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School Toilet Evaluation Survey
The objective of this Survey is to identify the status of the School Toilets in your School, please provide appropriate information. Configured by TeenTaal.in
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1
Project
Project for which fund is allocated or received
Google CA
SEWA International
Vistara
BayArea
UnitedWay Flood fund
HSS - Norway
Oracle - Wash Basins & Health Camp
Google CA
SEWA International
Vistara
BayArea
UnitedWay Flood fund
HSS - Norway
Oracle - Wash Basins & Health Camp
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2
Name of Surveyor
*
This field is required.
First Name
Last Name
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3
Day Visited:
-
Date
Month
Day
Year
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4
Select State > District > Taluk
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5
School Name
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6
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
School Type
HPS
LPS
KBS
MPS
GLPS
GHPS
HPUS
GLPUS
Others
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8
Head Master Name & Phone
Please enter name
Please enter your phone
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9
School Email
example@example.com
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10
School Student Strength
*
This field is required.
Count
Number of Girls
Row 0, Column 0
Number of Boys
Row 1, Column 0
Male Teacher
Row 2, Column 0
Female Teacher
Row 3, Column 0
Support Staff
Row 4, Column 0
Number of Girls
Number of Boys
Male Teacher
Female Teacher
Support Staff
Count
Row 0, Column 0
Count
Row 1, Column 0
Count
Row 2, Column 0
Count
Row 3, Column 0
Count
Row 4, Column 0
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of 5
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11
Akshya Patra available in School ?
YES
NO
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12
Annapurna Midday meal available in the School ?
YES
NO
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13
Midday meal available in the School ?
YES
NO
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14
Damaged in Flood?
Are Toilets & Urinals damaged in Floods during Aug 6th to 9th 2019?
YES
NO
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15
Damaged List
Select all that is damaged in School
Class Room Ceiling
Roofing Tiles(Hunch)
Wall Crack and Repair
Need Doors & Windows
Floor damaged
Water Tank
Class room Furniture
Class room Board
Need Painting
Water Pipe
Others
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16
Damage Additional info
Any additional information about School building damage
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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17
Number of Toilets Present in the School in the current condition
Information about the current state of the toilet as is, in-case there is no toilet, please enter 0, *Unit & Partitions are applicable to Urinal counts only. e.g 1 Urinal Unit may have 3 to 4 sections or partitions
Girl's
Boy's
*Unit
*Partition
Number of Toilets
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Number of Urinals
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Number of Toilets
Number of Urinals
Girl's
Row 0, Column 0
Boy's
Row 0, Column 1
*Unit
Row 0, Column 2
*Partition
Row 0, Column 3
Girl's
Row 1, Column 0
Boy's
Row 1, Column 1
*Unit
Row 1, Column 2
*Partition
Row 1, Column 3
1
of 2
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18
Status of the Toilet & Urinals
*
This field is required.
Please select
Good (Functional)
Moderate (Need Repair)
Bad (Non Funct)
Damaged (Flood)
Girl's Toilet
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Boy's Toilet
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Boy's Urinals
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Girl's Urinals
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Girl's Toilet
Boy's Toilet
Boy's Urinals
Girl's Urinals
Good (Functional)
Row 0, Column 0
Moderate (Need Repair)
Row 0, Column 1
Bad (Non Funct)
Row 0, Column 2
Damaged (Flood)
Row 0, Column 3
Good (Functional)
Row 1, Column 0
Moderate (Need Repair)
Row 1, Column 1
Bad (Non Funct)
Row 1, Column 2
Damaged (Flood)
Row 1, Column 3
Good (Functional)
Row 2, Column 0
Moderate (Need Repair)
Row 2, Column 1
Bad (Non Funct)
Row 2, Column 2
Damaged (Flood)
Row 2, Column 3
Good (Functional)
Row 3, Column 0
Moderate (Need Repair)
Row 3, Column 1
Bad (Non Funct)
Row 3, Column 2
Damaged (Flood)
Row 3, Column 3
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19
Toilets or Urinal Required or other services needed?
Yes (New Toilet)
No
Repair (Toilet or Urinal)
Hand Wash only
Health Camp
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20
Number of Toilets or Urinals Required
For Urinals, please mention the information in Units here. *Unit & Splits are applicable to Urinal counts only. e.g 1 Urinal Unit may have 3 to 4 sections or splits
New Needed
Repair Existing
Girls' Toilets
Row 0, Column 0
Row 0, Column 1
Boy's Toilet
Row 1, Column 0
Row 1, Column 1
*Boy's Urinals
Row 2, Column 0
Row 2, Column 1
*Girl's Urinals
Row 3, Column 0
Row 3, Column 1
Girls' Toilets
Boy's Toilet
*Boy's Urinals
*Girl's Urinals
New Needed
Row 0, Column 0
Repair Existing
Row 0, Column 1
New Needed
Row 1, Column 0
Repair Existing
Row 1, Column 1
New Needed
Row 2, Column 0
Repair Existing
Row 2, Column 1
New Needed
Row 3, Column 0
Repair Existing
Row 3, Column 1
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21
Soil Type
Black
Red
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22
Is this School selected for Installation of Wash Basin?
*
This field is required.
YES
NO
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23
Is Water Available in the Toilet or Nearby Toilet?
YES
NO
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24
Equipped with Drainage Facility?
Please mention any additional information in Notes section
YES
NO
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25
Photo of the Toilet
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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of
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26
Photo of current state of Toilet Taken?
YES
NO
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27
Sanitary Napkins for Girl Child?
Are you getting sufficient Supply of Sanitary Napkins for Girl Child?
YES
NO
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28
Any comments, questions or suggestions?
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29
Is Wash Basin installed for this School?
For Backend entry
YES
NO
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30
Ballpark Total Estimation in Rs
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31
Surveyor's Phone Number
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32
Surveyor's Signature
Clear
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33
Total Schools Surveyed
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34
Total New Toilet Construction
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35
Total New Urinal Construction
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36
Total Toilet Repair
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37
Total Urinal Repair
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38
Total Student Strength (Boys + Girls)
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39
Total Staff Strength (Teacher + Support Staff)
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Should be Empty:
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