WASHCon: Administrative Data Form

1	Does this healthcare facility have outpatient services (OPD)?
If NO, skip to Q4	□	Yes
□	No	
2	On average, how many outpatients are seen per month?		
3	How many days in a month are outpatients seen?		
4	Does this healthcare facility have inpatient services?
If NO, skip to Q8.	□	Yes
□	No	
5	On average, how many inpatients are seen per month?		
6	On an average day, how many inpatients are at the healthcare facility?		
7	How many inpatient beds are available?		
8	On average, how many deliveries take place per month?		
9	Of these deliveries, how many were cesarean sections?		
10	Are surgical procedures performed at this healthcare facility?
If no, skip to Q12	□	Yes
□	No	
11	If yes, on average, how many surgical procedures are performed each month?		
12	How many clinical staff are employed at the healthcare facility?
(i.e. doctors, midwives, nurses, etc.)		
13	Of the clinical staff, how many are medical doctors?		
14	How many non-clinical staff are employed at the healthcare facility?
(i.e. administrative staff, janitorial staff, etc.)		
15	Of the non-clinical staff, how many are cleaners?		
16	On average, how much water is used daily (in liters)?
Note: information may be found on water bill or best estimate from reliable source		

WASHCon: Aggregated Water Quality Data Form

1	Does the water have appropriate levels of chlorine residual?

CDC guidelines recommend between 0.2-2.0 mg/L (or ppm)	□	Water is chlorinated and more than 50% of samples meet CDC guidelines for chlorine residual
□	Water is chlorinated but less than 50% of samples meet CDC guidelines for chlorine residual
□	Water is not chlorinated OR chlorine residual levels are all below CDC guidelines for chlorine residual	
2	Does the water quality meet WHO microbial water quality guidelines?

WHO guidelines recommend less than 1 CFU E. coli per 100mL sample	□	Between 90-100% of all samples met WHO
guidelines for microbial water quality
□	Between 50-89% of all samples met WHO guidelines for microbial water quality
□	Less than 50% of all samples met WHO guidelines for microbial water quality	

1	Which of the following services or departments are available at this healthcare facility?

Read all options. Check all that apply.	□	Antenatal Care
□	Dentistry
□	Emergency Department
□	Environmental Services
□	Eye Clinic
□	HIV/VCT/ARV Clinic
□	Housing for Staff
□	Immunization
□	Inpatient
□	Intensive Care Unit
□	Kitchen
□	Labor and Delivery
□	Laboratory
□	Major Surgery
□	Morgue
□	Minor Surgery
□	Nutrition Services
□	Outpatient (OPD)
□	Pediatric
□	Pharmacy
□	Postnatal
□	TB Services
□	Other:	
ELECTRICITY: “Now I’m going to ask you some questions about electricity.”	
2	What sources of energy are used at the healthcare facility?

Read all options. Check all that apply.

If “No power  source” is selected, skip to Q5.	□	Utility power
□	Solar power
□	Generator (petroleum)
□	Firewood
□	Charcoal
□	LPG
□	No power source
□	Other:
□	Don't know		
3	What is the main source of energy?	□	Utility power
□	Solar power
□	Generator (petroleum)
□	Firewood
□	Charcoal
□	LPG
□	No power source
□	Other:
□	Don't know		

4	If electricity (utility, solar, generator) is used to power the facility, how many days last month was the electricity interrupted for more than 2 hours?	□	Everyday
□	Most days but not every day
□	Several times
□	Once
□	Never
□	Don't know		

WATER SUPPLY: “Now I’m going to ask you some questions about water  supply.”	
5	Please tell me which of the following sources of water are available to the healthcare facility:

Read all options. Check all that apply. If no water source, skip to Q32	□	Piped supply from outside the facility
□	Tube well
□	Borehole
□	Protected dug well
□	Rain Water	□	Unprotected dug well
□	Surface water
□	Tanker truck
□	Other
□	Don't know
□	No water source	
6	What is the main water source for the healthcare facility?

