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Household Template 25 -Form Fill
HOUSEHOLD CHARACTERISTICS
Q01
Name of the respondent
Q02
What is the sex of the respondent?
male
female
Q03
What is the religion of the household?
Hindu
Muslim
Sikh
Christians
Others(specify)
Q04
Which caste do you belong to?
Schedule Caste
Schedule Tribe
OBC
General
Others(specify)
Q05
What is the type of your family?
Nuclear
Joint
Q06
Please specify whether you belong to APL/BPL?
APL
BPL
Don’t know/cant say
Q07
Please tell me the names of the persons who usually live in your household starting with the head of the household including you
Q08
What is the relationship of (NAME) to the head of the household?
head
wife or husband
son or daughter
son-in-law or daughter-in-law
grandchild
parent
brother or sister
other
Q09
Is (NAME) male or Female?
male
female
Q10
What is the age of (Name)?
Q11
What is the current marital status of (NAME)?
Currently married
Widowed
Divorced
Separated
Never Married
Other
Q12
Whether (NAME) has any kind of disability?
Physical
Mental
None
Q12A
Whether (NAME) has any kind of chronic disease?
Physical
Mental
None
Q13
Can (NAME) read and write?
Yes
No
Q14
Has (NAME) ever Attended school?
Yes
No
Q15
What is the qualification of (NAME)?
Currently in class 1
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 Secondary School
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
Q16
What is the Primary Occupation of (NAME)?
Agriculture
Local Labour
Migrant labour
Salaried
Petty Trader
Skilled worker
Unemployed
Student
Housewife
Child not attending school
Self-Employed
Retired
Others (if any)
Household Assets and Income
A01
Does your household own a house?
Yes
No
A02
What is the type of your house?
Pucca
Semi Pucca
Kuccha
A03
How many rooms in this house are used for sleeping?
A04
What is the main source of drinking water for members of your household?
Piped water in residence/yard/plot
Hand pump in residence/yard/plot
Well water in residence/yard/plot
Public hand pump
Public tap
Public well
Bore well (Public/Private)
Canal
Other source (specify)
A05
Is the water available throughout the year?
Yes
No
A06
During which months of the year do you face scarcity of drinking water?
January
February
March
April
May
June
July
August
September
October
November
December
A07
What kind of toilet facility does your household have?
Open Defecation
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Ventilated improved pit biogas latrine
Pit latrine with slab
Pit latrine without slab/ open pit
Twin pit/composting toilet
Dry toilet
Others (specify)
A08
What is the main source of lighting for your household?
Electricity
Kerosene lamp
Gas lamp
Candle
Solar energy
Other (specify)
A09
What type of fuel does your household commonly use for cooking?
Wood
Crop residues
Dung cakes
Coal/ charcoal
Kerosene
Electricity
Liquid petroleum gas
Bio-gas
Other (specify)
A10
Does your household own any of the following items:
A10_1
Electric connection
Yes
No
A10_2
Pressure cooker
Yes
No
A10_3
Mixer/grinder
Yes
No
A10_4
Motorcycle/scooter
Yes
No
A10_5
Car/Jeep
Yes
No
A10_6
Tractor and/ or other agril. Equipment (incl. power tiller)
Yes
No
A10_7
Bicycle
Yes
No
A10_8
Animal-drawn cart
Yes
No
A10_9
Chair
Yes
No
A10_10
Table
Yes
No
A10_11
Cot/ Bed
Yes
No
A10_12
Mattress
Yes
No
A10_13
Clock or watch
Yes
No
A10_14
Electric fan
Yes
No
A10_15
Water pump
Yes
No
A10_16
Thresher
Yes
No
A10_17
Radio/Transistor
Yes
No
A10_18
Sewing machine
Yes
No
A10_19
Refrigerator
Yes
No
A10_20
B & W television
Yes
No
A10_21
Colour television
Yes
No
A10_22
Telephone
Yes
No
A10_23
Computer
Yes
No
A10_24
Cell Phone
Yes
No
A11
Whether engaged in the activity?
