Basic rapid assessment tool (BRAT): household questionnaire
[Response]:
1. Assessing agency information
Name of the surveyor
Date of assessment
Contact information of surveyor
2. Respondent information, demographics
2.1 Respondents age and sex:  Male  Female
Age: _____
occupation (in place of origin): ___________
ID (do they have any document – passport/ID card) _______________
2.2 District
2.3 Sub-district
2.4 Community/ Camp name ____
2.7
2.6 Non camp
 house (solid construction-bricks/wood)
2.5. host family _____
 tent
 tarp/plastic
 school
 public building (no services)
 rented home, apartment
 n/a
 other: _____________
What is the total number of people who are currently sleeping in this household? (including yourself)?
(applies to 2.4/2.5/2.6)
__________________
# of male in HH _______
# of female HH ________
Please check the box for all HH members. If more than one HH member falls into an age group add the
number of people to the side (ie. 3
3-5year)
 0-5 months
 6-10 years
if yes
male; female
enrolled in school; not enrolled (in place of origin)
 12-18 years
if yes
male; female
enrolled in school; not enrolled (in place of origin)
 18-35 years
 35-60 years
 60+ years
2.8
Are there any disabled people living in your HH?
 yes
 no
Compared to who lived in your HH six months ago, how many people are sleeping in your household now?
 more  less  the same
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Basic rapid assessment tool (BRAT): household questionnaire
2.9
2.10
2.11
2.12
How Many people were living in your HH 6 months ago? ____________
During the last 6 months how many people left the house? ______________
During the last 6 months how many people joined the house? _____________
Have you experienced human loss within the family during last 6 months?
Yes; no;
2.13
Have you experienced under 5 child loss within your family during last 6 months?
Yes; no;
3. Livelihoods
3.1
Who in your HH is currently working now for income?
 daughter (age____)
 son (age_______)
 wife
 husband
 no one
3.2
What are the main expenditures your HH currently has?
 food
 fuel
 health care
 clothing
 sheeting
 rent
 other
3.3 Current
What is your current primary livelihood—the one way you earn income or meet basic needs which
livelihood activities you rely on most? (select only 1)
 subsistence farming
 crop production/sales
 livestock production/sales
 casual (daily) labour
 small business
 artisan, textiles (shoe maker, tailor, craft making, etc.)
 construction trade: Carpenter, electrician, plumer, etc.
 teacher, educator
 doctor, nurse, medical staff
 formal salary/wages(office, government, corporation, store, etc.)
 petty trade (importing/selling goods, making/selling ice, etc.)
 remittances
 begging
 aid
 income from rental
 sharing/borrowing food, HH items
 loans to meet basic needs
 work for NGO
 no livelihood activity
 other: specify__________________
3.4
What additional seasonal/supplemental livelihood activities does your family engage in to support
yourselves? (check no more than three which apply)
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Basic rapid assessment tool (BRAT): household questionnaire
subsistence farming
 crop production/sales
livestock production/sales
casual (daily) labour
small business
artisan, textiles (shoe maker, tailor, craft making, etc.)
construction trades: carpenter, electrician, plumber, etc.
teacher, educator
doctor, nurse, medical staff
formal salary/wages(office, government, corporation, store, etc.)
petty trade (importing/selling goods, making/selling ice, etc.)
remittances
begging
aid
income from rental
sharing/borrowing food, HH items
loans to meet basic needs
 work for NGO
no additional livelihood activity
4. Protection
4.1
Please describe any problems or threats your family has faced in current settlement recently regarding your
protection, safety or security. (select top 3):
 theft
 conflict over land
 home invasion (armed or forced entry)
 Safety hazards (open well,
 community conflicts
rusty nails, etc.)
 intimidation
 arbitrary arrest and
 discrimination
detention
 physical assault
 Environmental risks (toxic
 sexual assault
spill, landslides, etc.)
 abduction, kidnapping
 health risks (epidemics,
 armed conflict (shelling, gun fire, warfare, etc)
household poisons, etc)
 other: _________________
 no threats
 do not know
4.2
Are there any specific groups of people who are especially vulnerable? Why? (physical and psychological)
 children (0-5 years of age)____________________
 displaced_______________
 children (6-11)_____________________________
 ethnic minority__________
 women____________________________________
 religious minority: ________
 pregnant women____________________________
 political minority: ________
 elderly_____________________________________
 livelihood: _____________
 children with disability (physical or cognitive)______
 geographic:
 adults with disability (physical or cognitive)
_______________
 orphans____________________________________
 other: __________________
 youth (12-18)_______________________________
4.3
What do children in this community need now? (select yes or no for each):
Yes No

safe, adequate shelter for living &

safe schools
sleeping

school uniform, supplies
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Basic rapid assessment tool (BRAT): household questionnaire







food
access to safe water
access to qualified health, medical care
clothes, footwear
safe places to play
toys, play items
affordable schools
 counseling, psycho-social support
 reunification with family
 security (from conflict, abusers, predators, thieves,
etc.)
 clean, sanitary environment
 other: _________________________________
 do not know
5. WASH
5.3
Can you please describe the kind of toilet facility your household uses now? (select one)
 family latrine or toilet
 gender segregated latrine
 shared toilet (with community/camp)
 pit latrine
5.4
 bucket
 bush
 other:
Please describe the conditions of this toilet facility (select one from each box):
Cleanliness:
 clean
 dirty
Safety:
 safe
 unsafe, explain why:
Privacy:
 privacy adequate
 privacy inadequate
Is the toilet functional?
