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Household Template 16 -Form Fill
HOUSEHOLD ROSTER
Q01
Line Number
Q02
Please tell me the names of all the persons who usually live in your household, starting with the head of the household.
Q03
What is the relationship of [NAME] to the head of household?
HEAD OF THE HOUSEHOLD
SPOUSE
SON/DAUGHTER
SON/DAUGHTER IN LAW
GRANDCHILD
FATHER/MOTHER
FATHER/MOTHER IN LAW
BROTHER/SISTER
BROTHER/SISTER IN LAW
NIECE/NEPHEW
GRAND PARENT/GRAND PARENT-IN-LAW
OTHER RELATIVE
ADOPTED/FOSTER/STEPCHILD
DOMESTIC SERVANT
OTHER (SPECIFY)
NOT STATED
Q04
What is the sex of [NAME]?
MALE
FEMALE
TRANSGENDER
Q05
How old is [NAME]?
Q06
What is [NAME’s] marital status?
CURRENTLY MARRIED
MARRIED, GAUNA NOT PERFORMED
WIDOWED
DIVORCED
SEPARATED
DESERTED
NEVER MARRIED
NOT MARRIED, BUT LIVE TOGETHER
Q07
Has (Name) had diarrhea in the last two weeks?
Yes
No
Q08
Was there any blood in the stools?
Yes
No
Q09
What was your age when you got married?
Q10
What was your age when you gave birth to your first child?
Q11
How old was your husband when you got married?
Q12
Do you know how to read and write?
YES, READ AND WRITE
YES, READ ONLY
CAN SIGN ONLY
CANT READ AND WRITE
Q13
Have you ever attended school?
Yes
No
Q14
What is the highest standard or class you completed?
Q15
Apart from housework, have you worked in any job for which you were paid in cash or kind in the last 12 months?
Yes
No
Q16
What kinds of work did/do you do?
FARMER (CROPS)
AGRICULTURAL DAY LABOR
HERDING ANIMALS
NON AGRICULTURAL DAY LABOR
MAID SERVANT
COOK
CHILD CARE PROVIDER
SERVICE/SALARIED WORKER
SMALL/COTTAGE INDUSTRY
PETTY BUSINESS/SHOP
BUSINESS/TRADER
OTHER SELF-EMPLOYMENT
SKILLED WORKER
OTHER (SPECIFY)
Q17
What is the highest standard or class your husband completed?
Q18
In the past 12 months, has your husband been employed?
Yes
No
Q19
What is your husband’s occupation?
FARMER (CROPS)
AGRICULTURAL DAY LABOR
NON AGRICULTURAL DAY LABOR
SERVICE/SALARIED WORKER
SMALL/COTTAGE INDUSTRY
BUSINESS/TRADERS
RICKSHAW/VAN PULLING
SERVANT
COOK
OTHER SELF-EMPLOYMENT
PETTY BUSINESS/SHOP
JOBLESS
SKILLED WORKER
TOO OLD TO WORK
PENSION
OTHER (SPECIFY)
DO NOT KNOW
HOUSEHOLD CHARACTERISTICS (ALL CATEGORIES)
A01
Name of the respondent
A02
Line Number of respondent
A03
What is your religion?
HINDU
MUSLIM
CHRISTIAN
SIKH
BUDDHIST/NEO-BUDDHIST
JAIN
JEWISH
PARSI/ZOROASTRIAN
NO RELIGION
SARNA
OTHER (SPECIFY)
A04
Which caste do you belong to?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CASTE
GENERAL
OTHER (SPECIFY)
A05
What is the type of your household?
Nuclear
Joint
Extended
Others
A06
Does your household own this house or any other house?
Yes
No
A07
Type of house?
Pucca
Semi-pucca
Kutcha
A08
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 TONE/MARBLE/GRANITE
OTHER (SPECIFY)
A09
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)
A10
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)
A11
TYPE OF WINDOWS
A11_1
ANY WINDOWS
Yes
No
A11_2
WINDOWS WITH GLASS
Yes
No
A11_3
WINDOWS WITH SCREENS
Yes
No
A11_4
WINDOWS WITH CURTAINS OR SHUTTERS
Yes
No
A12
How many rooms in this house are used for sleeping?
A13
Do you have a separate room which is used as a kitchen?
Yes
No
A14
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)
A15
What is the main source of lighting in this household?
LANTERN
KEROSENE LAMP
CANDLE
ELECTRIC
LPG/BATTERY
SOLAR ENERGY
NONE
OTHERS (SPECIFY)
A16
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
BOTTLED WATER
GOVERNMENT HAND PUMP
HAND PUMP AT HOME
NEIGHBOUR’S HAND PUMP
OTHER (SPECIFY)
A17
Is the main source of drinking water within the premises of the household?
Yes
No
A18
How far is the main source of drinking water located?
A19
How long does it take to go to the water source, get water, and come back during the rainy season?
A20
How long does it take to go to the water source, get water, and come back during the dry season?
A21
Do you treat / do something special with the water that you fetch to make it safer to drink?
