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Household Template 29 -Form Fill
INTERVIEW DETAILS AND QUALITY ASSURANCE
Q01
Name of the State
Q02
Name of the District
Q03
Name of the Block
Q04
Name of Panchayat
Q05
Name of the Village (PSU)
Q06
Structure Number
Q07
Household Number
Q08
Address of Household
Q09
Nearest Post Office
Q10
Pincode
Q11
Household type
Electrified……..For electrified HH Module A to Module G,K
Unelectrified…………For unelectrified Module A to B & Module H-K
Q12
Date
Q13
Result
Completed
Not at home
Postponed
Refused
Partly Completed
Others (specify)
HOUSEHOLD PROFILE
A01
Name of the respondent
A02
Respondent’s age
A03
What is the sex of respondent?
Male
Female
Transgender
A04
Name of the household head
A05
Age of household head
A06
What is the sex of household head?
Male
Female
Transgender
A07
What is your religion?
Hindu
Muslim
Christian
Sikh
Buddhist/Neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No Religion
Other (Specify)
A08
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)
A09
Member ID
A10
Name
A11
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
A12
Sex
Male
Female
Transgender
A13
Age
A14
Education
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 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
A15
Marital status?
Unmarried
Married
Widowed
Divorced
Separated
Deserted by spouse
A16
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
A20
Please specify whether you belong to APL/BPL?
APL
BPL
Don’t know/can’t say
A22
How many years since you have been staying in the current residence?
0-1 years
1-2 years
More than 2 years
A23
Where were you living before coming to this place?
Same block different village/ward
Same district different block
Different district same state
Different State
A24
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
HOUSEHOLD CHARACTERISTICS
B02
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)
B03
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)
B04
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)
B06
Type of window
WINDOWS WITH GLASS
WINDOWS WITH SCREENS
WINDOWS WITH CURTAINS OR SHUTTERS
B07
How many rooms in this house are used for sleeping?
B09
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)
B10
What is the main source of lighting in this household?
LANTERN
KEROSENE LAMP
CANDLE
ELECTRIC
LPG/BATTERY
SOLAR ENERGY
NONE
OTHERS (SPECIFY)
B11
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)
B12
How long does it take to go to the water source, get water, and come back?
B13
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)
B14
Does your household have
ELECTRICITY FROM NATIONAL GRID
C01
Since how many years do you have this grid connection?
C02
Who decided to get this connection?
C03
Under whose name is the connection?
C04
How much did your household pay for the grid connection fee?
C05
How much did your household pay for the internal wiring?
C06
How many days after you applied for the grid connection did your household get connected? (Insert 0 if immediate)
C07
How many days after you were connected were you able to use electricity in your home? (Insert 0 if immediate)
C09
How are you billed for electricity?
Fixed monthly fee
Pay based on lights and appliances used
Utility estimates consumption
Other, specify
No bill for electricity
C10
How do you pay for your electricity usage?
Cash
Vouchers/token/pre-paid card from local store
Credits using mobile money
Credit, using other ways
Other, specify
Do not pay for electricity usage
C11
How frequently do you make your payment?
Weekly
Bi-weekly
Monthly
Every 6 months
Other
C17
How long after the complain the issue was rectified
C18
If the respondent pays the energy company or has a record of the electricity payment, ask to see the electricity bill/invoice and use it for next two questions
Respondent has energy bill and shows it
Respondent has energy bill but refuses to show it or could not locate it
Respondent does not have an energy bill
Don’t Know
C19
In the last month, how much did you spend on the electric bill?
C20
In the last month how many units of electricity did your household consume?
C21
In a typical month, how much do you spend on electricity?
C23
How many hours of load shedding is done in a day?
C25
How many hours of electricity are available each evening, from 6:00 pm to 10:00 pm from the grid, during a typical month? (max 4 hours)
C27
In case of a complain, how many days does it take for resolution?
C28
The last time you asked for assistance in a power failure, how many days after you contacted the power company did they come to fix the problem?
C29
What is your main back-up source of lighting during outages/blackouts of the grid?
Local mini grid connection local
Electric generator
Rechargeable battery and storage devices (e.g.: car battery)
Solar Lantern
Solar Home System
Kerosene lamp
Dry-cell (non-rechargeable) battery/ Torch
Candle
Other, specify
No back-up source
C32
What are the most serious problems you experience with your grid electricity?
Supply shortage/not enough hours of electricity
Low/high voltage problems or voltage fluctuations
Unpredictable interruptions
Unexpectedly high bills
High cost of electricity
Cannot power large appliances
Maintenance/service problems
Other, specify
No problems
C35
What was the reason for this injury?
Carelessness or error
Lack of knowledge about the use of the appliance
Faulty wiring/connection
Other, specify
ENERGY LADDER
D01
Has there been a change in electricity requirement after access to it?
D02
What inspired you take the grid connection?
Electricity supply more regular than other sources
Quality of electricity supply (voltage/Flicker) better than other sources
Pricing of the connection cheaper than other sources
We are now dependant on electricity and other sources are not enough for your requirement
Other (Specify)
D03
Which of the following appliances at your household are connected with the national grid.
D04
Did you take this electrical appliance or increased the number after getting connected to national Grid?
D07
If yes, what all appliances are you planning to buy?
D08
What do you think would happen if you start using more appliances?
