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Household Template 36 -Form Fill

Household Detail
Q01

Name of the Enumerator
Q02

Name of Supervisor
Q03

Date of Survey
Q04

Participation in the survey
Q05

Type of Respondent
Q06

Country of Survey
Q07

Settlement Name
Q08

Scattered Settlement Name

Q09

Nomad Settlement Name

Q10

Settlement/Community Name

Q11

Respondent Name
Q12

Present Address

Q13

Permanent Address

Q14

Phone Number
Q15

Household ID Number

Q16

Gender of Head of Household
Q17

Number of resident members of the household

Q18

Number of non-resident members of the household

Q19

Number of members who permanently migrated within the country
Q20

Number of members who permanently migrated to another country
Q21

Details of members who permanently migrated to another country
Member Details Questionnaire
A01

Member ID

A02

Name
A03

Birth Country
A04

Relationship with Head of Household
A05

Sex

A06

Ethnicity

A07

Religion
A08

Year of Birth For people who do not remember date convert age into year YYYY
A09

Highest Education Level Attained (See code below) If s/he is a school graduate (XII Passed) or above, then go to “School Graduate / College Education” Questionnaire at the end of member detail questionnaire.
A10

If A09 is “12 = No formal education” or “14 = Monks & Nuns with no formal education”, then can s/he read and write.
A11

Marital Status

A12

Primary Occupation
A12A

If A12 is Unemployed / Home-maker, is s/he currently looking for job/work?
A12B

If “YES” to A12A, then specify the type of job/work s/he is seeking
A12C

If “YES” to A12A, specify the type of skill training s/he is seeking
A12D

If A12 is student, then specify the School Category
A12E

If A12 is student, then specify the school’s name and place
A12F

If A12 is retired, then specify if s/he has pension
A12G

If A12 is Monk/Nun/Tantric practitioner, name the monastery where s/he is resident.
A12H

If A12 is Monk / Nun / Tantric practitioner, then specify school of practice
A13

Is s/he a current resident in the household?
A13A

If “NO” to A13A, then Give Reason
A14

Is s/he a Person with Disability (PwD)? Note: Include mental illness and leprosy cured
A14A

If “YES” to A14, then categorise disability
A14B

If “YES” to A14, then does s/he have disability certificate?
A14C

If “YES” to A14, then in your opinion list the most beneficial CTA services received by you in the past one year
A14D

If “YES” to A14, then name any new services that you feel would be most beneficial to you
A15A

If “YES” to A15, then specify
A16

Has s/he contributed to the household income in the last 12 months?
A17

Enter the Greenbook Number
School Graduate (XII Passed) / College Education Questionnaire
B01

Stream/Course Name
B02

University / College / Schools Name and place
B03

Region
B04

Scholarship Category
B05

Course Completion year
Household Income
C01A

Are you entering the value in
C01B

How much money has your household earned/ (personal income if staying alone) have earner from the following sources during the last 12 months?

C01B_1

Net income from sale of agriculture produce [Please indicate net income after deducting your expenses towards input costs for farming]
C01B_2

Net income from animal husbandry (dairy farming, poultry, piggery, goatery, fish, bee keeping, cattle herding, etc.) [Please indicate net income after deducting your expenses towards input costs for animal husbandry]
C01B_3

Net income from petty trading business operating from no fixed premises (Hawkers, street vendors, seasonal traders of warm clothing, etc.) [Please indicate net income after deducting your expenses towards running your business]
C01B_4

Net income from own business enterprise operating from a fixed premises (manufacturing, service, or retail business with or without employees) [Please indicate net income after deducting your expenses towards running your business]
C01B_5

Income from non-professional self-employment providing vocational trade-based services (plumber, electrician, tutors, barber, tailor, artisans, domestic help, job-workers, etc.) 
C01B_6

Income from self-employment providing high-end professional services but not attached to a registered business unit (doctors, lawyers, architects, actors, photographers, private tutors, chartered/cost accountants, etc.) 
C01B_7

Income from regular salary, consulting fees, commissions, fixed remunerations, and honorarium 
C01B_8

Income from daily wages (agriculture or non-agricultural labor work)
C01B_9

Income from remittance 
C01B_10

Income from rentals  
C01B_11

Interest income from Fixed and Recurring deposits, interest earned from lending etc 
C01B_12

Income from regular pension (government or private) 
C01B_13

Income from donations/gifts
C01B_14

Income from academic scholarships
C01C

Based on what you have just reported, your total household income/ (personal income if staying alone) from the last 12 months considering all sources falls in the following range: (Income range given below) [This will be auto selected based on the total]. Could you please confirm if this is correct, or would you want to change the range?
C01D

If you wish to change, then please indicate which income range best represents your household income/ (personal income if staying alone) for the last 12 months.
C02