 Sufficient for HH and working properly
 Not sufficient for HH but working properly
 Working some of the time
 Not working
5.5
When do you wash your hands? (check yes or no for each)
 Before cooking
 Before eating
 After using the restroom
 After eating
 After changing a child’s nappy/diaper
 Other
Have you observed anything that is limiting people’s ability to wash their hands?
 not important to wash hands
 it’s not important to use soap
 water scarcity
 soap scarcity
 no place to wash hands
 other: _____________
5.6
Please describe the adequacy of hand-washing facility (select one from each box):
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Basic rapid assessment tool (BRAT): household questionnaire
Cleanliness
 Dirty
 clean
Functional
 broken tap
 leaking/bad drainage
 Working properly
Accessible
 Within 50meters of home or in home
(safe & well lit)
 Within 50 meters of home or in home
(not well lit)
further than 50 meters (not safe or well
lit)
 further than 50 meters (safe and well lit)
5.7
Please describe the type of bathing facility you use:
5.8
Please describe the general cleanliness, safety and privacy and drainage of the bathing facility (select one from
each box):
 family or private bathing area
 community or camp bathing facility
 open bathing area
 other bathing facility:
Cleanliness:
 clean
 dirty
5.9
Safety (lockable /welllit)
 safe
 unsafe, explain why:
Privacy:
Functionality:
 privacy adequate
 privacy inadequate
 functional
 not functional
How does your HH dispose of rubbish?
 HH bin
 HH burning
 HH member caries outside of camp
 HH buries
 Other______________________________
6. HEALTH
6.1
Have there been any health concerns for anybody in your HH in the past two weeks? For each issue, fill in the
corresponding information.
age sex
where treated
satisfaction
reasons if not fully satisfied
m=
male
f=
female
c = clinic
t = traditional healer
h = hospital
n = no treatment
dnk = don’t know
other: _________
f = fully
p = partially
n = not at all
dnk = don’t know
meds = inadequate medicines
doc = no/unqualified doctor
ill = illness not cured
death = patient died
other: ________
dnk: don’t know
diarrhea
fever
cough
disease
outbreak
Leishmaniasis
malnourishment
injuries
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Basic rapid assessment tool (BRAT): household questionnaire
anaemia
mental trauma
or disorder
diabetes
heart condition
pregnancy
other________
6.2
Please describe any obstacles to receiving the health care necessary for treating health concerns you described.
(all that apply):
 health facility too far
 unsafe to travel to health facility
 health facility overcrowded, wait too long
 can’t find a health facility
 insufficient qualified medical staff
6.3
6.4
6.5
 insufficient medicines
 can’t afford fees, too expensive
 no safe place to deliver baby
 other obstacle:
Have any of the women in your house been pregnant during the last six months.
 yes
 no
Have any of the women in your house given birth during the last six months.
 yes
 no
If Yes:
Where did they deliver? (please include the name of the specific clinic or hospital, if possible)
 hospital
 clinic
 home
 other
Who assisted with birth:
 skilled birth attendant
 nurse
 midwife
 doctor
 family
 nobody
 other
How is the baby currently fed?
 formula
 breast
 complimentary feeding
 breast milk and formula
 goat/cow milk
 Other___________________
During pregnancy, did you see a health worker prior to giving birth?
 0 times
 1 visit
 2 visits
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Basic rapid assessment tool (BRAT): household questionnaire
 2+ visits
6.6
Have you received any health or hygiene education?
 no
 yes
If yes, what?
 posters
 training / community health workers
 pamphlets
 through PHC / WAYCS
 family members
 radio
 personal books
 other______________________________
6.7
What topics have you received health or hygiene education on:
 personal hygiene
 baby hygiene
 infant and young child feeding practices (including breast feeding)
 hand washing
 waste disposal
 communicable diseases
 other _______________________________
7. Assistance/aid in community
7.1
From whom have you received direct support from (rating , top 3):
 LG
 UN
 NGOs
 Other
7.2
Have you been receiving enough information about aid and available services?
 yes
 no
 don’t know
7.3
7.4
who has been providing you with info on how to receive support?
 LG
 UN
 NGOs
 Other
How do you prefer to receive information? (select all that apply)
 agency staff
 community volunteers, mobilizers
 community leaders
 local government authority
 print materials (such as leaflets)
 public notice board
 banners, posters
 newspaper
 radio
 place of worship (mosque, church, temple, etc)
 other: ____________________________
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Basic rapid assessment tool (BRAT): household questionnaire
7.5
Will receiving assistance/aid put you, your family or neighbors at any safety or security risk?
 yes
 no
 don’t know
Please explain:
7.6
To date, has your family received any assistance?
 yes
 no
If yes, what type?
