| NAME:
|
_____________________________
|
| Economic Activity:
|
_____________________________
|
| Assets
|
_____________________________
|
| Land Ownership:
|
_____________________________
|
| Business Equipment:
|
_____________________________
|
| Does the household own a means of transportation?
|
_____________________________
|
| Household Data
|
_____________________________
|
| Number of rooms:
|
_____________________________
|
| Condition of roof:
|
_____________________________
|
| Condition of floor:
|
_____________________________
|
Is there electricity in the area?
In the house?
|
_____________________________
|
| Does the household have access to a clean source of water?
|
_____________________________
|
| Is there a school in the area and do the children of the household attend?
|
_____________________________
|
| Market information
|
_____________________________
|
| Does the household have access to markets?
|
_____________________________
|
| Does the household have access to raw materials?
|
_____________________________
|
| Other Concerns/Comments
|
_____________________________
|
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