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Household Template 38 -Form Fill
INTERVIEW DETAILS AND QUALITY ASSURANCE
Q01
SCHEDULE IDENTIFICATION NUMBER
Q02
Name of the State
Q03
Name of the District
Q04
Name of the Block
Q05
Name of Panchayat
Q06
Name of the Village (PSU)
Q07
Structure Number
Q08
Household Number
Q09
Address of Household
Q10
Nearest Post Office
Q11
Pin Code
Q12
Whether electrified or not
Yes
No
Q13
Interviewer’s Visits-1
Q13_1
Date
Q13_2
Result
Completed
Not at home
Postponed
Refused
Partly Completed
No Eligible Person
Eligible Person Incapacitated
Others (specify)
Q13_3
Supervisor
Q14
Interviewer’s Visits-2
Q14_1
Date
Q14_2
Result
Completed
Not at home
Postponed
Refused
Partly Completed
No Eligible Person
Eligible Person Incapacitated
Others (specify)
Q14_3
Supervisor
Q15
Interviewer’s Visits-3
Q15_1
Date
Q15_2
Result
Completed
Not at home
Postponed
Refused
Partly Completed
No Eligible Person
Eligible Person Incapacitated
Others (specify)
Q15_3
Supervisor
HOUSEHOLD PROFILE
A01
Name of the respondent
A02
What is the sex of respondent?
Male
Female
A03
What is the religion of your respondent?
Hindu
Muslim
Christian
Sikh
Buddhist/Neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No Religion
Other (Specify)
A04
Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CASTE
GENERAL
OTHER (SPECIFY)
A05
Please tell me the name of all the persons who live in your house, starting with your name
A06
Relation to HH Head
Household head
Husband/Wife
Son or daughter
Son in-law or daughter-in-law
Grandfather or grand mother
Grandson or granddaughter
Father or mother
Father in law or mother in law
Brother or sister
Brother in law or sister in law
Uncle or aunt
Other relatives (including cousins)
Foster/step/adopted children
Not related
A07
Sex
Male
Female
Transgender
A08
Age
A09
Education
Currently in class I
Completed class 1
Completed class 2
Completed class 3
Completed class 4
Completed class 5
Completed class 6
Completed class 7
Completed class 8
Completed class 9
Completed class 10
Completed Higher Secondary
BA/BSC pass/Fazil
BA/BSC honors/Fazil (Hons)
MA/MSC/Kamil & above
Hafezia/Kiratia/Nurani madrasa
Child less than 5 years
Never attended school
Currently in Aanganwadi/Pre-school Education
A10
Marital status?
Unmarried
Married
Widowed
Divorced
Separated
Deserted by spouse
A11
Main Occupation
Farming/Agriculture (Crops)
NTFP Collection
Livestock (goats, poultry, piggery, fishery & dairy)
Unskilled wage labour (agricultural labour, MGNREGA labour, construction work, brick kiln labour etc.)
Skilled worker(tailoring, masonry, electrician, plumbing, carpentry, welding, driving, etc.)
Salaried worker (teachers, AWW, ANM, etc.
Contractual or task based work ( ASHAs, CSPs, BC Agents, Tuitions, para-teachers etc.)
Micro-enterprises (kirana shops, dhabas, mobile shops, ferry shops etc.)
House Work
Unemployed
Old age/pensioner
Differently abled
Student
Child (age <5)
Other
A12
Whether differently abled or chronically sick?
Yes
No
DETAILS OF NON-RESIDENT FAMILY MEMBERS
B01
Do any women in the household have husbands who do not live in the household?
Yes
No
B02
Please provide details of such members
B03
Do any men in the household have wives who do not live in the household now?
Yes
No
B04
Please provide details of such members
B05
Do any children under age 15 in the household have parents who do not live in the household?
Yes
No
B06
Please provide details of such members
B07
Are there any family members who are students living away at college or school?
Yes
No
B08
Please provide details of such members
B09
Are there any other family members who send money to this household or receive it on a regular basis? What is their relationship to the household's head?
Yes
No
B10
Please provide details of such members
KNOWLEDGE ABOUT THE SCHEME
C01
Have you ever heard about UJALA scheme? Or any such scheme LED bulbs are being distributed at low costs?
Yes
No
C02
What have you heard?
Correct idea about the scheme
Incorrect idea about the scheme
C03
Where did you get to know first about the scheme?