Yes
No
A22
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
OTHER (SPECIFY)
DO NOT KNOW
A23
Does your household have a functional toilet?
Yes
No
A24
What kind of toilet facilities does your household have?
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
OTHER (SPECIFY)
A25
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)
A26
In the past week has anyone in your household including children defecated in the open for example in the field or in the river?
Yes
No
A27
The last time a child passed stools, what was done to dispose of the stools?
CHILD USED TOILET/ LATRINE
PUT/RINSED INTO TOILET OR LATRINE
PUT/RINSED INTO DRAIN OR DITCH
THROWN INTO GARBAGE
BURIED
LEFT/WASHED IN THE OPEN
NO CHILD IN HOUSEHOLD
OTHER (SPECIFY)
DO NOT KNOW
A28
Does the household have soap and water immediately near the toilet facility?
Yes
No
A29
On what occasions did you wash your hands with soap since this time yesterday?
NO SOAP AVAILABLE IN THE HOUSEHOLD
SOAP AVAILABLE IN THE HOUSEHOLD BUT DID NOT USE IT TO WASH HANDS
BEFORE COOKING
AFTER HANDLING FOOD
BEFORE EATING
BEFORE FEEDING THE INFANT
AFTER CLEANING INFANT FECES
WHEN I WASH CLOTHES
WHEN I BATHE
WHEN I WASH DISHES
AFTER USING TOILET
OTHER SPECIFY
A30
Does your household have
A30_1
Electricity
Yes
No
A30_2
A mattress
Yes
No
A30_3
A pressure cooker
Yes
No
A30_4
A chair
Yes
No
A30_5
A cot or bed
Yes
No
A30_6
A table
Yes
No
A30_7
An electric fan
Yes
No
A30_8
A radio or transistor
Yes
No
A30_9
A black and white television
Yes
No
A30_10
A color television
Yes
No
A30_11
A sewing machine
Yes
No
A30_12
A mobile telephone
Yes
No
A30_13
Any other type of telephone
Yes
No
A30_14
A computer/laptop
Yes
No
A30_15
A refrigerator
Yes
No
A30_16
A watch or clock
Yes
No
A30_17
A bicycle
Yes
No
A30_18
A motorcycle or scooter
Yes
No
A30_19
An animal-drawn cart
Yes
No
A30_20
A car
Yes
No
A30_21
A water pump
Yes
No
A30_22
A thresher
Yes
No
A30_23
A tractor
Yes
No
A30_24
Internet
Yes
No
A30_25
Air Conditioner or Cooler
Yes
No
A30_26
Washing Machine
Yes
No
EDUCATION
B01
Name of child
B02
Age
B03
Sex
Boy
Girl
transgender
B04
Reading level
BEGINNER
LETTER
WORD
PARAGRAPH
STORY
Not selected in category
B05
Math level
BEGINNER
NO. RECOGNITION
NO. RECOGNITION (1-9)
NO. RECOGNITION (10-99)
SUBTRACTION
DIVISION
Not selected in category
B06
Was [Name] ever enrolled in any school?
Yes
No
B07
What was the age of [child name] when s/he was enrolled in the school for first time?
B08
From the time that [Name] was enrolled for the first time till what age did s/he go to school without dropping out?
B09
Is [Name] currently attending school/college?
Yes
No
B10
Which school does (s) he go to?
GOVT
PVT
B11
Which standard is [Name] currently enrolled in?
B12
What are the entitlements that [Name] avail at school?
MID-DAY MEAL
POSHAK YOJANA
CYCLE YOJANA
STIPEND FOR DISABLED STUDENTS
MERIT SCHOLARSHIPS
SCHOLARSHIPS FOR SC/ST STUDENTS
BOOKS
OTHERS (SPECIFY)
NO ENTITLEMENT
ACESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
C01
Have you ever heard about _?
C01_1
Indira Awas Yojna (IAY)
Yes
No
C01_2
Swajaldhara
Yes
No
C01_3
Swachh Bharat Abhiyan
Yes
No
C01_4
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
C01_5
Pradhanmantri Surakha Beema Yojana (accidental death insurance)
Yes
No
C01_6
Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
Yes
No
C01_7
Atal Pension Yojana
Yes
No
C01_8
Pension for the disabled
Yes
No
C01_9
Mukhyamantri Grameen Awas Yojana
Yes
No
C01_10
Ladli Laxmi Yojana
Yes
No
C01_11
Ujjwala Yojana
Yes
No
C01_12
Prime Minister Crop Insurance Scheme
Yes
No
C01_13
Prime Minister Livestock Insurance Scheme
Yes
No
C02
Is your household / anyone in your household eligible for this scheme?
C02_1
Indira Awas Yojna (IAY)
Yes
No
C02_2
Swajaldhara
Yes
No
C02_3
Swachh Bharat Abhiyan
Yes
No
C02_4
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
C02_5
Pradhanmantri Surakha Beema Yojana (accidental death insurance)
Yes
No
C02_6
Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
Yes
No
C02_7
Atal Pension Yojana
Yes
No
C02_8
Pension for the disabled
Yes
No
C02_9
Mukhyamantri Grameen Awas Yojana
Yes
No
C02_10
Ladli Laxmi Yojana
Yes
No
C02_11
Ujjwala Yojana
Yes
No
C02_12
Prime Minister Crop Insurance Scheme
Yes
No
C02_13
Prime Minister Livestock Insurance Scheme
Yes
No
C03
Has anyone in your household ever availed this scheme?