The question refers to the source of water for general purposes, including drinking, washing, and cleaning. In case of water being available at multiple points, record the response closest to the outpatient area.	□	Piped supply from outside the facility
□	Tube well
□	Borehole
□	Protected dug well
□	Rain Water	□	Unprotected dug well
□	Surface water
□	Tanker truck
□	Other
□	Don't know
□	No water source	
7	Where is the main water source for the facility?

If on premises, skip to Q10	□	On premises
□	Off premises, within 500m
□	Off premises, farther than 500m
□	No water source
□	Don’t know	
8	What is the roundtrip travel time to collect water off premises? (in minutes)		
9	Who collects the water off premises?	□	Patients/caregivers only
□	Staff only
□	Both patients/caregivers and staff
□	Other
□	Don’t know	
10	Are there times when the main water source is unavailable?

If NO, skip to Q14.	□	Yes
□	No
□	Don’t know	

11	If yes, why?

Read all options. Check all that apply	□	Power outage
□	Water rationing/shortage
□	Equipment malfunction
(i.e. broken pump)
□	Season (dry or wet)	□	Pipe breakage
□	Problems at the water provider
□	Other:
□	Don't know	
12	How often is the main water supply unavailable?

Read all options.	□	For part of the day, rarely
□	For part of the day, frequently
□	For part of the year (seasonal problem), frequently
□	For part of the year (seasonal problem), rarely
□	Don’t know	
13	Is there routinely a time of year when the healthcare facility has a severe shortage or lack of water?	□	Yes
□	No
□	Don’t know	
14	Does the healthcare facility ever ration water? (i.e. is water use intentionally limited or used sparingly)

If NO, skip to Q16	□	Yes
□	No
□	Don't know	
15	If yes, why?

Check all that apply.	□	Cost of water
□	Concerned water will run out
□	Other:
□	Don't know	
16	How does the healthcare facility store water?

Check all that apply. If NO, skip to Q20	□	In centralized storage tank(s) (plastic/concrete/steel)
□	In storage tanks (plastic/concrete/steel) at the various wards
□	In containers (such as buckets/jerry cans) inside the wards
□	In containers on the facility premises
□	Other
□	No water storage available
□	Don’t know	
17	What type of water storage facilities are available?

Check all that apply.	□	Plastic tanks
□	Concrete tanks
□	Elevated steel tanks
□	Buckets/jerrycans within wards
□	Other
□	Don’t know	
18	What is the total water storage capacity at the healthcare facility in liters?		
19	Can this storage capacity provide at least
24 hours of water supply for the needs of the healthcare facility?	□	Yes
□	No
□	Don't know	

20	Which users have access to water?	□	Patients/caregivers
□	Staff
□	Community members
□	None
□	Don’t know	
21	Is water accessible to all users at all times?
i.e. water can be accessed any time of day by anyone (patients, staff and caregivers) at the healthcare facility

Note: this question is asking about equity of access, not water outages.	□	Yes
□	No, patients/caregivers do not have access at all times
□	No, staff do not have access at all times
□	No, both (patient/caregivers and staff) do not have access at all times
□	Don’t know	
22	Are there tastes, odors or colors that discourage consumption or use of the drinking-water?	□	Yes
□	Sometimes
□	No
□	Don’t know	
23	How is water accessed within the healthcare facility?

Read all options. Check all that apply.	□	Piped taps
□	Uncovered buckets/barrels
□	Covered buckets/barrels
□	Covered buckets with taps on bottom
□	Uncovered buckets with taps on bottom
□	Jerry cans
□	Other
□	Don’t know	
24	If buckets/barrels selected, how is water removed from buckets/barrels for use in the wards?

Read all options. Check all that apply.	□	Cup or ladle
□	Tap
□	Pour
□	Other
□	Don’t know	
25	Does this healthcare facility expect that pregnant women will bring their own water when they come to deliver?	□	Yes
□	Sometimes
□	No
□	Don’t know	

WATER TREATMENT: Now I am going to ask you some questions about water treatment.	
26	Is water from the main water source chlorinated (treated with chlorine)?	□	Yes
□	No
□	Don’t know	
27	Does chlorination occur on the healthcare facility premises?
As opposed to the water being chlorinated by the water utility.	□	Yes
□	No
□	Don’t know	

28	Does the healthcare facility purchase or produce drinking-quality water for staff, patients and caregivers?
This includes bottled water.

