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Household Template 11 -Form Fill

Identification
Q01

State
Q02

District
Q03

Block
Q04

Village (Hamlet Name)
Q05

Household No
Q06

Name of the household head

Q07

Name of the respondent
Q08

Religion of the respondent
Q09

Caste of the respondent
Household Composition
A01

Respondent ID
A02

Name of respondent
A03

Sex
A04

Age
A05

Highest completed education level

A06

Marital status
A07

Family Details

A08

No. of Males
A09

No. of Females
A10

No. of members attending anganwadi or school or college
A11

No of earning members in the family
A12

Occupation of main earning member
A13

What is the total annual income of the household?
Water Security
B01

Have you conducted any water harvesting/watershed management activities at household level?
B02

Did you or any other member of your household participate in the water harvesting/watershed management activities in your village?
B03

Is there any water management committee in your village?
B04

Is the water management committee functional now?
B05

Which organisation formed this water management committee in your village?
B06

Has anybody from your household participated in the water budgeting for your village?
B07

Is the water budgeting taken up every year in the village?
B08

(If yes) Do you/ Do the farmers usually do the annual planning of crops based on the known water budget?
B09

Do you think that the management of water resources has improved as a result of water budgeting?
B10

Have you ever participated in any water conservation trainings?
B11

On the scale of 1 to 5, how useful was the training? (one being least, 5 being highly useful)
B12

Were water harvesting structures built or renovated in your village since the year___( To be auto-filled)
B13

What type of water sources are available in your village?

B13_1

Farm Pond
B13_2

Earthen Check Dam
B13_3

Concrete Check Dam
B13_4

Well (New/ Renovated)/ Community Well

B13_5

Bori Bund
B13_6

Local Innovative Structure
B13_7

Rooftop Rain Water Harvesting Structure (New/ Renovated)

B13_8

Ferro Cement Water Tank
B13_9

Sump Well
B14

Does your household use these water sources for irrigation?

B14_1

Farm Pond
B14_2

Earthen Check Dam
B14_3

Concrete Check Dam
B14_4

Well (New/ Renovated)/ Community Well

B14_5

Bori Bund
B14_6

Local Innovative Structure
B14_7

Rooftop Rain Water Harvesting Structure (New/ Renovated)

B14_8

Ferro Cement Water Tank
B14_9

Sump Well
B15

Did your household use these water sources for irrigation before (refer the year)?

B15_1

Farm Pond
B15_2

Earthen Check Dam
B15_3

Concrete Check Dam
B15_4

Well (New/ Renovated)/ Community Well

B15_5

Bori Bund
B15_6

Local Innovative Structure
B15_7

Rooftop Rain Water Harvesting Structure (New/ Renovated)

B15_8

Ferro Cement Water Tank
B15_9

Sump Well
B16

Does your household use these water sources for domestic use?

B16_1

Farm Pond
B16_2

Earthen Check Dam
B16_3

Concrete Check Dam
B16_4

Well (New/ Renovated)/ Community Well

B16_5

Bori Bund
B16_6

Local Innovative Structure
B16_7

Rooftop Rain Water Harvesting Structure (New/ Renovated)

B16_8

Ferro Cement Water Tank
B16_9

Sump Well
B17

Did your household use these water sources for domestic use before (refer the year)?

B17_1

Farm Pond
B17_2

Earthen Check Dam
B17_3

Concrete Check Dam
B17_4

Well (New/ Renovated)/ Community Well

B17_5

Bori Bund
B17_6

Local Innovative Structure
B17_7

Rooftop Rain Water Harvesting Structure (New/ Renovated)

B17_8

Ferro Cement Water Tank
B17_9

Sump Well
B18

Has there been an increase, decrease or no change in the availability of water for irrigation in your village since_____ (year to be auto-filled as per the reference year)?
B19

Has there been an increase, decrease or no change in the availability of water for drinking in your village since_____ (year to be auto-filled as per the reference year)?