C03_1
Indira Awas Yojna (IAY)
Yes
No
C03_2
Swajaldhara
Yes
No
C03_3
Swachh Bharat Abhiyan
Yes
No
C03_4
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
C03_5
Pradhanmantri Surakha Beema Yojana (accidental death insurance)
Yes
No
C03_6
Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
Yes
No
C03_7
Atal Pension Yojana
Yes
No
C03_8
Pension for the disabled
Yes
No
C03_9
Mukhyamantri Grameen Awas Yojana
Yes
No
C03_10
Ladli Laxmi Yojana
Yes
No
C03_11
Ujjwala Yojana
Yes
No
C03_12
Prime Minister Crop Insurance Scheme
Yes
No
C03_13
Prime Minister Livestock Insurance Scheme
Yes
No
C04
When was the last time someone in your household used this scheme?
C04_1
Indira Awas Yojna (IAY)
C04_2
Swajaldhara
C04_3
Swachh Bharat Abhiyan
C04_4
Janani Shishu Suraksh Karykaram (JSSK)
C04_5
Pradhanmantri Surakha Beema Yojana (accidental death insurance)
C04_6
Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
C04_7
Atal Pension Yojana
C04_8
Pension for the disabled
C04_9
Mukhyamantri Grameen Awas Yojana
C04_10
Ladli Laxmi Yojana
C04_11
Ujjwala Yojana
C04_12
Prime Minister Crop Insurance Scheme
C04_13
Prime Minister Livestock Insurance Scheme
C05
Have you ever heard about Mahatma Gandhi National Rural Employment Guarantee Act?
Yes
No
C06
Does anyone in your household have a MGNREGA job card? If yes, please show me.
YES, SEEN
YES, REPORTED BUT NOT SEEN
NO
C07
In the past year, how many days did members of your household work for MGNREGA?
C08
For this total number of days worked by household members, how many days were worked by men and how many days were worked by women?
C09
When was the last time someone in your household worked for MGNREGA in last 1 year?
C10
Have you ever heard of Public Distribution System?
Yes
No
C11
Have you ever heard of Antyodaya Anna Yojana?
Yes
No
C12
Does your household have a ration card?
Yes
No
C13
Is your name included in the ration card?
Yes
No
C14
Which card do you have?
ANTODAYA ANNA YOJANA
ANNAPURNA
BPL
APL
OTHER
DO NOT KNOW
C15
In the past 30 days, did you buy anything from a ration shop?
Yes
No
C16
Which items did you buy from the ration shop in the last 30 days and in what quantity?
C16_1
Rice
Yes
No
C16_2
Wheat
Yes
No
C16_3
Sugar
Yes
No
C16_4
Salt
Yes
No
C16_5
Kerosene
Yes
No
C16_6
Clothes
Yes
No
C17
Quantity Purchased
C17_1
Rice
C17_2
Wheat
C17_3
Sugar
C17_4
Salt
C17_5
Kerosene
C17_6
Clothes
C18
Have you ever heard of the ICDS scheme / Anganwadi centre?
Yes
No
C19
At present is there any ____ in your household?
C19_1
Pregnant Woman
Yes
No
C19_2
Lactating Woman
Yes
No
C19_3
Child aged 6-35 months
Yes
No
C19_4
Child aged 3-6 years
Yes
No
C20
Did the member receive supplementary nutrition / hot cooked food from the AWC in the last 12 months?
C20_1
Pregnant Woman
Yes
No
C20_2
Lactating Woman
Yes
No
C20_3
Child aged 6-35 months
Yes
No
C20_4
Child aged 3-6 years
Yes
No
C21
How many times did the member receive food from the AWC in the last month?
C21_1
Pregnant Woman
C21_2
Lactating Woman
C21_3
Child aged 6-35 months
C21_4
Child aged 3-6 years
C22
Have you ever heard about the Janani suraksha Yojana Scheme?
Yes
No
C23
Do you know how much money the beneficiary is supposed to get under the JSY scheme?
C24
Does the household avail the following?
C24_1
SAVINGS
Yes
No
C24_2
CREDIT
Yes
No
C24_3
INSURANCE
Yes
No
C24_4
REMITTANCE
Yes
No
C24_5
PENSION
Yes
No
C25
Where does the household save?
SHG
GOVERNMENT BANK
COOPERATIVE BANK
PRIVATE BANK
POST OFFICE
FRIENDS / RELATIVES
AT HOME
OTHERS (Specify)
C26
From what sources does the household avail credit?
SHG
GOVERNMENT BANK
COOPERATIVE BANK
PRIVATE BANK
FRIENDS / RELATIVES
KISAN CREDIT CARD
MONEY LENDERS
OTHERS (Specify)
C27
What type of insurance does the household have?
