Reporting Month____________________________
County: ________________________ District: ________________________________
Name & Title of Person completing the form:_______________________________________
No. Indicators / Data Elements, Monthly Aggregated(quarterly) Number
# of water point with Total coli form per-100 ml
1
2
# of newly constructed wells
# of wells chlorinated
3
4
# of hand pump chlorinated
5
# of functional hand pump
6
# of water points tested
# of Community meeting on hygiene practices
7
# of community meeting held on proper hand washing
8
# of community members trained in hygiene promotion
9
# of household sensitized on basic hygiene
10
# of community open defecation free
11
# of community with proper garbage sites
12
# of community using the proper burial sites
13
# of burial taking place in the community
14
# of household with garbage pit.
15
16
# of home embalmment
# of household with clean environment
17
A1 The number of water point tested and found with coli form per 100 ml during the reporting month
A2 The number of wells that were completed the reporting month
A3 The number of wells that were treated with chlorine during the reporting month

A4 The number of hand pump treated with chlorine during the reporting month
A5 The number of hand pump that are that are working properly during the reporting month
A6 The number of water point tested during the reporting month for water quality
A7 Number of community that had meeting during the reporting month
A8
A9 People from the community who are trained in promoting hygiene
A10 Families trained in hand washing practices, keeping food and water safe etc
A11 communities with no trace of feces in the open
A12 site to dump garbage in community
A13 community whose members use approved sites to bury the dead
Burials (dead buried) in unapproved sites in the community
A14 Families that have their own pits to dump garbage
A15 corpses (dead bodies) embalmed in the community
A16 Families that keep around their houses clean
A17 People from the community who are trained in promoting hygiene