If NO, skip to Q31.	□	Yes
□	Sometimes
□	No
□	Don’t know	
29	If yes, how does the healthcare facility provide treated drinking-water?

Read all options, select all that apply.	□	Chlorination of drinking water onsite
□	Filtration of drinking water onsite
□	Boiling of drinking water onsite
□	UV treatment of drinking water onsite
□	Bottled (or sachet) water available
□	Water is treated before reaching the healthcare facility (i.e. by a utility treatment plant)
□	Other
□	Don’t know	
30	In the previous two weeks, was drinking- water available for patients throughout each day?	□	Yes
□	No
□	Don’t know	
I’m now going to ask you questions about water  treatment for various medical purposes.	
31	How is water treated for the following medical purposes?
Read all purposes. Check all that apply and circle the type of treatment.

Note: Select “Not Applicable” if the medical
purposes does not occur at this facility	□	Surgical procedures
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know
□	Labor and delivery
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know
□	Wound and burn care
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know
□	Processing of medical equipment
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know
□	Use in medical devices (CPAP, incubator, etc.) Chlorination, Filtration, Boiling, Distillation, Purchase, UV, Other,  No Treatment, Not applicable, Don’t know
□	Dentistry
Chlorination, Filtration, Boiling, Distillation, Purchase, UV, Other, No Treatment, Not applicable, Don’t know
□	Mixing medication
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know
□	Laboratory
Chlorination, Filtration, Boiling, Distillation, Purchase,
UV, Other,  No Treatment, Not applicable, Don’t know	

32	When is water typically treated?	□	Prior to storage
□	After storage
□	Both prior to and after storage
□	No water treatment	
HYGIENE: Now I am going to ask you some questions about hygiene.	
33	Does the healthcare facility provide the staff with soap for handwashing?	□	Yes
□	Sometimes
□	No
□	Don’t know	
34	Does the healthcare facility provide patients and caregivers with soap for handwashing?	□	Yes
□	Sometimes
□	No
□	Don’t know	
35	Are bathing facilities available to patients?	□	Yes
□	No and have inpatient services
□	No but do not have inpatient services
□	Don’t know	
36	Are beds, mattresses, pillows and/or mats cleaned between patients and whatever soiled with bodily fluids?

i.e. bed rails and mattresses are cleaned, linens are laundered or changed

Read all options.	□	Always
□	Sometimes
□	Rarely or never
□	Bedding is not provided by healthcare facility
(patients bring their own)
□	No inpatient services
□	Don’t know	
37	Are the healthcare facility floors, surfaces and toilets cleaned at least once a day with water and detergent and/or
whenever they are soiled?	□	Yes, cleaned every day with water and detergent
□	Cleaned with water and detergent, but less than once a day
□	No
□	Don’t know	
38	Are functional laundry facilities available to wash linens and medical scrubs?	□	Yes
□	No
□	Don’t know	
39	What functional sterilization equipment is available at the healthcare facility today?

Read all options. Check all that apply.	□	Autoclave (pressure & wet heat)
□	Dry heat sterilizer
□	Boiler or steamer (no pressure - electric or not)
□	Other
□	No functional sterilization equipment available
□	Don't know	
SANITATION: Now I am going to ask you some questions about sanitation.	
40	Are toilet facilities available on the healthcare facility premises?

If NO, skip to Q45	□	Yes
□	No
□	Don’t know	

41	Are there sufficient toilet facilities to meet
the healthcare facility’s needs?	□	Yes
□	No
□	Don’t know	
42	Are the toilet facilities in use?	□	Yes
□	No
□	Don’t know	
43	How is human waste (feces) from toilets disposed of most of the time?