LIFE INSURANCE
ASSET INSURANCE
LIVESTOCK INSURANCE
CROP INSURANCE
HEALTH INSURANCE
ACCIDENT INSURANCE
OTHER (SPECIFY)
C28
Does anyone in your household have a bank account opened under the Pradhan Mantri Jan Dhan Yojana?
Yes
No
C29
Has the account been operated in the last 3 months?
Yes
No
C30
What activity was performed on the account?
WITHDRAWL
DEPOSIT
OTHER (SPECIFY)
DO NOT KNOW
C31
Have you availed the overdraft facility from your account under the Jan Dhan Yojana in the last 1 year?
Yes
No
C32
If yes, what was the overdraft amount?
C33
Does any member of your household avail retirement pension?
Yes
No
C34
What are the pensions that the household members receive?
CENTRAL GOVERNMENT PENSION
STATE GOVERNEMENT PENSION
PRIVATE COMPANY PENSION
CONTRIBUTARY PENSION FROM BANK (NATIONALIZED OR PRIVATE)
OTHER
C35
Have you ever heard of the old Age Pension Scheme?
Yes
No
C36
How many members in your household were eligible for the Old Age Pension Scheme in the last 1 year?
C37
How many members availed the Old Age Pension Scheme in the last 1 year?
C38
Have you ever heard of the widow pension scheme?
Yes
No
C39
How many members in your household were eligible for the Widow Pension Scheme in the last 1 year?
C40
How many members have availed the Widow Pension Scheme in the last 1 year?
C41
Have you ever heard about Rashtriya Swasth Bima Yojana (RSBY)?
Yes
No
C42
Does your Household have a RSBY smart card?
Yes
No
C43
Was the smart card updated in the last one year?
Yes
No
C44
Did anyone in your household use the smart card in last one year?
Yes
No
Awareness to acts and entitlements
D01
Are you aware of NREGA scheme? EXPLAIN: In which you get a job card and can avail employment?
Yes
No
D02
Can you highlight some of the key provisions of NREGA?
D02_1
Every adult member of the HH whose name appears on the job card can apply for unskilled work under NREGA
Spontaneous
Prompt
Do Not Know
D02_2
Registration for job card has to be made at Gram Panchayat
Spontaneous
Prompt
Do Not Know
D02_3
A registered HH can get employment for maximum 100 days in a year
Spontaneous
Prompt
Do Not Know
D02_4
Wages paid within a fortnight of the end of the work
Spontaneous
Prompt
Do Not Know
D02_5
Work under NREGA has to be provided within a period of 15 days of application by HH
Spontaneous
Prompt
Do Not Know
D02_6
Work site facilities like toilet, drinking water, crèche for children, first aid etc.
Spontaneous
Prompt
Do Not Know
D02_7
Social audit in NREGA
Spontaneous
Prompt
Do Not Know
D03
Are you aware of Forest Right Act (FRA) which vests ownership of forest land for Scheduled Tribes and Other Forest Dwellers?
Yes
No
D04
What are the key provisions of FRA?
D04_1
Right to live in the forest
Spontaneous
Prompt
Do Not Know
D04_2
Community rights such as nistar
Spontaneous
Prompt
Do Not Know
D04_3
Right to collect, use or dispose NTFPs
Spontaneous
Prompt
Do Not Know
D04_4
Right to rehabilitation in case of eviction or displacement from forest land
Spontaneous
Prompt
Do Not Know
D04_5
Rights for conversion of leases or grants on forest land to titles
Spontaneous
Prompt
Do Not Know
D04_6
Right to conserve and manage any forest produce which has been traditionally protected and conserved
Spontaneous
Prompt
Do Not Know
D05
Are you aware of SC/ST Atrocities Act which protects disadvantaged sections of the society from atrocities committed against them by people from higher castes?
Yes
No
D06
What all offences/activities can be considered as atrocities?
D06_1
Caste or tribe based discrimination
Spontaneous
Prompt
Do Not Know
D06_2
Insult/injury with respect to caste or tribe
Spontaneous
Prompt
Do Not Know
D06_3
Forced not to vote or vote to a particular candidate in any election
Spontaneous
Prompt
Do Not Know
D06_4
Denied access or passage to a public place/resort
Spontaneous
Prompt
Do Not Know
D06_5
Forced to leave your house/village/land/other place of residence
Spontaneous
Prompt
Do Not Know
D07
Are you aware of Domestic Violence Act which protects the women against atrocities committed against them within the family?
Yes
No
D08
What are the provisions that come under DV Act?
D08_1
Different kind of abuses like physical, emotional, psychological, sexual and economic are punishable by law
Spontaneous
Prompt
Do Not Know
D08_2
Making an application to obtain relief by custody order, compensation order etc.
Spontaneous
Prompt
Do Not Know
D08_3
Right to free legal service to file a complaint
Spontaneous
Prompt
Do Not Know
D09
Are you aware of Right To Information (RTI) Act which lets citizens secure access to information under control of public authorities?
Yes
No
D10
What are the key provisions under RTI?