B20

Has there been an increase, decrease or no change in the availability of water for livestock in your village since _____ (year to be auto-filled as per the reference year)?
B21

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) that brought about this change in water availability. Record 98 (N/A) if organization not working

B21_1

Reliance Foundation
B21_2

State Rural Livelihood Mission (SRLM)
B21_3

Any other Government Agency/Body
B21_4

Other NGO
B21_5

Other Private Organisation

B22

During summer season, what are the sources of drinking water for your household?
B23

How far is the nearest drinking water source from your house during summer season?
B24

How long does it take to go to the water source, get water, and come back during the summer season?

Food and Nutrition Security
C01

Was yesterday a special day (celebration, feast day, or fasting) where anyone in the HH ate special foods or more or less than usual)?
C02

How many meals did the adult members (18+) of your household eat yesterday during the day and night?
C03

How many meals did the children 6 to18 years in this household eat yesterday during the day and night?
C04

Over the last 7 days, how many days did the children of 6 to18 years in this household consume following foods?

C04_1

Maize, maize porridge, Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
C04_2

Beans and peas, groundnuts, pulses and cashew nuts

C04_3

Vegetables (including relish and leaves)
C04_4

Fruits

C04_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
C04_6

Milk/yogurt/other dairy product

C04_7

Sugar or sugar products, honey
C04_8

Oils/fats/butter
C05

Over the last 7 days, how many days did the adult members age 18+ consume following foods?

C05_1

Maize, maize porridge, Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
C05_2

Beans and peas, groundnuts, pulses and cashew nuts

C05_3

Vegetables (including relish and leaves)
C05_4

Fruits

C05_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
C05_6

Milk/yogurt/other dairy product

C05_7

Sugar or sugar products, honey
C05_8

Oils/fats/butter
C05A

In the last 12 months, did your household face food shortage in any month?
C06

In the past 12 months, if there have been times when you did not have enough food or money to buy food, how often has your household had to

C06_1

Rely on less preferred and less expensive foods?
C06_2

Borrow food or rely on help from a friend or relative?
C06_3

Limit portion size at mealtimes
C06_4

Restrict consumption by adults in order for small children to eat
C06_5

Reduce number of meals eaten in a day
C07

Have you or any women, adolescent girls or children less than 5 yrs in your household been screened for detection of anaemia and malnutrition?
C08

When was the screening done last time?
C09

How many times were the female members screened in the last one year?
C10

How many times the children below 5 years were screened in the last one year?
C11

How many women, adolescent girls and children below 5 years from your household were found to be anaemic or malnourished?
C12

Please tell us if anyone from your household participated in the following activities on intake of nutritious food, malnutrition etc.

C13

Do you think that there has been any increase in the awareness level of your household on intake of healthy food and malnutrition?
C14

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

C14_1

Reliance Foundation
C14_2

State Rural Livelihood Mission (SRLM)
C14_3

Any other Government Agency/Body
C14_4

Other NGO
C14_5

Other Private Organisation
C15

Did your household ever have a Kitchen garden/Reliance Nutrition Garden?
C16

Is the Reliance Nutritition Garden/ Kitchen Garden currently functional?
C17

Who supported the creation of Kitchen Garden/Reliance Nutrition Garden?
C18

What percentage of the vegetable consumption requirement of your household is met from the Kitchen Garden /Reliance Nutrition Garden? (approximate)
C19

Has there been any decrease in your household’s expenditure in buying food (vegetables) from the market because of the Kitchen Garden/Reliance Nutrition Garden?
C20

Do you apply organic nutrients like compost, farm-yard manure or vermi-compost in your farmland or Kitchen Garden?
Income Security
D01

What are the sources of livelihood that your household members generate income from?

D01_1

Farming (cultivation of crops or plantations on his own farm/land)
D01_2

Horticulture cultivation (own land)
D01_3

Dairy (Cow/Buffalo rearing)
D01_4

Goat and Sheep Rearing
D01_5

Poultry and duck rearing
D01_6

Fisheries
D01_7

Bee – keeping
D01_8

Lac cultivation
D01_9

Agriculture Labour (engages in agriculture related activities on others’ field)
D01_10

Local Non-agriculture labour (Unskilled)
D01_11

Migration for labour
D01_12

Traditional skill - based occupation
D01_13

NTFP selling: (Mahua seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)
D01_14

Small business activities (street vending, shop keeping, handicrafts, sells liquor)
D01_15

Services/ Salaried person
D02

In which months do you get income from this livelihood activity?