Read all options.	□	Sewerage system
□	Septic Tank
□	Underground holding pit
□	Discharged into drain or immediate environment
□	Other
□	Don’t know	
44	If septic tank or underground holding pit, how is it emptied most of the time?	□	Manually remove waste
□	Call a waste company for removal
□	Build a new pit
□	Other:
□	Has never been full
□	Don’t know	

WASTE MANAGEMENT: Now I am going to ask you some questions about waste management.	
45	How is grey water/wastewater (i.e. water from sinks, laundry, cleaning etc.) disposed of?	□	Offsite sewage treatment
□	Soak pit
□	Drain field
□	Combined septic tank
□	Other:
□	Don’t know	
46	Are fenced and protected areas available for the storage of waste awaiting disposal or removal?	□	Yes
□	Sometimes
□	No
□	Don’t know	
47	Is there a functional incinerator? If yes, is fuel available for it?

Read all options.	□	Yes, and fuel is available today.
□	Yes, but no fuel is available today.
□	No
□	Don't know	
48	Is infectious waste separated from other waste in the wards?
i.e. blood soaked clothes, body parts removed during surgery, catheters, vomit, etc

If NO, skip to Q50	□	Yes
□	Sometimes
□	No
□	This kind of waste is not generated.
□	Don’t know	

49	How is infectious waste treated most of the time?	□	Autoclave
□	Chemical disinfection with hypochlorite (ex: chlorine, bleach, etc.)
□	Other:
□	Not treated
□	Don’t know	
50	How is infectious waste disposed most of the time?	□	Incinerate (two chamber, 850-1000 C)
□	Incinerate (brick incinerator)
□	Bury in a lined, protected pit
□	Bury in an unprotected pit
□	Burn in a protected pit
□	Open burning
□	Open dumping
□	Collect for medical waste disposal offsite
□	Collect for general waste disposal offsite
□	Add to general waste for onsite disposal
□	Other
□	Don’t know	
51	Is sharps waste separated from other waste in the wards?
i.e. disposable needles

If NO, skip to Q53.	□	Yes
□	Sometimes
□	No
□	This kind of waste is not generated
□	Don’t know	
52	How is sharps waste treated most of the time?	□	Autoclave
□	Chemical disinfection with hypochlorite (ex: chlorine, bleach, etc.)
□	Other
□	Not treated
□	Don’t know	
53	How is sharps waste disposed most of the time?	□	Incinerate (two chamber, 850-1000 C)
□	Incinerate (brick incinerator)
□	Bury in a lined, protected pit
□	Bury in an unprotected pit
□	Burn in a protected pit
□	Open burning
□	Open dumping
□	Collect for medical waste disposal offsite
□	Collect for general waste disposal offsite
□	Add to general waste for onsite disposal
□	Other
□	Don’t know	
54	How is non-infectious general waste disposed most of the time?	□	Incinerate (two chamber, 850-1000 C)
□	Incinerate (brick incinerator)
□	Bury in a lined, protected pit	

		□	Bury in an unprotected pit
□	Burn in a protected pit
□	Open burning
□	Open dumping
□	Collect for general waste disposal offsite
□	Other
□	Don’t know	
55	Are placentas separated from other waste?

If NO, survey completed.	□	Yes
□	Sometimes
□	No
□	This kind of waste is not generated
□	Don’t know	
56	How are placentas disposed most of the time?	□	Incinerate (two chamber, 850-1000 C)
□	Incinerate (brick incinerator)
□	Blend and dispose of in septic tank
□	Bury in a lined, protected pit
□	Burn in a protected pit
□	Open burning
□	Open dumping
□	Women bring placentas home
□	Collect for medical waste disposal
□	Other:
□	Not applicable
□	Don’t know	
57	Are placentas treated before the women bring them home?	□	Yes
□	No
□	Don’t know	