Newspaper
Flex boards
Saw the local kiosks
TV advertisement
Was printed on electricity bill
Was printed on railway/Flight Tickets
Other
Don’t remember
C04
Who is eligible to receive benefits under the scheme?
HH with metered connection
HH without electricity connection
Only BPL households
Any household
C05
Where can you go to buy the bulbs?
Kiosk in regional DISCOM office
Local kiosks in neighbourhood
Designated centres across the city
Don’t remember
C06
What documents are required to avail the scheme?
Only electricity bill
Only identity proof
Both a & b
No documents
Don’t remember/Don’t know
BENEFICIARY EXPERIENCE OF THE SCHEME
D01
Have you bought any LED bulb under the UJALA scheme?
Yes
No
D02
Name and address of the distribution centre where you bought bulbs for your house?
D03
How far is the distribution centre from your house?
D04
Were you given information on the installation or warranty of the bulbs?
Yes
No
don't remember
D05
Whose documents were used to purchase the bulbs? (can be multiple if purchase made more than once)
D06
How many bulbs have you bought so far?
D07
What sort of bulb/light source did you replace with the LED?
CFL
Incandescent bulbs
Tube lights
Kerosene lamp
Gas lamps
Other
D08
Cost of each bulb paid by you?
D09
Do you think this price is high?
Yes
No
D10
According to you what should be the price of one bulb?
D11
When did you buy the bulb?
D12
Did you receive any receipt or other documentation for the payment?
Yes
No
D13
Did you know about LED bulbs before this program?
Yes
No
D14
Would you have bought LED bulbs if the programme was not launched?
Yes
No
D15
Why did you buy the LED bulbs? (Multiple responses possible)
Reduction of electricity bill
Good for environment
Cheaper than the bulbs available in the market
Easily available
Everyone else was buying them
Promotion of programme by local politician
Promotion of programme by prime minister
D16
How did you buy the LED bulbs?
Paid the entire amount upfront
Opted to pay on monthly instalments through electricity bills
Bought some bulbs by paying upfront and some bulbs on monthly Instalments
Don’t remember
D17
Did you know that you could pay for LED bulbs on monthly instalments through electricity bills?
Yes
No
D18
If you had known about on-bill financing would you have opted for it?
Yes
No
D19
Have you bought any other energy saving appliance from the distribution center under UJALA scheme?
Yes
No
D20
What all did you buy?
D21
What do feel about the quality of these appliances?
Bad
Ok
Good
D22
Are all the LEDs you bought still working?
Yes
No
D23
How many do not work anymore or stopped working?
D24
What is the average duration for which the bulbs worked?
D25
When the bulb stopped working what did you do?
Threw it away, did nothing
Replaced it with a CFL
Replaced it with incandescent bulb or tube light
Called the helpline on the LED bulb box
Went to the local kiosk from where we bought the bulb
Went to the DISCOM office
D26
Why did you not replace them?
It was too cumbersome for me to replace
It doesn’t matter to me much
Tried to, but was unsuccessful
Not satisfied with helpline
Not satisfied with local kiosk
Not satisfied with Discom office
D27
Reason for not replacing.
D28
Were you aware that you can get the faulty bulbs replaced under the scheme?
Yes
No
D29
How many bulbs did you get replaced?
D30
Have you ever tried to call the UJALA helpline (other than for replacement of bulb)?
Yes
No
D31
Reason for the call?
Know more about the scheme
Find out the location of distribution centre
To enquire about bulb availability
To complain about higher cost than advertised
Any other
D32
Were you satisfied by the problem resolution?
Yes
No
D33
What will you do when all the bulbs bought under the program fuse? Replace with -
Incandescent bulb
CFL bulb
LED bulb
Ordinary tube light
LED tube light
Can’t say
D34
How much are you willing to pay for purchasing LED bulb from the market?
D35
Have you also bought any energy saving appliance outside of the scheme? (multiple responses)
Yes
No
D36
What have you bought?
Refrigerator
AC
Washing machine
Mixer Grinder
Others
D37
What is the star rating of the appliance bought? (please check)
5 star
4 star
3 star
2 Star
1 star
Don’t know
D38
Are you aware of any financing scheme/source of finance that helps in the purchase of energy saving appliance?
Yes
No
D39
Would you like to avail any such financing?
Yes
No
BENEFITS FROM THE ENERGY SAVING APPLIANCES
E01
How is the voltage of the house after installation of the appliances?
