VOS

Exit Survey

Village Observations Summary

* Village Name:

Village status

On-track

Off-track

Ward name:

LLG name:

Estimated population:

Estimated number of households:

Main religions:

Church/es?:

Current community programs:

	Activity Name	Stakeholder / Sponsor	Description	Duration
#1

#2

#3

#4

#5

Main Communication Channels in/out:

Water Supply:

Rubbish collection:

Community Noticeboard:

Community Hall / Meeting Place:

Toilets:

General Cleanliness:

Nearest Health Facility:

Type of Facility:

Distance from village:

Nearest Elementary School:

Name of School:

Agency:

Distance from Village:

About the Elementary School:

	Age Range	Male	Female	Total	Main Language of Instruction	# of Teachers
EP

E1

E2

General observations of school buildings / facilities:

Nearest Primary School:

In this village

Away from village

Name of village Primary School:

Agency responsible for village Primary School:

Village Primary School distance from Village:

How satisfied are you with the following:

	Age Range	Male	Female	Total	Main Language of Instruction	# of Teachers
#3

#4

#5

#6

#7

#8

General observations of Primary School buildings / facilities:

Location of Nearest Primary School:

Name of nearest Primary School:

Agency responsible for nearest Primary School:

Nearest Primary School distance from village:

Transport / Access to nearest Primary School:

Estimated # of children from this village who attend this Primary School:

	Male	Female	Total
#

Nearest Secondary School:

Name of Secondary School:

Agency responsible for High School:

Distance of High School from village:

Transport / Access to High School:

Estimated # of children from this village who attend this High School:

	Male	Female	Total
#

Guesthouses:

	Name	Description (capacity / services available)	# of Employees
#1

#2

#3

#4

Any other observations to report: