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Household Template 5 -Form Fill
Information
Q01
state name
Q02
state code
Q03
district name
Q04
district code
Q05
sub district name
Q06
sub district code
Q07
PSU name
Q08
PSU code
Q09
structure number
Q10
household number
Q11
Name of the head of the household
Q12
Address
Q13
Phone Number
SURVEY INFORMATION
A01
Respondent Name
A02
Code
A03
Interviewer Name
A04
Code
A05
Date
A06
Result of interview
Agreed
Refused
Household locked
Household not found/located
Incomplete
A07
Verification
A08
Supervisor Name
A09
Code
A10
Signature
A11
Date
A12
Remarks of Supervisor/ Enumerator /Data Operator
A13
GPS Coordinates
HOUSEHOLD ROSTER
B01
Name of the household member
B02
What is the relationship of (name) to the head of the household?
Head
Wife/Husband
Son/Daughter
Son-in-law/Daughter-in-law
Grandchild
Parent
Parent-in-law
Brother/Sister
Brother-in-law/Sister-in-law
Niece/Nephew
Other relative
Adopted/Foster/Step-child
Domestic servant
Other not related
Don’t know
B03
Is the member a usual resident of the household?
usual resident
temporary guest
B04
Is (name) male or female?
male
female
B05
How old is (name)?
B06
Mother ID
B07
What is the current marital status of (name)?
Currently married
Married, but Gauna not performed
Widowed
Divorced
Separated
Deserted
Never married
Don’t know
B08
Can (name) read or write?
Can read only
Can read and write
Can neither read nor write
Don’t know
B09
Has (name) ever attended school?
Yes
No
B10
What is the highest standard (name) has completed?
Less than one year completed
Don’t know
B11
Employment
HOUSEWIFE
AGRICULTURAL LABOURER
OTHER LABOURER
FARMER
ARTISAN
PETTY TRADER/SHOP
BUSINESS/ INDUSTRIALIST
UNSKILLED WORKER
SKILLED WORKER
SELF-EMPLOYED
GOVERNMENT EMPLOYEE
PRIVATE EMPLOYEE
NOT WORKING
STUDENT
OTHERS
Don’t know
B12
Index Child
HOUSEHOLD INFORMATION
C01
What is the main source of drinking water for members of your household?
PIPED INTO DWELLING
PIPED INTO YARD/PLOT
PUBLIC TAPS/STANDPIPE
TUBE WELL OR BOREHOLE
PROTECTED WELL
UNPROTECTED WELL
PROTECTED SPRING
UNPROTECTED SPRING
RAINWATER
TANKER TRUCK
CART WITH SMALL TANK
SURFACE WATER
BOTTLED WATER
OTHERS (SPECIFY)
C02
What is the main source of water used by your household for other purposes such as cooking or hand washing?
PIPED INTO DWELLING
PIPED INTO YARD/PLOT
PUBLIC TAPS/STANDPIPE
TUBE WELL OR BOREHOLE
PROTECTED WELL
UNPROTECTED WELL
PROTECTED SPRING
UNPROTECTED SPRING
RAINWATER
TANKER TRUCK
CART WITH SMALL TANK
SURFACE WATER
BOTTLED WATER
OTHERS (SPECIFY)
C03
Where is the water source located?
IN OWN DWELLING
IN OWN YARD/PLOT
ELSEWHERE
C04
Do you treat your water in any way to make it safer to drink?
YES
NO
DON’T KNOW
C05
What do you usually do to the water to make it safer to drink?
BOIL
USE ALUM
ADD BLEACH/CHLORINE TABLETS
STRAIN THROUGH A CLOTH
USE WATER FILTER
USE ELECTRONIC PURIFIER
LET IT STAND AND SETTLE
OTHERS (SPECIFY)
DON’T KNOW
C06
What kind of toilet facility do members of your household usually use?
FLUSH TO PIPED SEWER SYSTEM
FLUSH TO SEPTIC TANK
FLUSH TO PIT LATRINE
FLUSH TO SOMEWHERE ELSE
FLUSH, DON’T KNOW WHERE
VENTILATED IMPROVED PIT (VIP)/BIOGAS LATRINE
PIT LATRINE WITH SLAB
PIT LATRINE WITHOUT SLAB/OPEN PIT
TWIN PIT/COMPOSTING TOILET
DRY TOILET
NO FACILITY/USES OPEN SPACE OR FIELD
OTHERS (SPECIFY)
C07
Do you share this toilet facility with other households?
Yes
No
C08
How many households use this toilet facility?
LESS THAN 10
10 OR MORE HOUSEHOLDS
DON’T KNOW
C09
When members of household get sick, where do they generally go for treatment?
GOVERNMENT/MUNICIPAL HOSPITAL
GOVERNMENT DISPENSARY
CHC/RURAL HOSPITAL/PHC
SUB-CENTRE
ANGANWADI/ICDS CENTRE
GOVERNMENT MOBILE CLINIC
OTHER PUBLIC SECTOR HEALTH FACILITY
NGO OR TRUST HOSPITAL/CLINIC
PVT. HOSPITAL
PVT. DOCTOR/CLINIC
PARAMEDIC
VAIDYA/HAKIM/HOMEOPATH
TRADITIONAL HEALER
PHARMACY/DRUGSTORE
DAI (TBA)
OTHER PRIVATE SECTOR HEALTH FACILITY
SHOP
HOME TREATMENT
OTHER (SPECIFY)
C10
Why don’t members of your household generally go to a government facility when they are sick?
NO NEARBY FACILITY
FACILITY TIMING NOT CONVENIENT
HEALTH PERSONNEL OFTEN ABSENT
WAITING TIME TOO LONG
POOR QUALITY OF CARE
OTHERS (SPECIFY)
C11
What is the religion of the head of the household?