D10_1
To get information from the Government as a matter of right
Spontaneous
Prompt
Do Not Know
D10_2
Rs. 10 as prescribed fee for APL for seeking information
Spontaneous
Prompt
Do Not Know
D10_3
No fee prescribed for BPL for seeking information
Spontaneous
Prompt
Do Not Know
D10_4
No prescribed format for seeking information
Spontaneous
Prompt
Do Not Know
D10_5
Information to an applicant to be supplied within 30 days from the receipt of application by the public authority
Spontaneous
Prompt
Do Not Know
D11
Are you aware of the Right to Education Act, which provides free and compulsory education to all children aged 6 to 14 years
Yes
No
D12
What are the provisions that come under the RTE Act?
D12_1
Every child of the age of 6 to14 be provided 8 years of free and compulsory elementary education
Spontaneous
Prompt
Do Not Know
D12_2
Primary schools are established within walking distance of 1 Km of neighborhood
Spontaneous
Prompt
Do Not Know
D12_3
Secondary schools are established within walking distance of 3 Km of neighborhood
Spontaneous
Prompt
Do Not Know
D12_4
No child shall be liable to pay any kind of fee or charges or expenses which may stop the child from getting education
Spontaneous
Prompt
Do Not Know
D13
Are you aware of the entitlements under Public distribution system?
Yes
No
D14
What are the major commodities distributed through PDS?
D14_1
Wheat
Spontaneous
Prompt
Do Not Know
D14_2
Rice
Spontaneous
Prompt
Do Not Know
D14_3
Sugar
Spontaneous
Prompt
Do Not Know
D14_4
Kerosene
Spontaneous
Prompt
Do Not Know
D14_5
Clothes
Spontaneous
Prompt
Do Not Know
D15
Are you aware of the entitlements under Old Age Pension Scheme?
Yes
No
D16
What are the features of OAP scheme?
D16_1
Covers all Indians above 60 years of age and living below the poverty line
Spontaneous
Prompt
Do Not Know
D16_2
The beneficiaries aged 60-79 receive a monthly pension of Rs. 200
Spontaneous
Prompt
Do Not Know
D16_3
Those 80 years and above receive a monthly pension amount of Rs. 500
Spontaneous
Prompt
Do Not Know
D17
Are you aware of the entitlements from Angan Wadi Center?
Yes
No
D18
What are the entitlements available under this?
D18_1
Pregnant women in the village are provided supplementary nutrition / Take Home Ration
Spontaneous
Prompt
Do Not Know
D18_2
Lactating women in the village are provided supplementary nutrition / Take Home Ration
Spontaneous
Prompt
Do Not Know
D18_3
Children aged 6-35 years receive supplementary nutrition / Take Home Ration
Spontaneous
Prompt
Do Not Know
D18_4
Children aged 3-6 years receive hot cooked food at the AWC
Spontaneous
Prompt
Do Not Know
D18_5
Children aged 3-6 years receive pre-school education
Spontaneous
Prompt
Do Not Know
D19
Are you aware of the entitlements available under the Janani Suraksha Yojana?
Yes
No
D20
What are the entitlements available under this?
D20_1
Women giving birth to a child at a Government health facility are entitled to benefit from this
Spontaneous
Prompt
Do Not Know
D20_2
Such women are entitled to a sum of Rs. 1400 for institutional delivery
Spontaneous
Prompt
Do Not Know
D21
Are you aware of the entitlements available under the Swach Bharat Abhiyan?
Yes
No
D22
What are the entitlements available under this?
D22_1
Incentive to construct household latrines to BPL and identified APL families
Spontaneous
Prompt
Do Not Know
D22_2
HHs are provided upto Rs. 12,000 for construction of one unit of IHHL
Spontaneous
Prompt
Do Not Know
D22_3
Payments for these incentives are in the form of cash or construction materials or in the form of credit vouchers for construction materials
Spontaneous
Prompt
Do Not Know
D23
Are you aware of the entitlements available under the Mid-Day Meal scheme?
Yes
No
D24
What are the entitlements available under this?
D24_1
Every child in every Government and Government assisted Primary Schools will be provided a prepared mid-day meal each school day for a minimum of 200 days
Spontaneous
Prompt
Do Not Know
D24_2
The cost for preparation of food shall not be borne by children or their parents
Spontaneous
Prompt
Do Not Know
D24_3
In drought affected areas, midday meals shall be supplied even during summer vacations
Spontaneous
Prompt
Do Not Know
D25
Are you aware of the entitlements under the Sarva Shiksha Abhiyan?
Yes
No
D26
What are the entitlements available under this?
D26_1
Provision of free text books and stationary
Spontaneous
Prompt
Do Not Know
D26_2
Provision of school uniforms
Spontaneous
Prompt
Do Not Know
D26_3
Provision of bicylces to girls enrolled in upper primary sections outside the village
Spontaneous
Prompt
Do Not Know
LAND OWNERSHIP AND USE OF LAND FOR FARMING
E01
Does any your household own, lease in any agricultural land?
Yes
No
E02
Does your household engage in agricultural activities?
