Guyana Water Incorporated Household Sanitation Program 2025 Application form

I understand this survey will involve answering questions about my demographics, beliefs, and preferences. I am at least 18 years or older. I understand that all identifying data will be kept confidential and use to improve sanitation systems Guyana. I am free to withdraw at any time without giving a reason.

I confirm I have read and understand the above conditions and consent to participate. *

Yes

APPLICATION FORM

Please fill in the details below:

Personal Information:

1. Owner's Name: *

2. Owner’s Number: *

3. Your Full Name if not same as above:

4. Your Number if not stated above:

6. Address: *

7. Village Name: *

8. Region: *

9. Marital Status: *

Single

Married

Divorced

Widowed

10. Type of Family: *

Extended Family

Single Parent

Nuclear Family

11. Number of children in Household: *

Employment Information:

12. Are you employed? *

Yes

13. if yes, are employed in any of the following?

Public

Private

Self-employed

Household Information:

14. Are you 70 years old or above, or is there an elderly person a part of your household?

Yes

15. Are you disabled or have a disabled person living with you?

Yes

16. Are you the owner of the property?

Yes

17. Are you a tenant of the property?

Yes

18. Do you have a valid tenancy agreement?

Yes

19. If yes, to the question 16 or 17 please provide proof of ownership or tenancy agreement.

Files must be less than 2 MB.
Allowed file types: jpg jpeg png pdf.

20. Are there multiple (one or more) employed persons living in the household?

Yes

21. If yes, what is the monthly total income?

Waste Disposal and Utilities Information:

22. What method do you use to dispose of your fecal waste?

23. If the disposal method is through a pit latrine or open defecation?, Please state why you are still using this method of waste disposal:

24. Do you have a GWI water connection?

Yes

25. If yes, kindly provide your account number:

Toilet and Septic System:

26. Are you willing to demolish your pit latrine?

Yes

27. Do you have an available space in your house for the installation of a toilet system which include toilet bowl, cistern and hand washing sink?

Yes

Signature of Staff:

Date:

Month

Day

Year

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Guyana Water Incorporated Household Sanitation Program 2025 Application form