Always keeps fluctuating
Fluctuates sometimes
Never fluctuates
E02
Do you feel that your electricity bill has reduced after installation of energy saving appliances?
Yes
No
E03
What was your electricity bill in the month/period before the installation of the energy saving appliance?
E04
What was your electricity bill in the month/period after the installation of the energy saving appliance?
E05
Can you please list the top three benefits of installation of the bulbs?
LOCATION AND USAGE OF BULBS
F01
Where are the light bulbs installed? (mark options then note average hours each bulb is switched on in the household)
Kitchen
Bedroom
Living room
Verandah
Bathroom
Backyard/front yard
Near water source/tap
Other
F02
Which household activities has the installation of bulbs helped? (multiple responses)
Cooking
Children’s study time
Household chores
Home-based enterprise
Leisure activity
Other
F03
Where are the other appliances installed?
F04
Do women of the household have access to the areas illuminated by the bulbs?
Yes
No
F05
Do women of the household have access to the appliances installed?
Yes
No
F06
Have you changed your before after installing LED bulbs?
Keep bulbs on longer or even during the day
No Change
F07
Number of hours for which bulbs were lighted earlier?
F08
Number of hours for which bulbs are lighted now?
DECISION MAKING
G01
Who takes majority of the decision with regard to purchase of household appliances?
Only male members
Only female members
Both male and female members
G02
Who all are consulted before deciding to purchase the appliance?
Only male members
Only female members
Both male and female members
G03
Are there any appliances for which the women members of the households take a decision or have taken a decision in the past?
TV
Refrigerator
Mixer grinder
Others
BENEFICIARY SATISFACTION
H01
Are you satisfied with the LED bulbs?
Yes
Neutral
No
H02
Why are you not satisfied with the LED bulbs?
The light is too bright
The light is not bright enough
Aesthetic reasons
Other (Specify)
H03
Have you done any of the below after you bought LED bulbs (check all that apply)
We recommended others to buy LED bulbs
We bought LED bulbs and LED tube-lights from market
We replaced an old appliance with an energy efficient appliance
None of the above
H04
What are some of the problems with the scheme?
Larger appliances not available
Information about finance not available
Others
HH WITHOUT ACCESS TO THE SCHEME
I01
Why have you not bought bulb under the scheme?
Not informed about the scheme
We don’t know where to go
I feel that the quality of the bulbs will be bad
Poor stock or supply
High price of the bulb
I02
What are some of the media available to you?
Television
Radio
Newspaper
Mobile phone
Internet
Movies
I03
Did you see the program campaign at any of the media you just mentioned?
Yes
No
I04
How can it be ensured that all households receive information about such schemes in the future? (open ended)
I05
What appliances do you want to purchase?
Refrigerator
Television
LED bulb
Mixer grinder
None
I06
Are they included under the scheme?
Yes
No
don't know
I07
Would inclusion of such appliances push you to avail of the schemes?
Yes
No
HOUSEHOLD CHARACTERISTICS
J01
Does your household own this house or any other house?
Yes
No
don't know
J02
LOOK AT THE FLOOR AND CODE THE 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)
J03
LOOK AT THE ROOF AND CODE THE 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
Unburnt Brick
Loosely Packed Stone
Metal/Gi
Wood
Calamine/Cement Fiber
Asbestos Sheets
Rcc/Rbc/Cement/Concrete
Roofing Shingles
Tiles
Slate
Burnt Brick
Other (Specify)
J04
LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS
No Walls
Cane/Palm/Trunks/Bamboo
Mud
Grass/Reeds/Thatch
Bamboo With Mud
Stone With Mud
Plywood
Cardboard
Unburnt Brick
Raw Wood/Reused Wood
Cement/Concrete
Stone With Lime/Cement
Burnt Bricks
Cement Blocks
Wood Planks/Shingles
GI/Metal/Asbestos Sheets
Other (Specify)
J05
Do they have any window in their house? (OBSERVE)
Yes
No
J06
Type of window
WINDOWS WITH GLASS
WINDOWS WITH SCREENS
WINDOWS WITH CURTAINS OR SHUTTERS
J07
How many rooms in this house are used for sleeping?
J08
Do you have a separate room which is used as a kitchen?
Yes
No
J09
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)
J10
What is the main source of lighting in this household?
LANTERN
KEROSENE LAMP
CANDLE
ELECTRIC
LPG/BATTERY
SOLAR ENERGY
NONE
OTHERS (SPECIFY)
J11
What is the main source of drinking water for members of your household?