D02_1

Farming (cultivation of crops or plantations on his own farm/land)
D02_2

Horticulture cultivation (own land)
D02_3

Dairy (Cow/Buffalo rearing)
D02_4

Goat and Sheep Rearing
D02_5

Poultry and duck rearing
D02_6

Fisheries
D02_7

Bee – keeping
D02_8

Lac cultivation
D02_9

Agriculture Labour (engages in agriculture related activities on others’ field)
D02_10

Local Non-agriculture labour (Unskilled)
D02_11

Migration for labour
D02_12

Traditional skill - based occupation
D02_13

NTFP selling: (Mahua seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)
D02_14

Small business activities (street vending, shop keeping, handicrafts, sells liquor)
D02_15

Services/ Salaried person
D03

Did your household own any land in the year___

D04

How much land did your household own at that time?
D04A

Unit
D05

How much of this land was appropriate for agriculture?
D05A

Unit
D06

Does your household own any land now?
D07

How much land does your household own now?
D07A

Unit
D08

How much of this land is appropriate for agriculture?
D08A

Unit
D09

Have you also taken any land on lease from others?
D10

How much land have you leased in?
D10A

Unit
D11

Have you mortgaged or leased out your land to someone else?
D12

How much land have you leased/mortgaged out?
D12A

Unit
D13

How much land did you generally cultivate in a season in the year____
D13A

Unit
D14

How much land do you cultivate now?
D14A

Unit
D15

Do you have any source of irrigation for your land/the land that you cultivate?
D16

of the cultivable land, how much is irrigated?
D16A

Unit
D17

What was the land area irrigated in the year____ (Year to be auto-filled as per the reference year)?
D17A

Unit
D18

Is your land bunded and levelled?
D19

How much area is cleared, bunded and levelled?
D19A

Unit
D20

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

D20_1

Reliance Foundation
D20_2

State Rural Livelihood Mission (SRLM)
D20_3

Any other Government Agency/Body
D20_4

Other NGO
D20_5

Other Private Organisation
D21

Crop Code
D22

Cropping season:
D23

How much of the agricultural land was used in the cultivation of this crop?
D23A

Unit
D24

What is the total quantity produced? (Quantity in KG.)
D25

Out of the total quantity produced, how much of the produce was sold?
D26

What was the average market rate you got for this crop? (price per kg)
D27

Where do you normally sell the crop?

D28

Income from the sale of crops
D29

Crop Code
D30

Cropping season
D31

How much of the agricultural land was used in the cultivation of this crop in the year___

D31A

Unit
D32

What was the total quantity produced in the year___
D33

Out of the total quantity produced, how much of the produce was sold in the year__ (Year to be Auto-filled)?
D34

What was the average market rate you got for this crop in the year__
D35

Where did you sell the crop in the year__
D36

Income from the sale of crops
D37

How much did you spend on the following items in the last 12 months?

D37_1

Seeds
D37_2

Organic Fertilizers (Compost, Vermicompost)
D37_3

Inorganic Fertilizers like Urea, DAP, MOP, etc
D37_4

Irrigation
D37_5

Pesticides

D37_6

Labour for tillage

D37_7

Labour for sowing

D37_8

Labour for irrigation

D37_9

Labour for harvesting

D37_10

Tools & Implements

D38

In your opinion, since the year_____ (Auto filled according to the start year of BIJ programme in the area), has the cost of production per land unit increased, decreased or did not change?
D39

How many livestocks does your family own?

D40

Currently

D40_1

Cow
D40_2

Buffalo

D40_3

Bullocks

D40_4

Goat

D40_5

Poultry

D40_6

Fish

D40_7

Sheep

D41

In the year

D41_1

Cow
D41_2

Buffalo

D41_3

Bullocks

D41_4

Goat

D41_5

Poultry

D41_6

Fish

D41_7

Sheep

D42

Did you buy or sell any of your livestocks?

D42A

In past 12 months
D42B

In the year
D43

What was the net income from the purchase or sale of these livestocks?