HINDU
MUSLIM
CHRISTIAN
SIKH
BUDDHIST/NEO-BUDDHIST
JAIN
JEWISH
PARSI/ZOROASTRIAN
NO RELIGION
OTHERS (SPECIFY)
C12
What is the caste or tribe of the head of the household?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CLASS
GENERAL
DON’T KNOW
C13
Specify the name of your caste or tribe?
C14
Does your household have:
YES
NO
C14_1
ELECTRICITY
YES
NO
C14_2
MATTRESS
YES
NO
C14_3
PRESSURE COOKER
YES
NO
C14_4
CHAIR
YES
NO
C14_5
COT/BED
YES
NO
C14_6
TABLE
YES
NO
C14_7
ELECTRIC FAN
YES
NO
C14_8
RADIO/TRANSISTOR
YES
NO
C14_9
B&W TELEVISION
YES
NO
C14_10
COLOUR TELEVISION
YES
NO
C14_11
SEWING MACHINE
YES
NO
C14_12
MOBILE TELEPHONE
YES
NO
C14_13
ANY OTHER TELEPHONE
YES
NO
C14_14
COMPUTER
YES
NO
C14_15
REFRIGERATOR
YES
NO
C14_16
WATCH/CLOCK
YES
NO
C14_17
BICYCLE
YES
NO
C14_18
MOTORCYCLE/SCOOTER
YES
NO
C14_19
ANIMAL-DRAWN CART
YES
NO
C14_20
CAR
YES
NO
C14_21
WATER PUMP
YES
NO
C14_22
THRESHER
YES
NO
C14_23
TRACTOR
YES
NO
C15
What type of fuel does your household mainly use for cooking?
ELECTRICITY
LPG/NATURAL GAS
BIOGAS
KEROSENE
COAL/LIGNITE
CHARCOAL
WOOD
STRAW/SHRUBS/GRASS
AGRICULTURAL CROP WASTE
DUNG CAKES
OTHER (SPECIFY)
C16
Do you have a separate room which is used as a kitchen?
YES
NO
C17
Main material of the floor
MUD/CLAY/EARTH
SAND
DUNG
RAW WOOD PLANKS
PALM/BAMBOO
BRICK
STONE
PARQUET OR POLISHED WOOD
VINYL OR ASPHALT
CERAMIC TILES
CEMENT
CARPET
POLISHED STONE/MARBLE/GRANITE
OTHER (SPECIFY)
C18
Main material of the roof.
NO ROOF
THATCH/PALM LEAF/REED/GRASS
MUD
SOD/MUD AND GRASS MIXTURE
PLASTIC/POLYTHENE SHEETING
RUSTIC MAT
PALM/BAMBOO
RAW WOOD PLANKS/TIMBER
UN-BURNT BRICK
LOOSELY PACKED STONE
METAL/GI
WOOD
CALAMINE/CEMENT FIBRE
ASBESTOS SHEETS
RCC/RBC/CEMENT/CONCRETE
ROOFING SHINGLES
TILES
SLATE
BURNT BRICK
OTHER (SPECIFY)
C19
Main material of the exterior walls.
NO WALLS
CANE/PALM/TRUNKS/BAMBOO
MUD
GRASS/REEDS/THATCH
BAMBOO WITH MUD
STONE WITH MUD
PLYWOOD
CARDBOARD
UN-BURNT BRICK
RAW WOOD/REUSED WOOD
CEMENT/CONCRETE
STONE WITH LIME/CEMENT
BURNT BRICKS
CEMENT BLOCKS
WOOD PLANKS/SHINGLES
GI/METAL/ASBESTOS SHEETS
OTHER (SPECIFY)
C20
Type of windows.
YES
NO
C20_1
ANY WINDOWS
YES
NO
C20_2
WINDOWS WITH GLASS
YES
NO
C20_3
WINDOWS WITH SCREENS
YES
NO
C20_4
WINDOWS WITH CURTAINS AND SHUTTERS
YES
NO
C21
How many rooms in the household are used for sleeping?
C22
Does the household own this house or any other house?
YES
NO
C23
Does this household own any agricultural land?
YES
NO
C24
How much agricultural land does this household own?
ACRE
HECTARE
BIGHA
BISWAH
KATHA
C25
Out of this land, how much is irrigated?
ACRE
HECTARE
BIGHA
BISWAH
KATHA
NONE
C26
Does your household own any of the following animals?
YES
NO
C26_1
COWS/BULLS/BUFFALOES
YES
NO
C26_2
CAMELS
YES
NO
C26_3
HORSES/DONKEYS/MULES
YES
NO
C26_4
GOATS
YES
NO
C26_5
SHEEP
YES
NO
C26_6
CHICKEN/DUCKS
YES
NO
C27
Does any usual member of this household have a bank account or a post office account?
YES, BANK ACCOUNT
YES, POST OFFICE ACCOUNT
YES, BOTH
NO
DON’T KNOW
C28
Is any household member covered by a health scheme or health insurance?
YES
NO
DON’T KNOW
C29
What type of health scheme or health insurance?
EMPLOYEE STATE INSURANCE SCHEME (ESIS)
CENTRAL GOVERNMENT HEALTH SCHEME (CGHS)
COMMUNITY HEALTH INSURANCE PROGRAMME
OTHER HEALTH INSURANCE THROUGH EMPLOYER
MEDICAL REIMBURSEMENT FROM EMPLOYER
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE
OTHER (SPECIFY)
C30
Does this household have a BPL card?
YES
NO
DON’T KNOW
C31
Does the household possess a Rashtriya Swasthya Bima Yojana (RSBY) card?
YES
NO
DON’T KNOW
C32
If yes, then how many household members are enrolled in the programme?
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