A11_1
Agriculture labor
Yes
No
A11_2
Non-agriculture labor
Yes
No
A11_3
Skilled labor
Yes
No
A11_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
A11_5
Services
Yes
No
A11_6
Large scale business
Yes
No
A11_7
NTFP selling
Yes
No
A11_8
Poultry
Yes
No
A11_9
Fisheries
Yes
No
A12
Who in the household earned income over last 12 months?
A12_1
Agriculture labor
Men
Women
Both Men & Women
Children
All HH Members
A12_2
Non-agriculture labor
Men
Women
Both Men & Women
Children
All HH Members
A12_3
Skilled labor
Men
Women
Both Men & Women
Children
All HH Members
A12_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Men
Women
Both Men & Women
Children
All HH Members
A12_5
Services
Men
Women
Both Men & Women
Children
All HH Members
A12_6
Large scale business
Men
Women
Both Men & Women
Children
All HH Members
A12_7
NTFP selling
Men
Women
Both Men & Women
Children
All HH Members
A12_8
Poultry
Men
Women
Both Men & Women
Children
All HH Members
A12_9
Fisheries
Men
Women
Both Men & Women
Children
All HH Members
A13
How much did the household earn from [activity] ______ over the past 12 months?
A13_1
Agriculture labor
A13_2
Non-agriculture labor
A13_3
Skilled labor
A13_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
A13_5
Services
A13_6
Large scale business
A13_7
NTFP selling
A13_8
Poultry
A13_9
Fisheries
A14
Do you continue this acctivity during extreme weather conditions such as flood, drought, cyclone etc. ?
A14_1
Agriculture labor
Yes
No
A14_2
Non-agriculture labor
Yes
No
A14_3
Skilled labor
Yes
No
A14_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
A14_5
Services
Yes
No
A14_6
Large scale business
Yes
No
A14_7
NTFP selling
Yes
No
A14_8
Poultry
Yes
No
A14_9
Fisheries
Yes
No
A15
Does your Household have a MGNREGA job card?
Yes
No
A16
In total how many number of job days did your households members receive through MGNREGS in the last 12 months?
A17
Do you practice regular savings?
Yes
No
A18
How regularly do you save?
Weekly
Fortnightly
Monthly
Once in 6 months
Once a year
Others
Don’t Save
A19
Where do you save?
SHG
Cooperative
Bank
Post Office
At home
Others(specify)
A20
Do you have access to credit?
Yes
No
A21
Have you taken any loan in the last 12 months
Yes
No
A22
Where did you take the loan from?
SHG
Cooperative
Bank
Post Office
Familiy/relatives
Local Money lenders
Others(specify)
A23
What was the purpose of taking the loan
Purchase agricultural inputs
Purchase agricultural machinery
Small business
Large business
Education
Personal (Wedding, Death, Buying food)
Medical purposes
Repayment old loan
Others(specify)
A24
Has there been any situation where you have not been able to repay the loan or pay the instalment for the loans taken in the last 12 months?
Yes
No
A25
What were the reasons for the failure?
Less Income due to absence of earning member
Other large expenditure
Reduction in income due to crop failure
Reduction in income due to business failure
Repayment old loan
Others (specify)
A26
Does your houshold have access to insurance?
Yes
No
A27
What type of insurance does your household/ Crop/ Livestock have have?
Health
Accidental
Life
Vehicle
Regular Crop Insurance
Weather based crop insurance
Others(specify)
A28
Does you household have received any remittance?
Yes
No
A29
How often has your household received remittances in the last 12 months?
Weekly
Fortnightly
Monthly
Once in 6 months
Once a year
Others
A30
On average, how much money did your household receive each time you received remittances in the last 12 months?
A31
In the last 12 months, has there been any unexpected incident that has adversely affected the economic situation of your household?
Yes
No
A32
What has been the event?
Death of income earning HH member
Death of other HH member
Disease or injury of income-earning HH member
Disease or injury of other HH member
Loss of employment of any HH member
Divorce by husband/wife
Loss of crop due to flooding/cyclone/weather hazards
Loss of crop due to other reasons
Disease, injury, loss of cattle/ in fish pond
Damage to house or any productive assets (theft, fire, river erosion, cyclone etc.)