D43A

In past 12 months
D43B

In the year
D44

Did your livestock produce any _____ Iin past 12 months

D44_1

Milk (including that produced for milk products (In litres)
D44_2

Eggs (Number)
D44_3

Poultry meat/offal (in Kg.)
D44_4

Animal meat/offal (in Kg.)
D45

Did your livestock produce any ____ in the year___

D45_1

Milk (including that produced for milk products (In litres)
D45_2

Eggs (Number)
D45_3

Poultry meat/offal (in Kg.)
D45_4

Animal meat/offal (in Kg.)
D46

Did you sell any of these animal products?

D46A

In past 12 months
D46B

In the year
D47

What was the income you had from the sale of animal products in the past 12 months?

D47A

In past 12 months
D47B

In the year
D48

Which of the following NTFP you collected in the last 12 months?

D48_1

Mahua Flowers
D48_2

Mahua Fruit
D48_3

Mahua seeds

D48_4

Kossum fruit

D48_5

Kossum seeds
D48_6

Karanj fruit
D48_7

Chiraunjee
D48_8

Lac

D48_9

Honey

D48_10

Aonla
D48_11

Ber

D48_12

Tendu leaves

D48_13

Harra

D48_14

Baher

D48_15

Medicinal plants

D48_16

Gum collection
D49

Of these, which are the NTFPs you sold? (Yes / No)

D49_1

Mahua Flowers
D49_2

Mahua Fruit
D49_3

Mahua seeds

D49_4

Kossum fruit

D49_5

Kossum seeds
D49_6

Karanj fruit
D49_7

Chiraunjee
D49_8

Lac

D49_9

Honey

D49_10

Aonla
D49_11

Ber

D49_12

Tendu leaves

D49_13

Harra

D49_14

Baher

D49_15

Medicinal plants

D49_16

Gum collection
D50

What was the income from the sale of NTFPs in the last 12 months? (in Rs.)

D50_1

Mahua Flowers
D50_2

Mahua Fruit
D50_3

Mahua seeds

D50_4

Kossum fruit

D50_5

Kossum seeds
D50_6

Karanj fruit
D50_7

Chiraunjee
D50_8

Lac

D50_9

Honey

D50_10

Aonla
D50_11

Ber

D50_12

Tendu leaves

D50_13

Harra

D50_14

Baher

D50_15

Medicinal plants

D50_16

Gum collection
D51

In the year____ (To be auto-filled as per the reference year), Which are the NTFP you used to collect?

D51_1

Mahua Flowers
D51_2

Mahua Fruit
D51_3

Mahua seeds

D51_4

Kossum fruit

D51_5

Kossum seeds

D51_6

Karanj fruit
D51_7

Chiraunjee

D51_8

Lac

D51_9

Honey

D51_10

Aonla

D51_11

Ber

D51_12

Tendu leaves

D51_13

Harra

D51_14

Baher

D51_15

Medicinal plants

D51_16

Gum collection
D52

Of these, which are the NTFPs you used to sell?

D52_1

Mahua Flowers
D52_2

Mahua Fruit
D52_3

Mahua seeds

D52_4

Kossum fruit

D52_5

Kossum seeds

D52_6

Karanj fruit
D52_7

Chiraunjee

D52_8

Lac

D52_9

Honey

D52_10

Aonla

D52_11

Ber

D52_12

Tendu leaves

D52_13

Harra

D52_14

Baher

D52_15

Medicinal plants

D52_16

Gum collection
D53

In the year____ (To be auto-filled as per the reference year), what was the approximate yearly income from the sale of NTFPs? (inRs.)

