Village Code………………………………….. 

Village-level Water Availability Assessment Form 

(1) Name of Village Tract : …………………………………………………………….. 
(2) Name of Village : …………………………………………………………….. 
(3) Type of water sources : Rainwater .. , River / Stream water .. , 
Dug well .., Tubewell .., Pond • 
(4) Type of water sources in dry season : Running water .. , Pond .., 
Dug well .., Tubewell .., 
(5) How many of them were cleaned? ………… Pond / …………….Dug well 
(6) Are they suitable for drinking purpose? .. Pond • / Dug well • 
(7) Are they sufficient for dry season? .. Yes • / No • 
(8) If No, which alternative sources people use in dry season? 
a) Nearby pond .. , b) water vender .. , c) river / steam water 
(9) How far are they? About ……….…… miles 
(10) How is water collected from there?. a) by boat .. , b) by bullock cart .. , 
(11) How long do they suffice till when? ….from …………to………… 
(12) Other information ……………………………………………………………………………………… 
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aus;½Gm code………………………………….. 
aus;½GmtqifY aomufoHk;a& &½SdrSK tajctaeppfwrf; 

(1) aus;½Gmtkyfpktrnf : ……………………………………………………………………………………….. 
(2) aus;½Gmtrnf : ……………………………………………………………………………………….. 
(3) aus;½Gm½Sd aomufoHk;a& t&if;tjrpfrsm;: rdk;a& ..? jrpf acsmif;a& .. ? uefa& • 
vufwl;wGif;us,fa& ..? wHkuifwGif; ^pufa&wGif;a& • 
(4) aus;½Gm½Sd aEG&moDoHk; aomufoHk;a& t&if;tjrpfrsm;: jrpf acsmif;a& .. ? uefa& • 
vufwl;wGif;us,fa& ..? wHkuifwGif; ^pufa&wGif;a& • 
(5) a&ief^a&qdk;rsm; pkyfxkwfNyD;onfY ta&twGuf …………..… uef ? …………….…wGif; 
(6) jyKjyifNyD;onfY a&wGif;?a&uefrsm;onf aomufoHk;&ef ….oifYavsmfygonf .. roifYavsmfyg • 
(7) a&wGif;?a&uefrsm;onf aEG&moDtwGuf …….vHkavmufygonf? .. / rvHkavmufyg? • 
(8) tu,fν rvHkavmufygu? aEG&moDoHk; a&&½SdonfY enf;vrf;rsm;rSm 
(u) teD;½Sd aus;½Gmrsm;rS a&uefrsm;rS .. ? (c) a&a&mif;csolrsm;xHrS .. ?(*) jrpf acsmif;a& • 
(9) aus;½GmrS aEG&moDoHk; a&uef? jrpfacsmif;rsm; tuGmta0; ……….……… rdkifcefY/ 
(10) aEG&moDoHk; a&uef? jrpfawmfjzifY .. (c) EGm;vSnf;jzifY .. ?
acsmif;rsm;rS a&o,f,lyHk? (u) avS^armf

(11) aEG&moDoHk; a&wGif;?a&uefrsm;udk rDScdk toHk;jyKEdkifonfYumv/ 
………………………………………...v rS ……………………………..…...v txd 
(12) tjcm;azmfjyvdkaom tcsufrsm; ………………………………………………………………………………... 
……………………………………………………………………………………………………………………………………. 
…………………………………………………………………………………………………………………………………….… 
………………………………………………………………………………………………………………………………….…… 
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ppfwrf; jznfYoGif;enf;vrf;nTef 


-NrdKUe,fusef;rma&;OD;pD;t&m½Sd (TMO) tm; Budkwiftoday; aqG;aEG;xm;&ef vdktyfygonf/ aEG&moDwGif 
aomufoHk;a& tcuftcJ jzpfEdkifrnfU aus;&Gmrsm;udk od½S
dazmfxkwf ulnDay;Edkif&ef twGuf jzpfygonf/ 