1	Are there written guidelines pertaining to water, sanitation, and hygiene for the healthcare facility?	□	Yes
□	No	
2	Are cleaning protocols available?
Protocols should include 1) step-by-step techniques for specific tasks, such as cleaning a floor, cleaning a sink, cleaning a spillage of blood or body fluids, and 2) a cleaning roster or schedule specifying responsibility for cleaning
tasks and frequency at which they should be performed. The term for protocols may differ according to local practice; they may be referred to as Standard Operating Procedures (SOPs), guidelines, instructions, etc. Where possible, protocols should be observed by the enumerator.	□	Yes
□	No	
3	Are there written policies and protocols available within the facility relating to cleaning the delivery room?	□	Yes
□	No	
4	Are there written policies and protocols available within the facility relating to cleaning in-patient rooms (non- surgical)?	□	Yes
□	No	
5	Is there a water, sanitation, and hygiene improvement plan in place for the healthcare facility?	□	Yes
□	No	
6	If yes, is the improvement plan implemented and regularly monitored?	□	Yes
□	No	
7	Do you have an annual planned budget for the healthcare facility that includes funding for WASH infrastructure (sinks, toilets, etc.), services (pit emptying), personnel and the continuous procurement of WASH items (hand soap, chlorine/bleach, etc.)?	□	Yes
□	No	
8	Do you have a budget for the maintenance of the healthcare waste incinerator (if it applies)?	□	Yes
□	No
□	No incinerator	
9	Are regular audits of each ward undertaken to assess the availability of hand sanitizer, soap, single use towels and other hand hygiene resources?	□	Yes
□	No	
10	Is there a mechanism to track the supply of IPC-related materials (such as hand sanitizer, gloves and protective equipment)?	□	Yes
□	No	
11	Is there an up-to-date diagram (organogram) of the facility management structure clearly visible and legible?	□	Yes
□	No	
12	Are there sufficient cleaners and maintenance staff available at this healthcare facility?	□	Yes
□	No	

13	Are the activities related to ensuring the daily availability and function of water, sanitation and hygiene infrastructure (sinks, toilets, etc.) shared across more than one staff person?	□	Yes
□	No	
14	If yes, how many staff are involved with ensuring there is available and functional WASH infrastructure?		
15	Is there a focal person(s) who is responsible for managing the daily availability and function of water, sanitation and hygiene infrastructure for the healthcare facility (e.g., sinks, toilets, handwashing stations, etc.)?	□	Yes
□	No	
16	If yes, what is the job title of that person?		
17	Is there a focal person(s) who is responsible for managing water, sanitation and hygiene resources for the healthcare facility (e.g., soap, chlorine, disinfectant, etc.)?	□	Yes
□	No	
18	If yes, what is the job title of that person?		
19	Is there a dedicated staff responsible for the operation and maintenance of the incinerator?	□	Yes
□	No	
20	Does the healthcare facility have a dedicated infection control focal person or committee?	□	Yes
□	No	
21	Do all staff have a job description written clearly and legibly, including cleaners?	□	Yes
□	No	
22	Are the staff regularly appraised on their performance?	□	Yes
□	No	
23	Are high performing staff recognized and rewarded, while staff that do not perform well dealt with accordingly?	□	Yes
□	No	
24	Do you communicate with the maintenance staff frequently enough so that you are always aware of important WASH issues at the facility?	□	Yes
□	No	
25	Do new healthcare personnel receive infection prevention and control (IPC) training as part of their orientation program?	□	Yes
□	No	
26	Do new cleaners and maintenance personnel receive infection prevention and control (IPC) training as part of their orientation?	□	Yes
□	No	
27	Are healthcare personnel trained on infection prevention and control (IPC) every year?	□	Yes
□	No	
28	Has any staff been trained on WASH issues in healthcare facilities?	□	Yes
□	No	
29	Have all staff responsible for cleaning received training?	□	Yes, all have been	