Yes
No
E03
How much agricultural land does your household presently have access to:
E03A
OWNED LAND
E03A1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E03B
LEASED LAND
E03B1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04
Out of this land how much is irrigated or rainfed?
E04A
Owned land
E04A1
IRRIGATED LAND
E04A1_1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04A2
RAINFED LAND
E04A2_1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04B
Leased land
E04B1
IRRIGATED LAND
E04B1_1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04B2
RAINFED LAND
E04B2_1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
Risk taking Behaviour and adoption of new crop varieties
F01
What is the main crop that your produce?
WHEAT
RICE
MAIZE
FINGER MILLET
Cotton
soyabean
daal
Groundnut
OTHERS (SPECIFY)
F02
Now I would like to ask you whether you are completely dependent on your main crop or you also grow other crops or engage in livestock rearing or other non-farm activites.
OPT FOR DIFFERENT VARIETY OF SAME CROPS
GROW OTHER CROPS
ENGAGE IN LIVESTOCK REARING
ENGAGE IN OTHER NON-FARM ACTIVITIES
NO MEASURES TAKEN
OTHERs (SPECIFY)
F03
What type of crops do you choose to grow?
GROW OTHER VEGETABLE CROPS
GROW FRUIT CROPS
ENGAGE IN FLORICULTURE
OTHER CERIAL
OTHER PULSE
OTHERS (SPECIFY)
F04
What type of animals do you rear
COWS
BUFFALO
PIGS
POULTRY
FISHERY
GOAT
OTHERS (SPECIFY)
F05
What type of non-farm activities do you undertake?
SMALL SCALE ENTERPRISE
LARGE SCALE ENTERPRISE
LOCAL AGRI LABOUR
LOCAL NON-AGRI LABOUR
MIGRANT LABOUR
OTHERS (SPECIFY)
PRODUCTION TECHNOLOGY
G01
Main crop of household
WHEAT
RICE
MAIZE
FINGER MILLET
Cotton
soyabean
daal
Groundnut
OTHERS (SPECIFY)
G02
What type of seed was primarily used for production of ____?
Improved
Local
Don’t know
G03
When was the last time you purchased new seeds for this crop?
Within 12 months
12-24 months
24-36 months
Beyond 36 months
Never Purchased
Don’t know
G04
Do you treat the seeds in some way before planting?
Yes
No
G05
How long before transplantation/sowingdo you practice weeding?
G06
Do you use a germination test to check the seeds?
Yes
No
G07
Was any fertilizer used on the land during production of _______?
Organic
K (Potash)
P(Phosphate)
N (Nitrogen/ Urea)
Composite (DAP, N`PK, Gromor etc.)
Organic and chemical both
None
Other
Don’t know
G08
Do you apply anything else to improve the quality of the soil?
Apply Lime
Apply Dolomite
Apply anything else
Nothing
Don’t know
G09
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
First broadcast then line planting/transplanting
Don’t know
G10
At what stage of the cropping practices do you usually apply urea?
Never
At the time of sowing
After irrigation
Before irrigation
After weeding
Before weeding
During Eartning up
Flowering stage
Don’t know
G11
How many days after planting do you irrigate the crop?
G12
After planting, when do you practice earthing-up?
Immediately
Within 7 days
Within 30 days
After 1month
Any time
Never
Do not need earthing
Don’t know
G13
Do you practice hoeing in fields where you grow _____?
Yes
No
G14
What inputs does your HH normally purchase for a cropping season
SEEDS
CHEMICAL FERTILIZERS
ORGANIC FERTILIZERS
CHEMICAL PESTICIDES
ORGANIC PESTICIDES
FARMING TOOLS (such as spades, sickles etc.)
FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
G14A
Do you ever go to purchase _____ for the crop?
G14A_1
SEEDS
Yes
No
G14A_2
CHEMICAL FERTILIZERS
Yes
No
G14A_3
ORGANIC FERTILIZERS
Yes
No
G14A_4
CHEMICAL PESTICIDES
Yes
No
G14A_5
ORGANIC PESTICIDES
Yes
No
G14A_6
FARMING TOOLS (such as spades, sickles etc.)
Yes
No
G14A_7
FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
Yes
No
G15
Who decides on the purchase of inputs required for farming?
G15_1
SEEDS
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_2
CHEMICAL FERTILIZERS
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_3
ORGANIC FERTILIZERS
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_4
CHEMICAL PESTICIDES
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_5
ORGANIC PESTICIDES
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_6
FARMING TOOLS (such as spades, sickles etc.)
self
husband
any other male member
other female members
both male and female members
other (specify)
G15_7
FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
self
husband
any other male member
other female members
both male and female members
other (specify)
G16
Where does your HH purchase the inputs from?
G16_1
SEEDS
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_2
CHEMICAL FERTILIZERS
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_3
ORGANIC FERTILIZERS
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_4
CHEMICAL PESTICIDES
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_5
ORGANIC PESTICIDES
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_6
FARMING TOOLS (such as spades, sickles etc.)
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G16_7
FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
Farmers cooperative/group
others (specify)
do not know
G17
What according to you is the best place to buy the agricultural inputs from?
