Preparation of Rights-Based Municipal Water Supply, Sewerage and Sanitation Sector Plans (MW4SPs) Page 1 of 2

Data Form: Level 1 Water Source Public Facility

Region/Province: ________________________ Municipality: ___________________________

Data on Existing Level 1 Water Source Public Facility (For Drinking and Cooking Purposes)
Instructions: This form is intended for existing Level 1 Water Source Public Facility present within the municipality.
Use this form to list all Level 1 Water Source Public Facility per Barangay

Name of Interviewer: ____________________________ Date of Interview : ____________________________

Department/Office: ___________________________ Data Source/s : ____________________________

1. Information on Level 1 Water Source

Number of Safe Water Sources Number of Unsafe Water Sources No. of No. of
No. of No. of
Sources Sources
Rain Sources Sources
Covered/ Deve- Open Undeve- regularly with
Barangay Deep Shallow Shallow Water with with
Improved loped Total Dug loped Total tested for water
Well Well Well Col- water Water
Dug Well Spring Well Spring water quality
lector treatment Permit
quality problems

Note: Use additional Forms when necessary;

 Data Source: From RHU, MHO and etc.

2. Information on Household Access to Level 1 Public Facility

Safe water sources conforms with the Philippines National Standard for Drinking Water (PNSDW).
Preparation of Rights-Based Municipal Water Supply, Sewerage and Sanitation Sector Plans (MW4SPs) Page 2 of 2
Data Form: Level 1 Water Source Public Facility
Region/Province: ________________________ Municipality: ___________________________

Service Accessibility Fetching Distance Fetching Time No. of REMARKS

Total No. Household (Indicate when applicable: common type of water treatment,
Barangay Total No. No. of No. of No. of No. of with access
of Served water quality tests conducted and its frequency, and water
of House- HH HH HH HH to water 24
House- <250m >250m <30min >30min quality problems at source), use additional sheets when
hold hours/day
hold necessary.

Use additional Forms when necessary

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