MSUF Community Assessment Questionnaire

Mission Save Uganda Foundation

Serere District, Uganda — Kamodo Village

1. Family Information

Head of Household Name:

Village:

Phone:

No. of Children:

No. of Dependents:

Household Type:

Single Mother Widow Elderly Caregiver Other:

2. Current Livelihood

Primary Income Source:

Estimated Daily Income:

Less than $1 $1–2 $2–5 More than $5

Own Land?

Yes No

Own Livestock?

Yes No

If yes, what kind:

3. Education

School-age Children:

Currently Attending:

Distance to Nearest School:

Main Barrier to Education:

Fees Distance Child Labor Other:

4. Health & Water

Distance to Nearest Water Source:

Is Water Source Clean?

Yes No

Access to Healthcare?

Yes No

Family Members with Chronic Illness:

5. Needs Assessment

Rank the family's greatest needs (1 = most urgent, 5 = least urgent):

Skills of Head of Household:

Willing to Participate in 6-Month Program?

Yes No

6. Field Worker Notes

Assessor Name:

Date:

Recommendation:

Immediate Support Priority Standard Refer to Partner Org

7. Vulnerability Scoring Rubric

Income below $1/day	3 pts
Single mother / widow / elderly caregiver	3 pts
No livestock	2 pts
Children not in school	2 pts
No clean water access	2 pts

TOTAL SCORE: _______ / 12

8–12 = Immediate Support | 5–7 = Priority | Below 5 = Standard