	“Staff responsible for cleaning” refers to non-health care providers such as cleaners, orderlies or auxiliary staff, as
well as health care providers who, in addition to their clinical and patient care duties, perform cleaning tasks as part of their role. Training refers to structured training plans or programs led by a trainer or appropriately qualifed supervisor.	trained
□	No, some but not all have been trained
□	No, none have been trained
□	No, there are no staff responsible for cleaning	
28	Have staff responsible for cleaning the delivery room received training in the last 24 months?	□	Yes
□	No	
29	Have all healthcare staff (including cleaners) received training on sorting, storage and elimination of healthcare waste (e.g. used needles, bandages, tubes) in the last 24 months?	□	Yes
□	No	
30	When you bring up issues regarding water access and supply, how often are the maintenance staff able to resolve those issues?	□	All the time
□	Some of the time
□	Rarely
□	Never	
31	When the maintenance staff bring up issues regarding water access and supply, how often are you able to resolve those issues?	□	All the time
□	Some of the time
□	Rarely
□	Never	
32	In the past two years, has anyone tested and/or monitored the water quality within the facility?	□	Yes
□	No	
33	In the last year, have you assigned or contracted someone to complete tasks related to the maintenance and repair of your water source and/or distribution system?	□	Yes
□	No	
34	In the last year, has there been a time when you needed new sinks, taps or pipes but could not buy them?	□	Yes
□	No	
35	If yes, what was the main reason?	□	Insufficient funds
□	No supply chain/part unavailable
□	Other:	
36	Who mainly pays for WASH-related operation and maintenance costs for this healthcare facility?	□	Government (district or national)
□	Non-profit
□	Facility Revenue
□	Other:
□	No budget	
"I am now going to read you a few statements. Please respond with either true or false."	

37	The cleaning staff is an important part of infection prevention and control at the healthcare facility.	□	True
□	False	
38	Making sure that there is sufficient funding for the supplies associated with WASH is my responsibility.	□	True
□	False	
39	I am ultimately responsible for the sustainability of the WASH infrastructure, conditions, and behaviors at this facility.	□	True
□	False	
40	Spending time learning about WASH is a good use of my time as a director/manager.	□	True
□	False	
41	I consider water, sanitation and hygiene within the facility to be a top 10 priority issue.	□	True
□	False	
42	It is my responsibility to ensure that staff at the hospital are educated about IPC and WASH.	□	True
□	False	
43	WASH/IPC training should be mandatory for everyone working in a healthcare facility, including cleaners and cooks.	□	True
□	False	
44	Quality of care for patients includes a clean hospital environment.	□	True
□	False	
45	Overseeing the maintenance of WASH infrastructure, including preventative maintenance and repairs, is my responsibility.	□	True
□	False	

WASHCon: Sanitary Inspection Form

1	Is water available from the main source at the time of the survey?	□	Yes
□	No
□	Didn’t observe	
2	Is an alternative water source available at the time of the survey?	□	Yes and it is improved
□	Yes but it is unimproved
□	Have alternative source but it is unavailable
□	No alternative water source
□	Don’t know	
3	Is there at least one drinking water point available to staff, patients and caregivers on the healthcare facility's premises?	□	Yes
□	No
□	Didn’t observe	
4	Is there at least one drinking water point available to staff, patients and caregivers on the healthcare facility's premises available to people with reduced mobility?	□	Yes
□	No
□	Didn’t observe	
5	Is open defecation practiced at this healthcare facility?	□	Yes
□	No
□	Didn’t observe	
6	Are feces from babies uncontained? (e.g. diapers/nappies on the ground, babies open defecating)	□	Yes
□	No
□	Didn’t observe	
7	Is there uncontained solid waste on facility premises? (e.g. piles of trash)	□	Yes
□	No
□	Didn’t observe	
8	Please describe any other notable conditions of the facility:		

1

1	Is the facility locked from the outside?

This question indicates all toilets on toilet block.

If locked, respond to Q2-6	□	Yes and staff unlocked for observation
□	Yes, but staff did not unlock for observation
□	No
□	Didn’t observe	
2	What areas/wards does this toilet block primarily serve?

Select all services for which this toilet block is considered the primary toilet block.	□	Outpatients
□	Inpatients
□	Labor and Delivery
□	Administrative Services (and other non-patient care services)
□	Other
□	Didn’t observe	
3	Who uses this toilet block?	□	Staff
□	Patients/caregivers
□	Both staff and patients/caregivers
□	Both staff and patients/caregivers, but separated
□	Didn’t observe	
4	What gender has access to this toilet block?	□	Male
□	Female
□	Both male and female (unseparated)
□	Both male and female, but separated
□	Didn’t observe	
5	From what material is the slab made?