 Hygiene kit (women/Baby)
 Food assistance
 registration
 cash assistance (NGO; Government)
 winterization
 health care
 education (informal learning; CFS)
 counseling, psycho-social support
 Other:______________________________________
7.7
How would you prefer to share feedback about information and support provided?
 Comment box
 community meetings
 phone/sms;
 social media;
 Other________________________________
8. FOOD
8.1
8.2
Are the following food items available to your HH for purchase?
 wheat flour
 bread
 rice
 vegetable oil
 beans/pulses
Do you have an adequate kitchen/food preparation facility?
 yes, fully adequate
 partially adequate
 not adequate
8.3
(If partially or not adequate):
What would improve in your access to food preparation?
8.4
How many meals do HH members above the age of 18 consume daily?
1
2
3
 4 or more
How many meals do HH members under 18 years consume daily?
1
8.5
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Basic rapid assessment tool (BRAT): household questionnaire
2
3
 4 or more
9. What are the three most critical problems you and your community are currently facing? (select only 3)
Population movement
Shelter
 displaced from home
 lost household possessions (cooking equipment, clothing, furniture, etc.)
 Forced eviction from current place of settlement
 lost access to land
 left family behind to guard assets
 over-crowded (impacting facilities, markets, etc)
 other population movement problem:
 home damaged or destroyed
 over-crowded home
 living in camp
 living in streets, public area, bush
 living in public or abandoned building (school, mosque, empty building, etc.)
 inadequate cover (no tent, tarps)
 no privacy
 living on land without permission
 living in cold conditions
 other:
Food
 people are hungry
 food stocks destroyed
 food too expensive
 no food in markets
 food distributions insufficient
 gardens, fields not producing
 arable land destroyed
 not working, can’t pay for food
 other:
Livelihood, income
 can’t meet basic needs
 poverty
 jobs lost
 no employment opportunities in or near community
 must travel/migrate to find work
 no capital to restart business
 no access to credit/loans
 farmland lost, damaged
 lost farm equipment, irrigation system, seeds
 lost crops, harvest
 lost livestock
 lost, damaged trade tools, equipment (carpentry tools, sewing machines, handicraft
materials)
 lost, damaged petty trade carts, inventory
 business lost, damaged (building, inventory, equipment)
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Basic rapid assessment tool (BRAT): household questionnaire
 transport assets lost, damaged (cars, motorcycles)
 other:
Water
 insufficient for all household and religious needs (cooking, washing, cleaning)
 water contaminated, not safe for drinking,
 water point not functioning (dried up, broken)
 lack water collection or storage containers
 too expensive
 water source too far
 not sufficient for livestock
 insecurity prevents water collection
 takes too long to collect
 other:
Education
 no school/school building nearby
 children unable to register in formal schools
 children able to register but there is no space in formal schools;
 children can not understand the language of instruction I the classroom;
 no access to other alternative learning opportunities for children (6-18);
 no access to other alternative learning opportunities for adults (19-29);
 insecurity prevents children from going to school
 cost of education
 children are afraid to go to school;
Sanitation
 toilets, latrines non-functional
 toilets, latrines dirty, overcrowded
 toilets, latrines unsafe, insecure, lack privacy
 must defecate in open spaces, no privacy
 urine, faeces spreading into living spaces
 mounting garbage (not being collected)
 drainage damaged, missing, overflowing
 no safe, private area to bathe
 not sufficient hand-washing facilities
 other:
Health
 Disease (cholera, typhoid, e-coli , measles, hepatitis, etc.)
 sickness (cough, diarrhea, fever, etc)
 injuries
 living in unsanitary conditions (garbage, waste, dust, flies)
 unsafe to travel to health facility
 can’t find health facility
 health care facility too far
 health care facility overcrowded, wait too long
 insufficient qualified medical staff
 insufficient medicines
 no safe place to deliver baby
 can’t afford fees, too expensive
 other:
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Basic rapid assessment tool (BRAT): household questionnaire
Children
 children are hungry
 children are scared, traumatized
 no safe place for children to play
 children are separated from families, orphaned
 there are safety hazards causing children harm
 children are abducted by armed forces
 children are working;
 early marriage of girls;
 children take care of younger siblings;
 other:
Security/ protection
 theft
 home invasion (armed or forced entry)
 community conflicts
 intimidation
 discrimination
 physical assault
 sexual assault
 no access to support services (police; Social services; etc)
 abduction, kidnapping
 armed violence (gun fire, shelling, etc.)
 arbitrary arrest and detention
 safety hazards (open well, rusty nails, etc.)
 environmental risks (toxic spill, landslides, etc.)
 health risks (epidemics, household poisons, etc)
 animal attack (snake bite, scorpion, etc.)
 Fire and burns
 other: _________________
 death of family, friends
 death of breadwinner
 separation from family
 missing family members
 emotional difficulties, fear, anxiety
 physical injury / disability as result of conflict
 other:
Personal trauma/loss
Roads/ infrastructure
 roads damaged, destroyed
 bridges damaged, destroyed
 communications networks (phone, internet) cut off
 lack of electricity
 no transport
 no access to fuel
 other:
Other
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