Storage crop damage/theft
Business failure
Conflict, dispute, legal problems
Land ownership and usage
B01
Does your household own any agricultural land?
Yes
No
B02
What is size of the own land you are currently cultivating ??
B02A
unit
Decimal
Biswa
Kattha
Bigha
Acre
Hectare
Others
B03
Does your household leased out any agricultural land?
Yes
No
B04
What is size of the agricultural land you you leased out ?
B04_1
unit
Decimal
Biswa
Kattha
Bigha
Acre
Hectare
Others
B04A
Does your household leased in agricultural land?
Yes
No
B04B
What is size of the agricultural land you you leased in ?
B04B_1
unit
Decimal
Biswa
Kattha
Bigha
Acre
Hectare
Others
B05
Does your household mortgage any agricultural land?
Yes
No
B06
What is size of the agricultural land you mortgage?
B06A
unit
Decimal
Biswa
Kattha
Bigha
Acre
Hectare
Others
B07
Do you use irrigation on your land?
Yes
No
B08
Out of this land, how much is irrigated? (Investigator Note: Please use the local conversion unit in acres)
B08A
unit
Decimal
Biswa
Kattha
Bigha
Acre
Hectare
Others
B09
What is the source used for irrigating this land?
Tube well
Well
Canal
Drip Irrigation
Borewell
Lift irrigation
Others (specify)
B10
Do you fallow your land ?
Yes
No
B11
How long do you fallow your land?
Less than6 months
A year
More than a year
Others (specify)
B12
What all do you do to fallow your land?
Plough
Grow fallowing plants
Grow nothing
Add fertilizers
Others (specify)
Climatic changes
C01
In the recent past 20 years have you noticed any changes or variability in the climatic patterns?
Yes
No
C02
In the recent past 20 years have you noticed any changes or variability in the rainfall patterns?
Yes
No
C03
Has the intensity of rainfall decreased or increased?
Increased
Decreased
C04
In the recent past 20 years, have you noticed any changes or variability in the temperature patterns?
Yes
No
C05
Has the temperature decreased or increased?
Increased
Decreased
C06
Have you observed drought (as a result of increase in temperature/ decrease in raifall) in the past 20 years s?
Yes
No
C07
On average, how many times/years have you observed drought in the past 2 decades?
C08
Among all, how many times you have observed major drought impacts in the past two decades?
C08A
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
C09
Have you observed floods in the past 2 decades?
Yes
No
C10
On average, how many times/years have you observed floods in the past 2 decades?
C11
Among all, how many times you have observed major flood impacts in the past two decades?
C11A
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
C12
Have you observed cyclone in the past 2 decades?
Yes
No
C13
On average, how many times/years have you observed cyclone in the past 2 decades?
C14
Among all, how many times you have observed major cyclone impacts in the past two decades?
C14A
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
C15
Have you observed cold wave in the past 2 decades?
Yes
No
C16
On average, how many times/years have you observed cold wave in the past 2 decades?
C17
Among all, how many times you have observed major cold wave impacts in the past two decades?
C17A
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
C18
Have you observed heat wave in the past 2 decades?
Yes
No
C19
On average, how many times/years have you observed heat wave in the past 2 decades?
C20
Among all, how many times you have observed major heat wave impacts in the past two decades?
C21
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
25 to 50% failure
Less than 25 % Failure
Farming Practices
D02
What type of seed was primarily used for production of ____?
Improved
Local
Hybrid
Don’t Know
D03
Was any fertilizer used on the land during production of _______?
Organic
K (Potash)
P(Phosphate)
N (Nitrogen/ Urea)
Composite (DAP, NPK, Gromor etc.)
Other(specify)
None
D04
Was any pesticide used during cultivation of ________?
Organic
Chemical
Integrated
None
D05
For this crop, are you mostly using line planting/transplanting or do you broadcast the crop in the main field or both?
Line planting/ transplanting
Broadcast crop
Both
Don’t know
D06
Do you practice hoeing in fields where you grow _____?
Yes
No
D07
What is the total quantity produced?
D08
How much of the harvested was sold?
D09
At what rate was the produce sold
D09A
Where do you sell your products?
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
D10
Out of all the crops you mentioned, which crop is the most water- intensive?