If no slab, skip to Q7.	□	Sticks/wood
□	Concrete
□	Plastic
□	No slab
□	Didn’t observe	
6	Are there any cracks in the slab?

If toilets are locked, survey finished.	□	Yes
□	No
□	Didn’t observe	
7	What type of toilet(s) can be found in this block? Select all that apply.	□	Pit latrine without slab
□	Bucket latrine
□	Pit latrine with slab
□	Ventilated Improved Pit (VIP) Latrine
□	Flush
□	Pour-Flush
□	Other improved
□	Other unimproved
□	Didn’t observe	
8	How many usable improved toilets can be found in this toilet block?		
9	How many improved toilets have doors? (a barrier that provides privacy to the user)	□	All
□	Some
□	None
□	Didn’t observe	

10	How many usable improved toilets are available to patients?		
11	How many usable improved toilets are designated for staff?		
12	How many non-usable toilets can be found in this toilet block?		
13	Do the toilet blocks have adequate light, including at night?	□	Yes
□	No
□	No overnight health care service
□	Didn’t observe	
14	How many usable improved toilets have flies?	□	All
□	Some
□	None
□	Didn’t observe	
15	Is there an unpleasant smell (of urine or feces) on the block?	□	Yes
□	No
□	Didn’t observe	
16	Is the toilet block visibly clean, with no feces, blood or bodily substances?	□	Yes
□	No
□	Didn’t observe	
17	Is the toilet pit blocked?	□	Yes
□	No
□	Didn’t observe	
18	Are there major holes in the walls?	□	Yes
□	No
□	Didn’t observe	
19	Observe a functioning hand hygiene facility within 5 meters of this toilet block and select the available hand hygiene materials.

Select one.

If no, skip to Q21	□	Water only
□	Soap only
□	Water and soap
□	No supplies available
□	Didn’t observe	
20	Observe a functional hand hygiene facility accessible to people with reduced
mobility within 5 meters of this toilet block and select the available hand hygiene materials.

Note: A hand hygiene facility is considered accessible people with reduced mobility if it meets the following conditions:
• can  be accessed without stairs or steps
• is not too high to be accessed in a
wheelchair
• easy to turn on or tip container of water	□	Water only
□	Soap only
□	Water and soap
□	No supplies available that could be accessed by people with reduced mobility
□	Didn’t observe	

21	Is there at least one usable improved toilet designated for women and girls, which provides facilities to manage menstrual hygiene needs?

Note: To meet these needs, a female-only toilet must have a bin with a lid on it within the cubicle and water and soap available in a private space for washing.	□	Yes
□	No
□	Didn’t observe	
22	Is there at least one usable improved toilet that meets the needs of people with reduced mobility?

Note: A toilet is considered accessible if it can be accessed without steps or stairs, has handrails for support, has a door that is at least 80cm wide and has a door handle and seat are within reach of people using wheelchairs or crutches/sticks.	□	Yes
□	No
□	Didn’t observe	

1	Which ward are you observing?	□    Labor & Delivery Ward
□    Postnatal Ward
□    Surgery Ward
□    Pediatric Ward
□    Inpatient Ward
□    Outpatient Ward
□    Emergency Ward
□    Kitchen
□    Other:
2	Is water piped into this ward?	□    Yes
□    Yes, but currently unavailable
□    No
□    Didn’t observe

3	What type of water is currently available in this ward?

If no water available, skip to Q9.

4	How is water accessed in the ward?

Check all that apply.

5	Who has access to water in this ward?

Select one.

6	Is water stored in the ward?

If NO, skip to Q9.

7	If yes, how is water stored in the ward?

Check all that apply.

8	For Labor & Delivery only: Is there at least
100L of stored water available?

□    Treated water
□    Untreated water
□    Treated and untreated water
□    No water available
□    Didn’t observe
□    Pipe taps
□    Uncovered buckets/barrels
□    Covered buckets/barrels
□    Uncovered buckets with taps on bottom
□    Covered buckets with taps on bottom
□    Jerrycans
□    Other
□    Didn’t observe
□    Staff
□    Patients/caregivers
□    Both staff and patients/caregivers
□    Neither staff nor patients/caregivers
□    Didn’t observe
□    Yes
□    No water storage for the ward, but storage for whole facility
□    No water storage available at all at this healthcare facility
□    Didn’t observe
□    Storage tank
□    Covered container
□    Uncovered container
□    Jerrycan
□    Other
□    Didn’t observe
□    Yes
□    No
□    Didn’t observe

Commented [1]: Simplify.

