ScoPeO
Endline Questionnaire
Programme: ____________________________________________________________
Name of the project: ______________________________________________________
Questions A1 to A8 are to be filled in by the interviewer before the interview.
A1 - Interviewer
number:
A2 - Interviewee
number:
A3 - Interview date:
A4 - Interview place:
A5 - Interview
modalities:
A6 - Sex of
interviewee:
A7 –Please indicate if
the individual present
one or more of the
following personal or
environmental risk
factors:
(Check the right
column (Yes/No) for
each proposition.
More than one
response possible)
Code
20___/ ____/ ____
-
□ Individual
□ Proxy:
Please specify who (mother, husband…): _______________
1
2
-
□ Male
□ Female
1
2
Yes
1
No
0
Yes
1
No
0
 Person with disabilities (Please Go to question A8)
 Person with disabling disease (Chronic, non-communicable
or communicable diseases; as HIV, diabetes or epilepsy)
 Person with injuries
 Present/ Past victim/survivor of protection issues
 (violence, tortures)
 Refugee or displaced person
 Person living in a disaster area
 Person exposed to the dangers of weapons, munitions
 and explosive devices
 Other. Please specify : ___________________________
 Don’t know
A8 - For person with
disabilities,
please
specify the type of
impairment:
(Check the right
column (Yes/No) for
each proposition.
More than one
response possible)








Physical
Hearing
Visual
Intellectual
Mental
Psycho-social
Other. Please specify :_________________________
Don’t know
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
1
Before starting the interview, remember to introduce yourself and present the goals of
the survey.
Begin the interview in a safe place where you and the interviewee feel secure.
Transition:
Before going any further with this questionnaire, I would like to assure you that all
your answers will remain strictly confidential. I will keep no record of your name and
address. You are free to refuse to participate. You may stop the interview at any t ime
or skip any questions that you don’t wish to answer.
You may find some of the questions strange. There is no right or wrong answer.
Your participation is voluntary.
This questionnaire will take about 30 minutes.
Do you have any questions?
Do you understand what we’re going to do?
Is this a good time for us to talk?
Can we talk here or would you rather we went somewhere else?
Can we begin?
We are now going to discuss factors affecting the quality of your life, such as your
health, your relationships, your day-to-day existence, etc
Quality of life linked to health
Transition:
We’ll start by talking about your health.
1- How, in general, would you rate your
health:
2- To what extent do you feel that physical
pain prevents you from doing what you
need to do?
3- How often do you have negative feelings,
such as blue mood, despair, anxiety,
depression?
4- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, has your health:
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Excellent
Very good
Good
Fair
Poor
Not at all
A little
A moderate amount
Very much
An extreme amount
Never
Seldom
Quite often
Very Often
Always
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
Code
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
2
Quality of life linked to social and personal relationships
Transition:
We are now going to discuss your relationship with your family, your friends and your
neighbours.
5- Do you consider your relationship with the
members of your family to be:
□
□
□
□
□
Excellent
Very good
Good
Fair
Bad
Code
5
4
3
2
1
6- Do you consider your relationship with your
friends to be:
□
□
□
□
□
Excellent
Very good
Good
Fair
Bad
5
4
3
2
1
7- Do you consider your relationship with your
neighbours to be:
□
□
□
□
□
Excellent
Very good
Good
Fair
Bad
5
4
3
2
1
□
□
□
□
□
Excellent
Very good
Good
Fair
Bad
5
4
3
2
1
(If the person doesn’t have any economic
activity, please check “non applicable”)
□ Non applicable
0
9- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, has your relationship with your family,
friends or neighbours:
□
□
□
□
□
5
4
3
2
1
8- Transition: Now I would like to ask you the
same question concerning the people you are
in touch with when working and/or running
your economic activities. These could be your
colleagues, partners or clients…
Do you consider your relationship with these
persons to be:
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
3
Quality of life linked to subjective well-being
Transition:
I'm going to read a series of comments about you. Can you tell me whether or not you
agree with them?
10- In most ways, my life is close to my ideals:
□
□
□
□
□
□
□
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
Code
1
2
3
4
5
6
7
11- The conditions of my life are excellent:
□
□
□
□
□
□
□
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
1
2
3
4
5
6
7
12- I am satisfied with my life:
□
□
□
□
□
□
□
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
1
2
3
4
5
6
7
13- So far I have gotten the important things I
want in my life:
□
□
□
□
□
□
□
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
1
2
3
4
5
6
7
14- If I could live my life over, I would change
almost nothing:
□
□
□
□
□
□
□
Strongly disagree
Disagree
Slightly disagree
Neither agree nor disagree
Slightly agree
Agree
Strongly agree
1
2
3
4
5
6
7
15- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, has your state of mind:
□
□
□
□
□
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
5
4
3
2
1
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
4
Quality of life linked to basic needs
Transition:
We are now going to discuss your day-to-day existence and needs.
16- Throughout the year, do you manage to
get enough food for all the members of your
household?
□
□
□
□
□
Very easily
Easily
Not very easily
With difficulty
With much difficulty
Code
5
4
3
2
1
17- Throughout the year, do you manage to
get enough drinking and cooking water for all
the members of your household?
