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OUTCOME MONITORING AND PDM FORM

PROVINCE CONTROL NO. DISTRICT WARD VILLAGE DATE REPORT BY HH Head Name

A.DEMOGRAPHICS and WELFARE A1 A2 A3 A4 A5 What What What What is is is is the the the the sex of the respondent? sex of the HH head age of the HH head? marital status of the HH head? <5 years Males Females Please circle all being received 3= WASH 4= Cash Transfers 1.Granary 1.Inputs 1.RWT 1.Cash 2. Inputs 2. Training 2.Latrine 3. Training 3. Marketing linkage 3.Sand dam 4. Marketing Linkage 4.Health clubs 1. Agriculture 2. Cross border trading 3. Formal employment 4. Petty trading/small business 5. Remittances/Migrant 6. Casual labour 1=Field Crops 2= HH Gardens 7. A8 A9 How many of the following productive assets does your HH own? ( insert number) How many of the following productive assets did your HH purchase as a result of income from programme interventions? ( insert number) workers Gold panning 2.Donkeys |__ | 8. Other___________________ 3. Sheep/goats |_____ | 8. Harrow|____| 3.Sheep/goats |_____ | 7.Hand hoes|___ 4.Poultry |_____| 4. Poultry |_____| 8.Harrow|___| 9. 5.Ox plough|____ 5=HBC Support 1.HBC Client 2. HBC Caregiver 1= Male 1= Male 2= Female 2= Female 4 = Divorced 5 = Never married

What is the total number of people who have been living in your HH during the past three months (including non-family)?

1 = Married 2 = Widow 3. Widower 5- 18 19=/> Total years 60 60 years years

A6

Interventions being received by the HH?

A7

What is the Livelihood source for your family?

1. Cattle |_____ |

6. Scotch cart|____| 7. Hand hoes|___ 1. Cattle |_____ | 2.Donkeys |__ | 5. Ox plough|____ 6.Scotch cart|____|

B1 B2 B3 B4 B5

B6

Other___________________ B.AGRICULTURAL PRODUCTION, FOOD CONSUMPTION AND NUTRITION How much land did you cultivate last season? 1=0 2=0.5-1 3=1-3 4=<3 (hectares) How many hectares of land did you cultivate under 1=0 2=0.5-1 3=1-3 4=<3 CF? Where or from whom did you learn CF? 1=NGO 2=Gvt 3=Neighbor/Friend 4=Churches How much cereal did you harvest from last season? 1=<50 2=51-200 3=201-500 4=501-1000 5=<1000 kgs How long did/will the food you harvested last your 1=1-3 months 2=3-5 months 3=5-8 months 4=9-12months 5=>1 year family (# of months) Type of Coping Strategy (tick appropriately) 1.Sold livestock 2.Reduce number of meals eaten per day 3.Rely on Food aid and Gifts from friends and relatives 4.School children dropped 5.Gather wild food/hunt 6.Received remittances from relatives 7.Rely on casual labour for food In the past 6 months, what was your HHs main 1 = own production 2=purchases 3=Barter 4.Remittances

5.Gifts

source of food? 4= Gifts/borrowing B7 How many days in the last 7 days did this household eat the following foods? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. B8 B9 B10 C1 C2 C3 C4 C5 C6 Are you a Maize seed producer? How much seed did you produce in the previous season? How much did you sell? (kgs) Who primarily provides care if a family member is ill? How often do caregivers visit this HH? What specific tasks are undertaken during each visit? Are you satisfied with the type of support you receive from the Caregivers? Are men contributing to caring for the sick? Investigate the clients mobility and self-sufficiency and highlight the cases that apply for this client. 5= Food assistance 6= Other (name) [ [ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] ] ]

Maize, maize porridge Other cereal (rice, sorghum, millet, bread, pasta etc) Roots and Tubers (cassava, potatoes, sweet potatoes) Sugar or sugar products Beans and peas Groundnuts and cashew nuts Vegetables (including relish and leaves) Fruits Beef, goat, or other red meat and pork (game) Poultry and eggs Fish Oils/fats/butter Milk/yogurt/other dairy products Corn-soya blend and other soya products

If Household did not eat food item, RECORD 0

1=Yes 1= 10-50kgs 2=50- 100kgs 3= 101-150kgs 4= >150kgs

[ ] [ ] [ ] 2=No

1= 10-50kgs 2=50- 100kgs 3= 101-150kgs 4= >150kgs C.HBC Support 1 = Children 2= mother 3= father 4= spouse 5= community members 1. Once a month 2. Twice a month 3. Once a week 4. Twice a week 5. More than twice a week 6. Never 1. Bathing 2. Cooking 3. Washing clothes 4. Feeding 5. Household chores 6. Psychosocial Support 1=Yes 2=No 1=Yes 2=No Moderate = 3 Can walk 500 m Once per week Once per week Needs some assistance

Mobility

Normal = 1 Can walk 3 km All meals All cleaning Independent

Good = 2 Can walk 2 km

Cooking Cleaning Toileting

Twice per day Twice per week Usually independent

Poor = 4 Can walk around the house Occasionally Occasionally Needs considerable assistance

Very poor = 5 Bed-Bound

Code

Not at all Not at all Dependent

C7

What challenges is the HBC client facing in everyday life?