Commented [2]: How frequently is the water from the containers refilled?
Commented [3]: How frequently are the containers cleaned?

1

9	Observe a functional hand hygiene facility at the point of care and select the available hand hygiene materials.

Skip to Q11.	□    Water only
□    Soap only
□    Hand sanitizer only
□    Water and soap
□    Soap and sanitizer
□    Water and sanitizer
□    Water, soap and sanitizer
 □     Hand hygiene facility non-functional
□    No supplies available
□    Didn’t observe		
10	Observe a functional hand hygiene facility accessible to patients/caregivers and select the available hand hygiene materials.	□    Water only
□    Soap only
□    Hand sanitizer only
□    Water and soap
□    Soap and sanitizer
□    Water and sanitizer
□    Water, soap and sanitizer
□    No supplies available
□    Didn’t observe		
11	Observe if the following resources/supplies used for infection control are available today in the ward:

Select all that apply.

Note: This question is not applicable to kitchen observation.	□    Disposable latex gloves
□    Environmental disinfectant (chlorine, ethanol, alcohol, etc.)
□    Hand sanitizer
□    Soap/detergent
□    Mop and bucket
□    Broom
□    For L&D only: Clean blade for cord cutting
□    For L&D only: Clean cord for tying
□    For L&D only: Clean towels to wrap baby and mother
□    For L&D only: Clean delivery surface
□    Didn’t observe		
12		Is chlorhexidine available for the		□    Yes
□    No		
		treatment of umbilical cords?				
		□    Didn’t observe		
13	Is waste safely segregated into at least three labeled bins, including sharps waste, infectious waste and non- infectious general waste?

Note: The bins should be clearly labeled, no more than 75% full, and each bin should not contain waste other than that corresponding to their label.	□    Yes
□    Bins are present but do not meet all requirements
□    No
□    Didn’t observe		
14	Are there functional needle cutters/hub cutters available next to the sharps bin?	□    Yes
□    No
□    Didn’t observe		

Commented [4]: Use saline solution (0.9%)

2

15	Is the ward visibly clean and free from dust and soil?	□    Yes
□    No
□    Didn’t observe	
16	Are there uncleaned spills from bodily fluids (blood, urine, feces, vomit, etc.)?	□    Yes
□    No
□    Didn’t observe	
17	Are the floors clean?	□    Yes
□    No
□    Didn’t observe	
18	Are there hand hygiene promotion materials clearly visible and understandable at key places within the ward?	□    Yes
□    No
□    Didn’t observe	
19	Is there a toilet accessible by patients within 30m of this ward?

Note: This question not applicable to kitchen.	□    Yes
□    Toilet available, but nonfunctional
□    No
□    Didn’t observe	
20	Is there a bathing shelter available to patients?	□    Yes
□    Yes, but not hygienic or nonfunctional
□    No
□    Didn’t observe	

3

WASHCon: Water Sample Form

Sample Number:		
1	Sample Location	□	Water Source
□	Antenatal Care
□	Dentistry
□	Emergency Department
□	Environmental Services
□	Eye Clinic
□	HIV/VCT/ARV Clinic
□	Housing for Staff
□	Inpatient
□	Intensive Care Unit
□	Kitchen
□	Labor and Delivery	□	Laboratory
□	Major surgery
□	Morgue
□	Minor surgery
□	Nutrition Services
□	Outpatient
□	Pediatric
□	Pharmacy
□	TB Services
□	Other:
□	Don’t know	
3a	Free Chlorine		Units	□	ppm
□	mg/L	
3b	Total Chlorine				
4	Total Coliform		Units	□	CFU
□	MPN
□	Presence/Absence	
5	E. coli				

1