Preparation of Rights-Based Municipal Water Supply, Sewerage and Sanitation Sector Plans (MW4SPs) Page 1 of 1

Data Form: Level 1 Water Source Individual Household Facility

Region/Province: ________________________
Municipality: ___________________________
Data on Existing Level 1 Water Source Individual Household Facility (For Drinking and Cooking Purposes)
Instructions: This form is intended for existing Level 1 Water Source Individual Household (Private) Facility present within the municipality.
Use this form to list all Level 1 Water Source Individual Household (Private) Facility per Barangay

Name of Interviewer: ____________________________ Date of Interview : _____________________

Department/Office: ___________________________ Data Source/s : _____________________

Number of Household with Number of Unsafe

Number of Household with Safe Water Sources No. of HH
Water Sources
Registered Remarks
Barangay Covered/ Open Undeve- Rain
Deep Shallow Developed Shallow with
Improved Total Dug loped Water Total
Well Well Spring Well NWRB
Dug Well Well Spring Collector

Use additional Forms when necessary

Safe water sources conforms with the Philippines National Standard for Drinking Water (PNSDW).