), details if there:………………………………..…….….………….…………….……………………….

3. House health information

3.1 Nature of the house :(one store / two store/other)

3.2 Lightning: (enough/not enough) 3.3 Ventilation: (enough/not enough)

3.4 Accident contributing area: (have/haven’t), details if there:………………………….….………….…………….……………………….

3.5 Ownership of house: (household/rent/government/other)

3.6 Methods Communication: ……………………………………………..…………………………………………………………………………………...

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4. Economic information

4.1 Gross monthly income:……………………………………………… 4.2 Gross monthly cost:………..………………………………………

4.3 Have you taken a loan? ( Yes/ No ) 4.4 Do you receive any subsidies? (yes/no)

5. Health information

5.1 Immunizations of children at relevant age :(yes/no) notes: …………………………………………..…………………………………

5.2 If family members have bad habits: (yes/no) notes: …………..…………………………………………………….….………

5.3 How to get medical treatment services: (gov . Hospital / private Hospital / Ayurveda / other )

Note ……………………………………………………………………………………………………………………………………………………………………….

5.4 Do family members exercise? (yes/no) How many hours per day or week: ……………………………………………………..

5.5 Has any family member suffered from an infectious disease within the last six months? (yes/no)

Note ……………………………………………………………………………………………………………………………………………………………………….

6. More information

6.1 What are the specific environmental problems identified in your area?

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6.1 What are your suggestions for solving those problems?

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6.1 What are the current solutions for that?

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