D11
How many times in a year do you cultivate this crop?
D12
Have you ever shifted to less-water intensive crop cultivation?
Yes
No
D13
How do you store your crops?
At home
Village level godown facilities
Government godown facilities
Others(specify)
D14
Do you think current storage facility available is adequate?
Yes
No
D15
Does your HH have access to cold storages for storing your crops?
Yes
No
D16
Has your HH utilized coldstorage facility in the past 12 months?
Yes
No
D17
Is the cold storage facility available whenever required?
Yes
No
IMPACT OF CLIMATE CHANGE ON CROP
E02
By which hazard is your crop affected the most?
Flood
Drought
Hail
Cyclone
Heat Wave
Cold Wave
E03
Which stage of the crop is affected?
Pre-sowing
Seedling
Vegetative
Flowering/Tillering
Maturity
Others (specify)
E04
How severe is the loss or crop failure?
75% to 100 % failure
50% to 75% failure
25 % to 50% failure
Less than 25 % failure
Alternate Livelihoods
F01
Does your household own livestock?
Yes
No
F02
Did you rear any of these in the last 12 months?
F02_1
Bullocks
Yes
No
F02_2
Cow
Yes
No
F02_3
Cross bred cow
Yes
No
F02_4
Buffalo
Yes
No
F02_5
Goats/Lambs
Yes
No
F02_6
Poultry
Yes
No
F02_7
Fisheries
Yes
No
F02_8
Piggery
Yes
No
F02_9
Other (Specify)
Yes
No
F03
Did you sell any of these in the last 12 months?
F03_1
Bullocks
Yes
No
F03_2
Cow
Yes
No
F03_3
Cross bred cow
Yes
No
F03_4
Buffalo
Yes
No
F03_5
Goats/Lambs
Yes
No
F03_6
Poultry
Yes
No
F03_7
Fisheries
Yes
No
F03_8
Piggery
Yes
No
F03_9
Other (Specify)
Yes
No
F04
How many did you sell?
F04_1
Bullocks
F04_2
Cow
F04_3
Cross bred cow
F04_4
Buffalo
F04_5
Goats/Lambs
F04_6
Poultry
F04_7
Fisheries
F04_8
Piggery
F04_9
Other (Specify)
F05
What was the unit price? (INR)
F05_1
Bullocks
F05_2
Cow
F05_3
Cross bred cow
F05_4
Buffalo
F05_5
Goats/Lambs
F05_6
Poultry
F05_7
Fisheries
F05_8
Piggery
F05_9
Other (Specify)
F06
Does your HH has access to veterinary services?
Yes
No
F07
In the past 12 months, has your HH ever utilize veterinary health services?
Yes
No
Production
G01
Did you produce any ___ during the last 12 months?
G01_1
Animal meat
Yes
No
G01_2
Poultry meat/offal
Yes
No
G01_3
Milk
Yes
No
G01_4
Milk products
Yes
No
G01_5
Eggs
Yes
No
G01_6
Fisheries/sea food
Yes
No
G02
Did your household sell any of the ___ produced?
G02_1
Animal meat
Yes
No
G02_2
Poultry meat/offal
Yes
No
G02_3
Milk
Yes
No
G02_4
Milk products
Yes
No
G02_5
Eggs
Yes
No
G02_6
Fisheries/sea food
Yes
No
G03
How much did you sell?
G03_1
Animal meat
G03_2
Poultry meat/offal
G03_3
Milk
G03_4
Milk products
G03_5
Eggs
G03_6
Fisheries/sea food
G04
Where do you sell your products?
G04_1
Animal meat
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G04_2
Poultry meat/offal
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G04_3
Milk
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G04_4
Milk products
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G04_5
Eggs
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G04_6
Fisheries/sea food
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
Others (specify)
G05
What was the unit price? (INR)
G05_1
Animal meat
G05_2
Poultry meat/offal
G05_3
Milk
G05_4
Milk products
G05_5
Eggs
G05_6
Fisheries/sea food
Migration
H01
In the last 12 months, have any adults (people aged at 15 years or more than 15 years) in your household migrated?
Yes
No
H02
What was/were the reason(s) for migration?
