Community Assessment Survey

Form approved

OMB NO.0920-06AT

Exp. Date xx/xx/20xx

Community Assessment Survey

Public reporting burden of this collection of information using the survey is projected to take 1 hour. This time includes the time for interviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333-0920-06AT.

Introduction

My name is _______________________ and I come from CARE and I am working on a joint project with CDC in Atlanta.

In the implementation of many development projects, people don’t return to get/ hear your suggestions/ requests about the progress of plans. We have come here to learn from you about community plans for reproductive health and other development plans that are being implemented in your village.

What we will talk about in our discussion will take one hour and this information will not be shared. You do not have to tell us anything that you don’t want to tell us, and you can skip any questions if you want. We will not write your name down or tell anyone how you answered the questions. I ask your permission.

Can we start? Are you ready?

Date: ___________ Assessment team: ____________________________

Village: _________ Ward: ________ Division _____________

1. COMMUNITY SUPPORT FOR HEALTH INITIATIVES

The 10 respondents should meet the following criteria

No.	Type	Criteria
1.	Female community leader	Any member of community government
2.	Woman of reproductive age	Resides outside of village centre, aged more than 30 years
3.	Woman of reproductive age	Resides outside of village centre, aged 30 years or less
4.	Male community leader	Either Chairman or VEO
5.	Male community leader	Sungu Sungu leader
6	Male community leader	Sub-village leader
7.	Man of reproductive age	Resides outside of village centre, aged more than 30 years
8.	Man of reproductive age	Resides outside of village centre, aged 30 years or less
9.	Key informant	Most active village health worker
10.	Key informant	Government extension worker (teacher, clinician, agriculture, community development officer)

Respondent type (enter number corresponding to above) _______

Does a maternal health Surveillance system exists in your village?

Yes

No

Unsure

How are the data used?

Given to the dispensary

Given to the village leadership

Kept by the VHW__________________ describe how it is used_______________________

In a health emergency how do people get to a health facility?

(Write down everything a person says)

Does this village have an emergency transport system for getting people to a health facility?

 Yes  No  Unsure If no, then skip to question X.

If yes what is it? ________ (Check all that apply)

Fund

Canoe

Tricycle

Vehicle (e.g., car, bus, moped)

Oxcart

Multiple (e.g., tricycle, oxcart)

Stretcher

Something else, please describe__________________

How long has this system been available?

 1 year  1-2 years  more than 2 years  unsure

Who maintains it?

Who has used the emergency transport?

 Pregnant women people from the village who need to go to a health facility

How many people have used it in the past year?

_________number of pregnant women _____________number of other people

Do people pay money to use the transport system each time?

Yes No (if yes, record the amount)

______________Shillings per use for people from the village

______________Shillings per use for people outside of the village

Have you ever attended a community meeting? If yes, continue, if no thank respondent for participation.

Who generally attends meetings in this community?

 Men  Women  Children visitors from outside the village

Thinking about the last meeting you went to, can you think about who generated ideas and how much sharing went on during the meeting? (Please circle the persons and then amount of sharing)

Group (circle)	Degree of sharing (circle) Defined as the amount or number of times they spoke?
Leaders	Low Medium High
Visitors from outside	Low Medium High
Men	Low Medium High
Women	Low Medium High
Youth	Low Medium High
VHWs	Low Medium High

In your last meeting, describe some things that came up and the way decisions were made?

(Write down the issues that came up such as a need to build a community water tank)

Probe further and then tick one of these below.

Voting

Consensus (discussion)

Leaders make the decisions

Tell us your opinion about this method of decision making.

Please describe how you feel about each of these statements.

Village leaderships is responsive to my concerns	Disagree	Agree	Not sure	Comment
When decisions are made during the village meetings, I think that my opinions are counted
People in the village are concerned about each other
We take care of people who are in need
I feel like I am an important member of my village
Villagers provide help to others in times of need
No-one cares about anyone in this community

During the last meeting you attended, can you please share an example of an issue that was discussed and steps developed to address it-interviewer should be careful not to shape answers- it is ok if no steps were taken to address an issue it may be that it was discussed but left unresolved…(please write down everything the respondent says.)

3. Village health workers

Please describe the types of things the village health workers do in your village?

Do the village health workers get paid?

Yes

No

How often do they get paid?

Monthly

Yearly

Sometimes

Where does the money come from?

Are they also paid in other ways? (E.g. help around their home, food or other items?)

What impacts do think their work has on the community?