The electricity bill will remain the same
The electricity bill will decrease
The electricity bill will increase
Don’t know
EXPENSE
E01
How much do you spend on these in a month?
E01_1
Solar lamps
E01_2
Micro grid
E01_3
Diesel generator
E01_4
Kerosene
E01_5
Fuelwood
E01_6
Solar Home System
E01_7
Others
E02
What is the total monthly expenditure of running the household?
To be administered to female above 18 in the household
F01
Who normally takes the decision about the purpose for which electricity is to be used?
Male members of household
Female members of household
Both male and female members
In the Veranda not lighting the kitchen
F02
Who took the decision of the location of the light to be installed at home?
Male members of household
Female members of household
Both male and female members
In the Veranda not lighting the kitchen
F03
Who will take the decision on the purchase of electrical appliance in the HH
Male members of household
Female members of household
Both male and female members
In the Veranda not lighting the kitchen
F04
Where is the light installed at your house? (Multiple Response)
In the Veranda lighting the kitchen
In the kitchen
In the room used for sleeping
In the Bathroom
Others (Please specify)
F05
How many hours do the children study between 6:00 P.M to 10:00 P.M ?
BENEFITS OF ELECTRICITY ON HEALTH
BENEFITS OF ELECTRICITY ON WOMEN EMPOWERMENT
BENEFITS OF ELECTRIFICATION ON PUBLIC INFRASTRUCTURE
I04
How does the street light make you feel safer?
Safety from theft
Safety from reptiles and insects
Safety from wild animals
Safety of women
Others, specify
CUSTOMER SATISFACTION
J01
Are you satisfied with
J01_1
Installation fees
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_2
Installation process
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_3
Ease of usage
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_4
Hours of electricity supply
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_5
Consistency in terms of voltage
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_6
Quality of service provided such as maintenance
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_7
Accuracy of billing
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_8
Tariff
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
J01_9
Timeliness in addressing complaints
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
Module For unelectrified
K02
Please mention all the energy/Electricity source you have, and the amount spent on each of the source of energy in a month?
K03
What is the average daily requirement of electricity in your household? (in hours)
K06
If yes, what all appliances are you planning to buy?
K08
What is the total monthly expenditure of running the household?
K10
Which of these is a potential reason why you would want a grid connection?
Electricity supply more regular than other sources
Quality of electricity supply (voltage/Flicker) better than other sources
Pricing of the connection cheaper than other sources
We are now dependant on electricity and other sources are not enough for your requirement
Other (Specify)
K11
Why haven’t you taken connection, if the village is electrified?
Lack of funds of initial installation fee
Process of getting a connection very cumbersome
Monthly electricity bill is too high
Internal wiring cost too high
The hours of electricity received per day is too low and not worth spending the initial fee
Others
K13
Why did your household got disconnected to the grid?
Had pending bill amount
Supply was irregular hence got disconnected
The connection issued remained unfixed for many days hence got disconnected
Was disconnected by electricity department without any reason
The bill was inaccurate so got disconnected
Others
To be administered to female above 18 in the household 2
L01
If it was to be decided that electricity connection is to be taken, who would be the decision maker?
Male members of household
Female members of household
Both male and female members
L02
Who would take decision on the location of the light to be installed at home?
Male members of household
Female members of household
Both male and female members
L04
Where is the light installed at your house? (Multiple Response)
In the Veranda not lighting the kitchen
In the Veranda lighting the kitchen
In the kitchen
In the room used for sleeping
In the Bathroom
Others (Please specify)
L05
How many hours do the children study between 6:00 P.M to 10:00 P.M ?
IMPACT OF UNAVAILABILITY OF ELECTRICITY ON HEALTH
BENEFITS OF BASED ELECTRICITY ON PUBLIC INFRASTRUCTURE
N04
How does the street light make you feel safer?
Safety from theft
Safety from reptiles and insects
Safety from wild animals
Safety of women
Others, specify
N12
Are you satisfied with
N12_1
Village electrification
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
N12_2
Fuel availability
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
N12_3
Monthly expenditure on fuel
Very Satisfied
Satisfied
Neutral
Somewhat satisfied
Not Satisfied
Not Relevant
HH Income
O02
What is the amount of money received under remittances in the last 12 months?
O04
What is the type of pension received by you / your household members?
National old age pension scheme
Widows' Pension Scheme
National Maternity Scheme
National Disability Pension
Other Government Programmes
Assistance from NGOs /Charities
Others (specify)
O05
What is the amount of money received from pension (all types) in the last 12 months?
O06
Please mention the name of all household members who are gainfully employed?
O07
Gross Annual income / revenue from primary occupation
O08
Gross Annual income / revenue from secondary occupation (including rent from houses owned and land)
O09
Annual Expense/ Cost
O10
Income from sale of livestock or livestock produce like egg, milk, chicken, goat, etc?
O11
Cost of feeding and maintaining the animals?
O12
Income from property renting (in INR)
Land
House
Agricultural machinery
Others
O13
Income from sale of property in the last one year?
Land
Residential Property
O15
IF YES, How much land?
O16
IF YES, About how much was that land worth?
LAND OWNERSHIP
P02
Total agricultural land owned
P03
How much of your own land do you cultivate?
P05
How much of leased-in land do you cultivate?
P07
What are the two most important modes of irrigation?
Tube Well
Other Well
Government
Private Canal
Tank/pond/nala
Other
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