1= Adequate food sanitation facilities

2= Drugs 5= other (specify

3= Clean water

4= proper

D1 D2

How far is your nearest water source (in meters/kms)? How many HHs access the water point?

D.WASH AND HEALTH AWARENESS 1= <200M 2=200-500M

3=500M-1km

4=>1 Km

D3

Has anyone in your house had diarrhoea (3 or more watery stools in 24 hours) in the last 3 months?

< 5 years Male Female

5- 18 years

19-60 years

=/> 60 years

D4 D5

If yes, what did you do with the person? What care are you taking now to avoid diarrhoea (which you were not doing before programme implementation)?

1=nothing 1=Nothing 5=Cover food

2= gave home remedies 2=Cook eating food completely

3= took them to hospital before 3=Wash defecation 7=Store container hands water in after clean 4=Use water safe drinking

6= Defecate in a latrine

8=Other (specify)_______

E1

Any income raised from the garden proceeds?

E.GARDENS Name of Garden: 1= Yes 2= No State amount in the last 3 months: 1. School fees, uniforms, stationery 2. Grinding meal 3. Non staple items like sugar, cooking oil 4. Medication State the challenges: F.CASH TRANSFERS 1= Yes Amount of cash: Use Buying staple food Buying non staple food-sugar, cooking oil Buying non food items soap, paraffin, firewood Education Expenditure 1.0-1 hrs 2. 2 hrs 3. 3-4 hrs 1.0-1 hrs 2. 2 hrs 3. 3-4 hrs As a % of Total expenditure in the last 3 months 2= No

E2

Use of the Income by the HH?

E3

Any challenges under gardens?

F1 F2 F3

Did you or any HH member receive any cash from the programme in the past months? Total Expenditure incurred in the last 3 months? What was the money used for?

F4 F5 F6

How long did you walk to the distribution point to receive the Cash (hrs) How long did you wait at the distribution point to receive the money (hrs)? Are you satisfied with the following aspects of the distribution process?

4. 5-6 hrs 4. 5-6 hrs

5. more than 6 hours 5. more than 6 hours

1= Yes 2= No Information about date and time of distribution Information about the amount of money to be received Information about who is eligible for cash transfer Distance to travel to the distribution centre G. INPUTS UTILISATION AND SATISFACTION

G1

What were the quantities you redeemed with your voucher?

Item Maize seed Basal Fertiliser Top dressing Sorghum Ground nuts Bambara

KGs

G2

Of the Inputs redeemed, what was used for the following purposes (please indicate the quantities)?

Items Maize (kgs) Fertilizer (kgs) Bambara (kgs) Groundnuts (kgs) Item Maize Sorghum Ground nuts Bambara Fertiliser 1. Good 1=Yes

(Planted)

Bartered

Sold

Shared with kin

Other

G3

What do you think about the quality and packaging of the Inputs you received

Quality

Packaging

2. Moderate 2=No

3. Poor

G4 G5 G6 G7 G8

Were the quantities redeemed enough for your Farming needs? If some inputs were not used by HH, what is the main reason for not using? How long did you walk to the agro dealer point to redeem the voucher? (in hours) How long did you wait at the agro dealer to redeem the voucher? (in hours) Are you satisfied with the following aspects of the distribution process?

1=Household Inputs more than adequate 2= Inputs Not Appropriate 1.0-1 hrs 2. 2 hrs 3. 3-4 hrs 4. 5-6 hrs 5. more than 6 hours 1.0-1 hrs 2. 2 hrs 3. 3-4 hrs 4. 5-6 hrs 5. more than 6 hours

1= Yes 2= No Information about the redeeming dates of vouchers Information about the process of voucher system Information about the inputs to be distributed Information about who is eligible for inputs Distance to travel to the distribution centre H.TARGETING, & ACCOUNTABILITY

H1

Are you aware of why you were selected as a beneficiary for this programme? Beneficiary should state the reason: Is there a help desk or suggestion box to receive and address community complaints? Probe to see if beneficiary knows the composition of the help desk Are you satisfied with the way the help desk receives and handles complaints and other programme related issues? Have you heard about anyone in this village

1= Yes

2= No

H2

1= Yes If yes, are you making use of it? 1= Yes

2= No 1= Yes 2= No 2= No

H3

H4

If yes, please select what type of favors/ services? (Allow for multiple answers)

/community providing favors or services in exchange for cash transfers or inputs? (Please do not lead the respondent by offering suggestions of possible answers. Leave the question open and then according to their response select the appropriate/matching answers.)

1. Work/ labor 2. Sexual favors _____________________ To whom? (Allow for multiple answers) 1. Programme staff _______________

3. Money

4. Assets

5. Other (specify)

2. Secondary caregivers

3. Community leaders

4. Other (specify)