Considering all expenditure on food and non-food items consumed by all members of your household/ (personal consumption if staying alone), what was your household/ (personal if staying alone) average monthly household expenditure? (consider last month’s expenditure as a reference)

C02_1

Regular monthly expenditure on food (including out-of-home dining and ordering food from outside)
C02_2

Regular monthly expenditure of non-food household consumables and transportation (cooking oil, toiletries, clothing, petrol/diesel costs, cost of commuting using public transport, etc.)
C02_3

Regular monthly expenditure on utility services and rent (electricity, water charges, telephone bills, internet/broadband charges, cable/DTH charges, LPG/cooking gas charges, house rent)
C02_4

Regular monthly expenditure on housekeeping services (laundry, domestic help, driver, watchman/caretaker, sweeper)
C02_5

Regular monthly expenditure on education (including private tuition fees, school fees, transportation charges, books and uniform, hostel/PG charges)
C02_6

Regular monthly expenditure on healthcare and childcare (medicine costs, day-care charges, doctor’s consultation charges, non-medicine costs associated with care of elderly and chronically ill patient 
C02_7

Regular monthly debt servicing expenses and premium payments (EMIs on loans, insurance premiums, payments for ULIPs and SIP) 
C02_8

Remittance payments
C02A

Based on what you have just reported, your total average household expenditure/ (personal expenditure if staying alone) last month falls in the following range: [This will be auto selected based on the total] Could you please confirm if this is correct, or would you want to change the range?
C02B

If you wish to change, then please indicate which income range best represents your household’s / (personal if staying alone) average monthly expenditure
C02C

To the best of your ability, can you indicate from the range below the average amount of money spent in in a typical month to meet the regular running expenses of your household / personal expenses if staying alone)? Please consider only regular expenses that are met through the monthly household budget / personal expenses budget if staying alone) and not one-time expenses, business expenses, or expenses for agriculture inputs.
C03

During 2023, can you indicate whether there were any months where you struggled to meet all your regular monthly household expenses?
C04

If any month is indicated in C03, please tell us how did you cover the deficit?
C05

Which of the following assets are available in your house? Select all that apply

C05_1

Refrigerator
C05_2

Traditional Stove gas/burner (kerosene, firewood, cow dung etc)
C05_3

Modern cooking gas stove/burner

C05_4

Microwave oven
C05_5

Telephone / Mobile Phone (Smart phone not included)
C05_6

Smart Phone
C05_7

Computer/Laptop/Tablet
C05_8

Motorcycle / scooter
C05_9

Car/Jeep/Van
C05_10

Sewing / weaving tools
C05_11

Cooler
C05_12

Air Conditioner (AC)
C05_13

Washing Machine
C05_14

Generator / Inverter set
C05_15

Dining table and chair
C05_16

Chair/stool/bench/table
C05_17

Sofa/Couch
C05_18

TV
C05_19

Smart TV
C05_20

WIFI
C05_21

Ceiling Fan
C05_22

Individual solar light / panel
C05_23

Electricity Connection
C05_24

24hrs Electricity Connection
C05_25

Bank account
C06

Please indicate whether your household own livestock and their numbers.

C06_1

Goat/sheep
C06_2

Cowns/buffaloes/bullocks
C06_3

Poultry birds (chicken/duck)
C06_4

Horses
C06_5

Yaks
C06_6

Pigs
C06_7

Other animals (donkeys/camels, etc.)
C07

What is the main source of drinking water in your household?
C08

What kind of toilet facilities do members of your household usually use?
C09

What is the ownership status of the house in which you are currently residing?
C10

If you or any member of your household uses or occupies any land (agricultural/non-agricultural land, excluding the house you live in currently)?
C10A

IF C10=Yes, what is the ownership status of that agricultural/non-agricultural land (excluding the house you live in currently)?
C11

Any death in your household since January 2020? TICK ONE
C11A

If “YES” to C11, then How many death/s in your household since January 2020? If there were deaths, go to “Mortality Detail” Form with as many rows as deaths OR else continue with C12
C12

Does your household own a business in the settlement/your place of residence?
C12A

If “YES” to C12, then what type of settlement-based business?
C13

Did the household obtain a loan in the last one year?
C13A

If “YES” to C13, then specify the followings source/s of loan
C13B

Purpose of loan
C13C

Number of loans taken since January 2023?

C13D

Loan Amount
C13E

Rate of Interest
C13F

Duration of loan
C13G

If “NO” to C13, then give reason/s
C14

[Do not ask this question to the respondent] Based on your observation, please indicate what material has been used to construct the walls and the roof of the structure where this family/individual resides.

C14A

Is the material used to construct the walls any of the following?
C14B

Is the material used to construct the roof any of the following?
C15

Type of the Structure of House
Mortality Detail Questionnaire
D01

Gender
D02

Age in years at the time of death
D03

Year of death

D04

Name of the Place of Death
D05

Greenbook Number of the deceased