D53_1

Mahua Flowers
D53_2

Mahua Fruit
D53_3

Mahua seeds

D53_4

Kossum fruit

D53_5

Kossum seeds

D53_6

Karanj fruit
D53_7

Chiraunjee

D53_8

Lac

D53_9

Honey

D53_10

Aonla

D53_11

Ber

D53_12

Tendu leaves

D53_13

Harra

D53_14

Baher

D53_15

Medicinal plants

D53_16

Gum collection
D54

Current Annual Income (2017-2018)

D54_1

Agricultural Labour
D54_2

Agricultural Labour (Working outside the village)
D54_3

Non- Agricultural Labour (working in same village)
D54_4

Non- Agricultural Labour (working outside the village)
D54_5

Remittance from Migrated Person (members who stay and work outside village or country and send money)
D54_6

Salaried employees
D54_7

Micro-enterprise/business
D54_8

Pension
D55

Earlier Annual Income in the year_____

D55_1

Agricultural Labour
D55_2

Agricultural Labour (Working outside the village)
D55_3

Non- Agricultural Labour (working in same village)
D55_4

Non- Agricultural Labour (working outside the village)
D55_5

Remittance from Migrated Person (members who stay and work outside village or country and send money)
D55_6

Salaried employees
D55_7

Micro-enterprise/business
D55_8

Pension
D56

In your opinion, has your household income increased, decreased or did not change since the year____ (year to be auto-filled as per the reference year)?
D57

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

D57_1

Reliance Foundation
D57_2

State Rural Livelihood Mission (SRLM)

D57_3

Any other Government Agency/Body
D57_4

Other NGO
D57_5

Other Private Organisation
D58

Do you avail credit?
D59

What all sources of credit are available to you?
D60

Where have you availed credit from in the past three years?

D61

What is the loan outstanding as on date?
D62

What is the interest rate on the loan?
D63

Have you settled any loan in the last three years?
D64

How much loan amount was settled? (in Rs.)
Institution Building
E01

Which of the following institutions / associations of your village are you or your family members enrolled in?
E02

Who facilitated the formation of this Farmer Association?
E03

For how long have you/your family member been a member of this Village Farmer Association/ Farmer Association?
E04

Which of the following activities of Village Farmer Association / Farmer Association you have attended so far?

E05

How often do you participate in the VFA/ Farmer Association meetings?
E06

Do you voice your opinions in the meetings of the VFA/ Farmer Associations?
E07

Are there any actions taken on your opinion you raised during meetings?
E08

Have you ever contributed to the development of village in either cash or kind?

E09

In the last two years, how much have you contributed in cash? (in rupees)
E10

In the last two years, what are your contribution in kind? (multiple response possible)
E11

In your opinion, what would be the monetary value of your contribution in kind? (in rupees)
E12

In the last two years, how many times you have contributed either in cash or kind for your village development?

E13

Have you contributed your labour by means of Shramdaan for your village development?

E14

Approximately how many days have you contributed by means of Shramdaan? (in days)
E15

Who facilitated the formation of this Producer Company?
E16

For how long have you or your family members been a member/employee of this Producer Company?

E17

How often do you attend the meetings of the producer company?
E18

Do you voice your opinions in the meetings of the producer company?
E19

Are your opinions deliberated and discussed in the meetings of the producer company?
E20

What are the benefits of a Producer Company?
E21

Do you know how is the distribution of profit done in the producer company?
E22

What are the top three crops that you sell through the Producer Company?
E23

What is the quantity sold in the last one year through the Producer Company? (in KG)
E24

What is the selling price per KG in the Producer Company? (in rupees)
E25

What was the market price prevailing at that time? (in rupees)
E25A

Income from sale of crops through PC
E26

What are the top three agricultural inputs that you purchased through the Producer Company?

E26_1

Input 1
E26_2

Input 2
E26_3

Input 3
E27

What is the purchase price in the Producer Company? (in rupees)

E27_1

Input 1
E27_2

Input 2
E27_3

Input 3
E28

What was the market price prevailing at that time? (in rupees)

E28_1

Input 1
E28_2

Input 2
E28_3

Input 3
E29

Please name the various types of physical infrastructure added to your village over the last five years?
E30

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

E30_1

Reliance Foundation
E30_2

State Rural Livelihood Mission (SRLM)
E30_3

Any other Government Agency/Body
E30_4

Other NGO
E30_5

Other Private Organisation
Ecological Security
F01

Have you or any other member of your household ever participated in any soil conservation workshop/training?
F02

Have you ever got soil testing done for your farm land?
F03

How many times you have got soil testing done so far?
F04

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

F04_1

Reliance Foundation
F04_2

State Rural Livelihood Mission (SRLM)
F04_3

Any other Government Agency/Body
F04_4

Other NGO
F04_5

Other Private Organisation
F05

Did you or any other member of your household plant any saplings in your village after the year____ (To be auto-filled as per the reference year)?

