OVC Squared INC. Beneficiary Screening Baseline Survey.

OVC Squared Inc. is a non profit organization dealing with orphans and vulnerable children in the horn of Africa. Instructions: Kindly fill in all the information required on the form

Key in Your Bio Data Full Name:* Email: Age:

Gender: Male Female N/A

Year of Birth:

Enter your HouseHold Details Are you the Head of your household? Yes No
How many children under 5?
Male Female

How many children are Over 5years?
Male Female

Enter your Geographical Location for Intervention You can only choose one Constituency under Homa Bay County

Kindly pick below your nearest collection point

Kasipul Kabondo East Kamagak Kakelo Kasewe Kodera Kokech Ramba

Additional Information Intervention Required: Dry Food Vegetables Farm Inputs Fertilizers Cash Voucher

I hereby confirm that the information provided in this survey is true and complete and shall be helpful in the shortlisting of beneficiaries of the program. I am aware that any false information or fraudulent information shall automatically lead to my disqualification.
Agree Disagree