Temporary work/job
Permanent work/job
No land for ariculture
Cannot do agriculture cultivation anymore
No income generating activity at village
Other (specify)
Don’t know
H03
How often do they migrate for work?
Each month
Many times/year
Twice a year
Once a year
Most of the mebers have migrated
Others (specify)
Support and Trainings
I01
How many times have you met with any agricultural/livestock/fisheries NGO extension worker in the past 12 months?
I02
What all topics did you discuss?
Agricultural practices
Seed subsidies
Crop/livestock/fisheriesInsurance
Farm machineries
Agro-chemicals and fertilizers/pesticides
Irrigation
Others (specify)
I03
How many times have you met with any agricultural/livestock/fisheries government extension worker in the past 12 months?
I04
What all topics did you discuss?
Agricultural practices
Seed subsidies
Crop/livestock/fisheriesInsurance
Farm machineries
Agro-chemicals and fertilizers//pesticides
Irrigation
Others (specify)
I05
Did your household use any of the following items during the 12 months?
I05_1
Improved Farm tools (e.g., wheel hoe, weeders, broad casters)
Yes
No
I05_2
Mechanized tools (e.g., thresher, harvester)
Yes
No
I05_3
Pesticides
Yes
No
I05_4
Herbicides
Yes
No
I05_5
Packaged animal feed
Yes
No
I05_6
Animal drugs/vaccines
Yes
No
I06
Have you or anyone else from your household ever received any training on agriculture, poultry or livestock related work?
Yes
No
I07
Did you or anyone else from your household ever receive training on_________ in the last 12 months?
I07_1
Agriculture Training
Yes
No
I07_2
Field crop selection or rotation
Yes
No
I07_3
Improved seeds or crop varieties
Yes
No
I07_4
Pest management
Yes
No
I07_5
Soil improvement
Yes
No
I07_6
Poultry
Yes
No
I07_7
Livestock
Yes
No
I08
Who provided the training?
Government
NGO
Business groups
Community organizations
Family members/friends
Others (specify)
I09
Have you (yourself) or any of your household members been on an exposure visit related to agriculture practices in the past 12 months?
Yes
No
I10
How many times have you or your household member been on agriculture related exposure visit in the past 12 months?
I11
Where did you or your household member go for agriculture related exposure visit in the past 12 months?
Within village
Neighbouring village
Block
Others (specify)
I12
Have you ever heard about farmer support centres?
Yes
No
I13
Have you or your household member ever accessed services from farmer support centre (Private/NGO)?
Yes
No
I14
Where is the nearest farmer support centre you or your family memberhave accessed?
Within village
Neighbouring village
Block
District
Others (specify)
I15
Are you currently availing any government or NGO facilitated agricultural schemes?
Yes
No
I16
Do you access agriculture related information from any other sources such as Mobile, Radio or TV?
Yes
No
SHG and Community Membership
J01
Are you or any of your HH member part of any SHG?
Yes
No
J02
Are or any of your HH member you an active member of this group, (meaning that you participate in meetings, for example)?
Yes
No
J03
Does your self-help group have savings and credit activities?
Yes
No
J04
Do you or any of your HH member personally participate in these savings and credit activities?
Yes
No
J05
Do you discuss any of the following in the self-help group?
J05_1
Livelihoods/socio-economic problems in the community
Yes
No
J05_2
Agriculture problems
Yes
No
J05_3
Education problems
Yes
No
J05_4
Health and nutrition problems
Yes
No
J06
Has any household member ever gone for any exposure visit as part of the SHG?
Yes
No
J07
Where have you gone for the exposure visit?
Neighbouring village
Nearest town
Block town
Neighbouring district
Outside state
Others (specify)
J08
Does your village have community welfare group?
Yes
No
J09
Are you a member of any community welfare group?
Yes
No
J10
What all activities do the group engage in?
Agriculture
Aquaculture
Poultry
Micro enterprise
Credit and savings
Others (specify)
J11
Have you received any kind of support you receive from the group in the past 12 months?
Yes
No
J12
What kind of support do you receive from the group?
credit
Grain banks
Aid (both cash and kind)
Employment
Access to market
Others (specify)
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