F06

If Yes, how many saplings did you or any other member of your household plant in the past 12 months?
F07

Do the members of your household take care of the planted saplings?
F08

Out of the total saplings planted by you or any other member of your household how many have survived?
F09

In your opinion, to what extent the green cover has changed in your village after (refer the year)?

F10

Are biodiversity registers being maintained in your village?
F11

Do you or anyone from your household participate in managing these registers?
F12

Has Biodiversity mapping taken place in your village?
F13

Has any Bio-diversity Protection group been formed in your village?
F14

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

F14_1

Reliance Foundation
F14_2

State Rural Livelihood Mission (SRLM)
F14_3

Any other Government Agency/Body
F14_4

Other NGO
F14_5

Other Private Organisation
Trainings
G01

Have you or anyone else from your household ever received any training on agriculture, horticulture, preparation of Reliance Nutrition Gardens, poultry or livestock, watershed, lac cultivation, fisheries, bee-keeping, financial literacy related work?
G02

Did you or anyone else from your household receive training on_________ since 2011?

G02_1

Sustainable agricultural practices
G02_2

Preparation and production of biopesticide/compost/ vermicompost
G02_3

Alternate livelihoods
G02_4

RNG/Kitchen Gardens, cultivation of vegetables and fruits etc.
G02_5

Construction and renovation of watershed structures
G02_6

Financial Literacy
G02_7

Health and Nutrition
G02_8

Marketing of Produce
G02_9

Soil Testing
G03

Did you or members of your household know about these practices before the organisation gave the training?

G03_1

Sustainable agricultural practices
G03_2

Preparation and production of biopesticide/compost/ vermicompost
G03_3

Alternate livelihoods
G03_4

RNG/Kitchen Gardens, cultivation of vegetables and fruits etc.
G03_5

Construction and renovation of watershed structures
G03_6

Financial Literacy
G03_7

Health and Nutrition
G03_8

Marketing of Produce
G03_9

Soil Testing
G04

Did you or other members of your household found this training useful and adopted it in your livelihood activities?

G04_1

Sustainable agricultural practices
G04_2

Preparation and production of biopesticide/compost/ vermicompost
G04_3

Alternate livelihoods
G04_4

RNG/Kitchen Gardens, cultivation of vegetables and fruits etc.
G04_5

Construction and renovation of watershed structures
G04_6

Financial Literacy
G04_7

Health and Nutrition
G04_8

Marketing of Produce
G04_9

Soil Testing
G05

Can you or members of your household practice this activity independently after the training?

G05_1

Sustainable agricultural practices
G05_2

Preparation and production of biopesticide/compost/ vermicompost
G05_3

Alternate livelihoods
G05_4

RNG/Kitchen Gardens, cultivation of vegetables and fruits etc.
G05_5

Construction and renovation of watershed structures
G05_6

Financial Literacy
G05_7

Health and Nutrition
G05_8

Marketing of Produce
G05_9

Soil Testing
G06

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

G06_1

Reliance Foundation
G06_2

State Rural Livelihood Mission (SRLM)
G06_3

Any other Government Agency/Body
G06_4

Other NGO
G06_5

Other Private Organisation
G07

Does your household have access to the following for cultivation on your farmland?

G07_1

Agricultural implements and tools
G07_2

Farm yard manure (FYM)
G07_3

Compost

G07_4

Nadep

G07_5

Vermicompost

G07_6

Oil cakes as manure

G07_7

Chemical fertilizers

G07_8

Soil enhancer like ------, azola etc
G07_9

Pond silt

G07_10

Insecticides

G07_11

Biopesticides

G07_12

Fungicides

G07_13

Fencing on your farmland
G08

Has there been an increase, decrease or no change in access to these inputs since the year___ (year to be autofilled as per the reference year)?
G09

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

G09_1

Reliance Foundation
G09_2

State Rural Livelihood Mission (SRLM)
G09_3

Any other Government Agency/Body
G09_4

Other NGO
G09_5

Other Private Organisation
Household Characteristics
H01

Does your household own this house or any other house?
H02

Did you buy/renovate this house after the year___ (year to be auto-filled as per the reference year)?