-aus;½Gm code tm; oufqdkif&m ,l
eDquf½Hk;rsm;rS jznfUpGufay;&ef jzpfygonf/ 

- trSwfpOf (1) rS (12) txd oufqdkif&m tajccH usef;rma&; 0efxrf;rsm;rS jznfYpGuf ay;&efjzpfygonf/ 
- aus;½Gmtkyfpktrnf qdkonfrSm NrdKUe,f taxGaxG tkyfcsKyfa&;OD;pD;|mersm;rS owfrSwfxm;onfY twdkif; 
jzpfygonf/ 
- aus;½Gmtrnf qdkonfrSmvnf; NrdKUe,f taxGaxG tkyfcsKyfa&;OD;pD;|mersm;rS owfrSwfxm;onfY twdkif; 
jzpfygonf/ tjcm;trnf ½Sdyguvnf; jznfYpGufay;&ef jzpfygonf/ pm&if;ayguf r[kwfyguvnf; jznfYpGuf 
ay;&ef jzpfygonf/ 
- aus;½Gm½Sd aomufoHk;a& t&if;tjrpfrsm; jznfUpGuf&mwGif trSefjcpf Β jcpfay;&efom jzpfygonf/ 
- aus;½Gm½Sd aEG&moDoHk; aomufoHk;a& t&if;tjrpfrsm; jznfUpGuf&mwGifvnf; trSefjcpf Β jcpfay;&efom 
jzpfygonf/ 
- a&ief^a&qdk;rsm; pkyfxkwfNyD;onfY ta&twGuf qdk&mwGif uef ^wGif; ta&twGufudkom qdkvdkygonf? 
pkyfxkwfNyD;onfU tBudrfudk jznfUpGuf&ef rvdkyg/ 
- jyKjyifNyD;onfY a&wGiff …oifYavsmf^roifYavsmf twGuf trSefjcpf Β jcpf
;?a&uefrsm;onf aomufoHk;&eay;&efom jzpfygonf/ 

-a&wGif;?a&uefrsm;onf aEG&moDtwGuf …vHkavmufygonf^rvHkavmufyg twGuf trSefjcpf Β jcpf 
ay;&efom jzpfygonf/ 
-tu,fν rvHkavmufygu? aEG&moDoHk; a&&½SdonfY enf;vrf;rsm; twGufvnf; trSefjcpf Β jcpf 
ay;&efom jzpfygonf/ 
- aus;½GmrS aEG&moDoHk; a&uef? jrpfacsmiffNyD; ta0;qHk;udk
;rsm; tuGmta0;twGuf cefYrSef;rdkif omjzpjznfYay;&ef vdkygonf/ 

- aEG&moDoHk; a&uef? jrpff
acsmif;rsm;rS a&o,f,lyHk twGufvnf; trSefjcpΒ jcpf ay;&efom jzpfygonf/ 

- aEG&moDoHk; a&wGif;?a&uefrsm;udk rDScdk toHk;jyKEdkifonfYumvtwGuf t*Fvdyfvudk qdkvdkygonf/ 
-tjcm;azmfjyvdkaomtcsufrsm;qdkonfrSm 
-a&vHkavmufrSK r½Sdygu a&oGm;a&muf cyf,l&onfY a&wGif;? a&ueftrnf 
-a&udk vma&mufa&mif;csolrsm;½Sdygu a&a&mif;ol\ trnf? o,f,lvmonfY a&t&if;tjrpfESifY 
ydkifqdkifrSKU? o,f,lvmyHk? aps;ESKef; 
-tjcm; a&&,lEdkifonfU a&wGif;?a&uefrsm;? a&csKdonfYae&mrsm; ponfwdkUESjcm;azmfjyvdkonfY 

ifY t
tcsufrsm;udk azmfjyEkdifygonf/ 



Instruction for Filling of Assessment Forms 

. Inform Township Medical Officer in advance for smooth implementation of the 
activity. 
. The purpose of this exercise is to collect information of villages where there will 
be shortage of drinking water supply during the dry season. 
. Village code should be filled by WASH staffs of UNICEF Field offices. 
. Name of village tract name should be same as official name of GAD 
. Name of village name is also same as village tract. But please mention other 
local name if they have. And also please mention also name of village which are 
not in the list of GAD 
. Please tick appropriate boxes for existing water sources within village 
. Please tick appropriate boxes for drinking water sources in dry season 
. Please mention number of ponds / dug wells only, not frequency of rehabilitation 
. Please tick appropriate box for suitability of drinking purpose 
. Please tick appropriate box for sufficiency of drinking water during dry season 
. Please tick again appropriate box for alternate water sources 
. Please mention approximate and farthest place of alternate water source 
. For water trucking or boating or transportation of water please tick actual 
transportation mechanism only. 
. Please name of English months, Myanmar months 
. With regard to other information the data required are: 
-the location of dug well or pond or river where water quality is fresh 
-the name of water vender, where do they fetch the sold fresh water, 
transportation mechanism, price of water 
-what are the other probable water sources such as dug well, pond, place of 
fresh water 
-other information related to water supply during dry season