G18
Why do you think ____ is the best place to buy the agricultural inputs?
G18_1
SEEDS
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_2
CHEMICAL FERTILIZERS
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_3
ORGANIC FERTILIZERS
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_4
CHEMICAL PESTICIDES
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_5
ORGANIC PESTICIDES
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_6
FARMING TOOLS (such as spades, sickles etc.)
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G18_7
FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
easily accessible
cheaper inputs are available
better quality inputs are available
more stock availability
Get on credit
Because hh members/all villagers purchase from there
others (specify)
G19
Does your hh sell any of the agricultural produce in the market?
Yes
No
G19A
Do you ever go to sell _____?
G19A_1
Cereal
Yes
No
G19A_2
Pulses
Yes
No
G19A_3
Vegetable
Yes
No
G19A_4
Fruits
Yes
No
G20
Who decides on the sale of the produce in the market?
G20_1
Cereal
self
husband
any other male member
other female members
both male and female members
other (specify)
G20_2
Pulses
self
husband
any other male member
other female members
both male and female members
other (specify)
G20_3
Vegetable
self
husband
any other male member
other female members
both male and female members
other (specify)
G20_4
Fruits
self
husband
any other male member
other female members
both male and female members
other (specify)
G21
Where does your hh sell the produce?
G21_1
Cereal
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G21_2
Pulses
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G21_3
Vegetable
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G21_4
Fruits
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G22
What according to you is the best place to sell the agricultural produce?
G22_1
Cereal
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G22_2
Pulses
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G22_3
Vegetable
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G22_4
Fruits
local weekly markets (haat)
local dealers
market in nearest town
market in block headquarters
market in district headquarters
other villagers
Government Centres where produce is sold at MSP
OTHERS (SPECIFY)
do not know
G23
Why do you think ____ is the best place to sell the agricultural produce?
G23_1
Cereal
Easily accessible/convenient
Better market price
Do not produce sufficient quantity to sell in larger markets
Because household members/all villagers sell there
G23_2
Pulses
Easily accessible/convenient
Better market price
Do not produce sufficient quantity to sell in larger markets
Because household members/all villagers sell there
G23_3
Vegetable
Easily accessible/convenient
Better market price
Do not produce sufficient quantity to sell in larger markets
Because household members/all villagers sell there
G23_4
Fruits
Easily accessible/convenient
Better market price
Do not produce sufficient quantity to sell in larger markets
Because household members/all villagers sell there
Women’s space in agricultural decision making and gendered division of labor
H01
Did you participate in_____ in the past 12 months?
H01_1
Food crop farming: crops that are grown primarily for household food consumption
Yes
No
H01_2
Cash crop farming: crops that are grown primarily for sale in the market
Yes
No
H01_3
Livestock raising
Yes
No
H01_4
Poultry (e.g. chicken, duck, pigeon)
Yes
No
H01_5
piscicultue or fishpond culture
Yes
No
H02
How much input did you have in making decisions about_____?
H02_1
Food crop farming: crops that are grown primarily for household food consumption
NO INPUT
INPUT INTO VERY FEW DECISIONS
INPUT INTO SOME DECISIONS
INPUT INTO MOST DECISIONS
INPUTS INTO ALL DECISIONS
H02_2
Cash crop farming: crops that are grown primarily for sale in the market
NO INPUT
INPUT INTO VERY FEW DECISIONS
INPUT INTO SOME DECISIONS
INPUT INTO MOST DECISIONS
INPUTS INTO ALL DECISIONS
H02_3
Livestock raising
NO INPUT
INPUT INTO VERY FEW DECISIONS
INPUT INTO SOME DECISIONS
INPUT INTO MOST DECISIONS
INPUTS INTO ALL DECISIONS
H02_4
Poultry (e.g. chicken, duck, pigeon)
NO INPUT
INPUT INTO VERY FEW DECISIONS
INPUT INTO SOME DECISIONS
INPUT INTO MOST DECISIONS
INPUTS INTO ALL DECISIONS
H02_5
piscicultue or fishpond culture
NO INPUT
INPUT INTO VERY FEW DECISIONS
INPUT INTO SOME DECISIONS
INPUT INTO MOST DECISIONS
INPUTS INTO ALL DECISIONS
H03
Are you engaged in any of the agricultural activities?
Yes
No
H04
Are you engaged in ________?
H04_1
Tilling/ Ground preparation
Yes
No
H04_2
Sowing/Transplanting
Yes
No
H04_3
Intercultural operations (weeding, hoeing)
Yes
No
H04_4
Fertiliser application
Yes
No
H04_5
Irrigation application
Yes
No
H04_6
Harvesting
Yes
No
H05
Why do you think you should be involved in this activity?
H05_1
Tilling/ Ground preparation
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
H05_2
Sowing/Transplanting
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
H05_3
Intercultural operations (weeding, hoeing)
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
H05_4
Fertiliser application
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
H05_5
Irrigation application
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
H05_6
Harvesting
IT’S MY RESPONSIBILITY
IT REQUIRES LESS LABOUR
THIS WORK IS BETTER SUITED FOR WOMEN
IT SAVES TIME OF OTHER MEMBERS
INCOME
I01
Did anyone in the household earn income from any of the following sources in the last 12 months?