□
□
□
□
□
Very easily
Easily
Not very easily
With difficulty
With much difficulty
5
4
3
2
1
18- Throughout the year, if a member of your
household is ill, do you manage to do and get
what you need to care for him/her (medical
consultation, medicines, etc.)?
□
□
□
□
□
Very easily
Easily
Not very easily
With difficulty
With much difficulty
5
4
3
2
1
19- Throughout the year, do you manage to
send all the school-age members of your
household to school?
□
□
□
□
□
Very easily
Easily
Not very easily
With difficulty
With much difficulty
5
4
3
2
1
(If the person doesn’t have any dependent
children or youth in age to go to school,
please check “non applicable”)
□ Non applicable
0
20- To what extent are you satisfied with your
accommodation (state of repair, hygiene,
etc.)?
□
□
□
□
□
Very satisfied
Satisfied
Moderately satisfied
Not very satisfied
Not at all satisfied
5
4
3
2
1
21- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, have your living conditions:
□
□
□
□
□
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
5
4
3
2
1
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
5
Perception of safety
Transition:
We’re now going to discuss your safety and how you perceive it.
22- Do you feel safe at work and/or when you
run your economic activities?
(If the person doesn’t work or run any
economic activity, please check “non
applicable”)
23- Do you feel safe at home?
24- Do you feel safe throughout the day in
usual activities and travel?
25- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project has your security :
□
□
□
□
□
Extremely
Very
Moderately
Slightly
Not at all
Code
5
4
3
2
1
□ Non applicable
0
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
Extremely
Very
Moderately
Slightly
Not at all
Extremely
Very
Moderately
Slightly
Not at all
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
Quality of life linked to material well-being
Transition:
We’re now going to talk about your financial situation. In this respect…
26- Given the resources available to you
personally, do you consider that you live well?
(If the person doesn’t have any resources,
please check “non applicable”)
27- Given the resources available to your
household, do you consider that you live…
28- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, has your financial situation:
□
□
□
□
Well
Not too badly
Alright, but I have to be careful
It’s difficult
Code
4
3
2
1
□ Non applicable
0
□
□
□
□
□
□
□
□
□
4
3
2
1
5
4
3
2
1
Well
Not too badly
Alright, but I have to be careful
It’s difficult
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
6
Participation in society and family life
Transition:
I'm going to read a series of comments about you. Can you tell me whether or not you
agree with them?
29- I consider that I attend family gatherings
sufficiently (family meals to mark special
occasions, weddings, birthdays, etc.):
□
□
□
□
□
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Code
5
4
3
2
1
30- I consider that sufficient account is taken
of my opinion in family decisions (schooling,
constructions):
□
□
□
□
□
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
5
4
3
2
1
31- I consider that I take sufficient part in
discussions with my neighbours, in religious
events, in meetings of neighbourhood
associations,
sports
clubs
or
other
associations:
□
□
□
□
□
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
5
4
3
2
1
32- I consider that sufficient account is taken
of my opinion in decisions that concern me
(choice of spouse, education, etc.):
□
□
□
□
□
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
5
4
3
2
1
33- I consider that sufficient account is taken
of my opinion in the decisions taken in my
neighbourhood:
□
□
□
□
□
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
5
4
3
2
1
34- In your opinion, since the actions
undertaken during the [NAME OF PROJECT]
project, has your participation in family and
community life :
□
□
□
□
□
Greatly improved
Improved
Neither improved nor deteriorated
Deteriorated
Greatly deteriorated
5
4
3
2
1
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
7
Socio-demographic information
Transition: Finally, some personal details…
35- How old are you?
............... years-old
36- The next questions ask about difficulties you may have doing certain activities because of a
health problem…
i) Do you have difficulty seeing, even if wearing glasses?
□ No, no difficulties
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
ii) Do you have difficulty hearing, even if using hearing □ No, no difficulties
aid?
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
iii) Do you have difficulty walking or climbing steps?
□ No, no difficulties
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
iv) Do you have difficulty remembering or concentrating? □ No, no difficulties
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
v) Do you have difficulty (with self-care such as) washing □ No, no difficulties
all over or dressing?
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
vi) Do you have difficulty communicating (for example □ No, no difficulties
understanding others or others understanding you)?
□ Yes, some difficulties
□ Yes, a lot of difficulties
□ Cannot do it at all
37- Are you:
□ Married
□ Divorced
□ Widowed
□ Living with a partner
□ Single
□ Don’t want to answer
38- What is the highest education you received?
□ None at all
□ Elementary School
□ High School
□ College/ University
□ Don’t know
39- Do you have an income-generating activity?
□ No
□ Yes
□ Don’t want to answer
If YES, what kind of activity is it?
.......................................................
40- Do you have any children?
□ No
□ Yes
□ Don’t want to answer
If YES, how many?
............... CHILD(REN)
Code
-
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
5
999
1
2
3
4
99
1
2
999
1
2
999
-
Thank the person for participating and ask them if they enjoyed the interview.
ScoPeO - Last update: 2016/01/26 – Impact, Monitoring & Evaluation Unit – Handicap International
8