H03

LOOK AT THE FLOOR AND CODE THE MAIN MATERIAL OF THE FLOOR
H04

LOOK AT THE ROOF AND CODE THE MAIN MATERIAL OF THE ROOF
H05

LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS
H06

How many rooms in this house are used for sleeping?
H07

Do you have a separate room for cooking?
H08

What type of toilet facility do you have?
H09

Who motivated you in constructing toilets?
H10

Who funded the construction of toilets?
H11

What is the main source of lighting
H12

What type of fuel does your household mainly use for cooking?
H13

Does your household own any of the following items:

H13_1

Mattress
H13_2

Pressure cooker

H13_3

Chair

H13_4

Cot/ Bed

H13_5

Table

H13_6

Electric fan

H13_7

Almirah

H13_8

Radio/Transistor

H13_9

Sewing machine

H13_10

Clock or watch

H13_11

Bicycle

H13_12

Animal-drawn cart/Bullock Cart

H13_13

Black & White television
H13_14

Colour television
H13_15

Mobile Phone
H13_16

Landline Phone
H13_17

Water pump

H13_18

Thresher

H13_19

Power Tiller

H13_20

Spray Machine/Sprayer

H13_21

Refrigerator

H13_22

Air conditioner / Cooler

H13_23

Washing Machine

H13_24

Internet

H13_25

Computer

H13_26

Motorcycle/scooter
H13_27

Car/Jeep
H13_28

Tractor
H14

What is your overall opinion about Reliance Foundation?

H15

Why do you say so?
Questions to be asked to the woman of the household
I01

Name of respondent
I02

Age
I03

Highest completed education level
I04

Marital status

I05

Main Occupation
I06

For how long have you been a member of this WTG/SHG?
I07

What all activities are undertaken by these WTG’s/SHG’s?
I08

How many metings have you attended so far?
I09

Do you voice your opinions in the meetings of the WTG/SHG?
I10

Are your opinions deliberated and discussed in the meetings of the WTG/SHG?
I11

What is the total amount saved by you in the WTG or SHG?
I12

Have you taken any loan from your WTG or SHG?
I13

What issues do you discuss in the WTG/SHG meetings?
I14

Do you have a bank account?
I15

Was this bank account opened under the “Jan Dhan Yojana”?
I16

Who facilitated opening this account?
I17

What do you use your bank account for?
I18

Who operates your bank account?
I19

Did you make any transaction from your bank account in the past three months? (depositing money or withdrawing money)
I20

What are the reasons for not having a bank account?
I21

How do you go to banks, markets, health centres or places outside the village?
I22

Can you travel on your own to these places?

I22_1

To the market?
I22_2

To a friend or family member’s house less than one hour away?
I22_3

To the temple, church or mosque?

I22_4

To a public village meeting?
I22_5

To a meeting of any association of which you are a member including a Women Thrift Group/ Self-Help Group?
I22_6

Outside your village?
I22_7

To see a health care provider?
I23

Has there been an increase in awareness about banking/ saving habit/ insurance in the past five years?
I24

Rate the organisations on a scale of 1 to 5(where 1 being the lowest and 5 being the highest) for this development. Record 98 (N/A) if organization not working

I24_1

Reliance Foundation
I24_2

State Rural Livelihood Mission (SRLM)
I24_3

Any other Government Agency/Body
I24_4

Other NGO
I24_5

Other Private Organisation
I25

Have you participated in gram sabha meeting since the year___ (year to be autofilled as per the reference year)?
I26

How many meetings have you participated since the year___ (year to be auto-filled as per the reference year)?
I27

What were the reasons for attending the Gram sabha meetings?
I28

Have you ever raised any concern or given your opinion in any gram sabha meeting in these years?
I29

Has ever your concern or suggestion resulted in resolution being adopted at gram sabha?
I30

What was the reason for not attending last gram sabha meeting?