PIPED INTO DWELLING
PIPED TO YARD/PLOT
PUBLIC TAP/STANDPIPE
TUBE WELL/BOREHOLE
PROTECTED WELL
UNPROTECTED WELL
PROTECTED SPRING
UNPROTECTED SPRING
RAINWATER
TANKER TRUCK
CART WITH SMALL TANK
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL)
BOTTLED WATER
GOVERNMENT HAND PUMP
HAND PUMP AT HOME
NEIGHBOUR’S HAND PUMP
OTHER (SPECIFY)
J12
How long does it take to go to the water source, get water, and come back?
J13
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
OTHER (SPECIFY)
J14
Does your household have
Yes
No
J14_1
Electricity
Yes
No
J14_2
A mattress
Yes
No
J14_3
A pressure cooker
Yes
No
J14_4
A chair
Yes
No
J14_5
A cot or bed
Yes
No
J14_6
A table
Yes
No
J14_7
An electric fan
Yes
No
J14_8
A radio or transistor
Yes
No
J14_9
A black and white television
Yes
No
J14_10
A color television
Yes
No
J14_11
A sewing machine
Yes
No
J14_12
A mobile telephone
Yes
No
J14_13
Any other type of telephone
Yes
No
J14_14
A computer/laptop
Yes
No
J14_15
A refrigerator
Yes
No
J14_16
A watch or clock
Yes
No
J14_17
A bicycle
Yes
No
J14_18
A motorcycle or scooter
Yes
No
J14_19
An animal-drawn cart
Yes
No
J14_20
A car
Yes
No
J14_21
A water pump
Yes
No
J14_22
A thresher
Yes
No
J14_23
A tractor
Yes
No
OTHER HOUSEHOLD DETAILS
K01
Does your household have a bank account?
Yes
No
K02
Does your household have a post-office account?
Yes
No
K03
Please specify whether you belong to APL/BPL or pripority/non-priority?
APL non-priority
BPL priority
Don’t know/can’t say
K04
Does your household have a MGNREGA job card?
Yes
No
K05
How many years since you have been staying in the current residence?
0-1 years
1-2 years
More than 2 years
K06
Classification of Previous address
Same block different village/ward
Same district different block
Different district same state
Different State
K07
Reason for moving to this address
Moved for a job
Moved because house was destroyed in a natural calamity
Moved for treatment of an ill member of family
Moved because of better education at destination
Moved because infrastructure was better at destination
Moved because were not allowed to live in old house/village anymore
Others
K08
Answer the questions in reference to your current place of residence
Distance from main road
Distance from main market area
Distance from bus stop
Distance from station
Distance from nearest health facility
Distance from school
HH Income
L01
Do you / your household members receive any remittances from any sources / person?
Yes
No
L02
What is the amount of money received under remittances in the last 12 months?
L03
Do you / your household members receive any pension?
Yes
No
L04
What is the type of pension received by you / your household members?
National old age pension scheme
Widows' Pension Scheme (WPS)
National Maternity Scheme (NMBS)
National Disability Pension
Other Government Programmes
Assistance from NGOs /Charities
Others (specify)
L05
What is the amount of money received from pension (all types) in the last 12 months?
L06
Please mention the name of all household members who are gainfully employed?
L07
Gross Annual income / revenue from primary occupation
L08
Gross Annual income / revenue from secondary occupation (including rent from houses owned and land)
L09
Annual Expense/ Cost
Additional Sources of Income
M01
Income from sale of livestock or livestock produce like egg, milk, chicken, goat, etc?
M02
Cost of feeding and maintaining the animals?
M03
Income from property renting (in INR)
M04
Income from sale of property in the last one year?
M05
In the last two years, has anyone in the household received land from the government?
Yes
No
M06
IF YES, How much land?
M07
IF YES, About how much was that land worth?
LAND OWNERSHIP
N01
Does this household own any agricultural land?
Yes
No
N02
Total agricultural land owned
N03
How much of your own land do you cultivate?
N04
Do you also cultivate leased-in land?
Yes
No
N05
How much of leased-in land do you cultivate?
N06
Of all the land you cultivate, including rented land, is any land irrigated at any time of the year?
Yes
No
N07
What are the two most important modes of irrigation?
Tube Well
Other Well
Government
Private Canal
Tank/pond/nala
Other
N08
Do you know any other household where people have purchased the bulbs?
Yes
No
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