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| What is the name of the community? | | |
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| What is the name of the section? | | |
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| What is the name of the chiefdom? | | |
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| What is the name of the district? |
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| Enter the respondents name. | | |
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| Enter the age of the respondent | | |
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| Please specify the respondents gender |
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| What is the name of the household head? | | |
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| What is the gender of the household head? |
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| Please enter the age of the household head | | |
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| How many household members? | | |
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| How many female and male live in the household? Female | | |
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| How many female and male live in the household? Male | | |
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| What has been your main source(s) of livelihood for your household? |
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| Have community associations and services been in existence during the past four months (May - August)? |
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| Where do you ususally source your commodities from? |
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| Has there been any changes to the main source of livelihood within the last four months (May-Aug)? |
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| When did you notice these changes? |
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| What has led to the changes in livelihood? |
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| Has your income decreased or increased? |
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| Has any family member migrated/relocated to another community within the last four months? |
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| Please specify the reason for the migration/relocation. |
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| If they migrated/relocated because of Ebola, please specify the reason. |
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| How has the migration pattern been? |
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| Are you involved in agricultural activities? |
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| Please specify your activities you are involved in.
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| Were you engaged in those activities last year? |
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| If no, please specify your reason. |
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| What agricultural goods have you produced in this year? |
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| What is the expected production for this year? |
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| What is your expectation in terms of yield/volume of produce in the last 4 months? |
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| How would you assess the agriculture labour during the last 4 months as compared to the same time lastyear?
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| Was there any support for this planting season? |
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| If yes, in which form support was offered? |
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| Are the women/disabled considered for access to (agricultural related) loans |
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| Please specify the type of loan facility | | |
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| Does your household engage in any livestock activity? |
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| Please specify the type of livestock you are engaged with. |
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| Please specify the use of the livestocks. |
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| Do you hunt or trap bushmeat? |
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| Please specify the use of the bushmeat. |
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| Please specify the type of bush meat |
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| How often do you sell/consume
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| Please select the food items that are normally available to your household. |
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| In the last four months, what has been the availability of food items for your household? |
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| Which foods are currently scarce in the market? |
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| Please describe your food consumption within the last 4 months. |
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| How many times per day do you eat staple foods? |
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| Has your frequency of eating been affected? |
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| What is the extent knowledge on EVD? |
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