I01_1
In last 12 months has anyone in your household engaged in agriculture labour
Yes
No
I01_2
In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging wells etc.
Yes
No
I01_3
In last 12 months has anyone in your household engaged in skilled labour
Yes
No
I01_4
In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
I01_5
In last 12 months has anyone in your household engaged in NTFP selling
Yes
No
I01_6
In last 12 months has anyone in your household earned from salaried job?
Yes
No
I01_7
In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock as we will talk about agriculture and livestock later
Yes
No
I02
Who in the household earned income over last 12 months?
I02_1
In last 12 months has anyone in your household engaged in agriculture labour
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_2
In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging wells etc.
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_3
In last 12 months has anyone in your household engaged in skilled labour
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_4
In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_5
In last 12 months has anyone in your household engaged in NTFP selling
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_6
In last 12 months has anyone in your household earned from salaried job?
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I02_7
In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock as we will talk about agriculture and livestock later
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
I03
How much did the household earn from [activity] ______ over the past 12 months?
I03_1
In last 12 months has anyone in your household engaged in agriculture labour
I03_2
In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging wells etc.
I03_3
In last 12 months has anyone in your household engaged in skilled labour
I03_4
In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
I03_5
In last 12 months has anyone in your household engaged in NTFP selling
I03_6
In last 12 months has anyone in your household earned from salaried job?
I03_7
In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock as we will talk about agriculture and livestock later
I04
In the last 12 months, has any member of the household or other relatives have sent you any money from outside?
Yes
No
I05
How often has your household received remittances in the last 12 months?
EACH MONTH
MANY TIMES / YEAR
TWICE A YEAR
ONCE A YEAR
LESS THAN ONCE A YEAR
DO NOT KNOW
I06
How much money did your household receive as remittances in the last 12 months?
I07
During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc.?
Yes
No
I08
How many _______ did you sell in the last 12 months?
I08_1
Buffalo
I08_2
Oxen
I08_3
Cow
I08_4
Goat
I08_5
Sheep
I08_6
Duck
I08_7
Poultry
I08_8
Pig
I08_9
Fish
I09
How much did your household receive for the sale of these _________ in the last 12 months?
I09_1
Buffalo
I09_2
Oxen
I09_3
Cow
I09_4
Goat
I09_5
Sheep
I09_6
Duck
I09_7
Poultry
I09_8
Pig
I09_9
Fish
I10
Now we would like some information on your household's production and selling of animal products. Please only consider the previous 12 months.
I11
Did you produce any ___ during the last 12 months?
I11_1
Animal/Fish meat/offal
Yes
No
I11_2
Poultry meat/offal
Yes
No
I11_3
Milk (including that produced for milk products)
Yes
No
I11_4
Eggs
Yes
No
I12
Did your household sell any of the ___ produced?
I12_1
Animal/Fish meat/offal
Yes
No
I12_2
Poultry meat/offal
Yes
No
I12_3
Milk (including that produced for milk products)
Yes
No
I12_4
Eggs
Yes
No
I13
How much in total did your household receive for the sale of ________?
I13_1
Animal/Fish meat/offal
I13_2
Poultry meat/offal
I13_3
Milk (including that produced for milk products)
I13_4
Eggs
I14
Did your household engage in agricultural activities in the past 12 months?
Yes
No
I15
Crop Code
RICE
WHEAT
MAIZE
SORGHUM
MILLETS
BUCKWHEAT
BARLEY
GROUNDNUT
SOYBEANS
LENT
PEAS
CHICKPEAS
BEANS
SUGARCANE
COTTON
SUNFLOWER
TOBACCO
TEA
OIL SEEDS
SWEET POTATOES
POTATOES
CARROTS
CUCUMBER
CHILI
EGGPLANT
GREEN LEAFY VEGETABLES
OKRA / LADY FINGER
ONION
CAPSICUM
CABBAGE
CAULIFLOWER
BOTTLE GOURD
SPONGE GOURD
BITTER GOURD
GREEN BEANS
GARLIC
GINGER
PUMPKIN / ZUCHIMI
TOMATO
AVOCADO
GUAVA
MANGO
LEMON / LIME
ORANGE / TANGERINE
PAPAYA
MELON
LYCHEE
APPLE
BERRIES
BANANAS
SARSON
URAT DAL
MUSSOR DAL
ARHAR DAL
CHANA
OTHER (SPECIFY)
I16
What is the total quantity produced?
I17
How much of the harvested____was sold?
I18
What was the income from the sale of ___?
I19
Does your household receive any farm produce from the land that you lease out?
Yes
No
I20
Crop Code
RICE
WHEAT
MAIZE
SORGHUM
MILLETS
BUCKWHEAT
BARLEY
GROUNDNUT
SOYBEANS
LENT
PEAS
CHICKPEAS
BEANS
SUGARCANE
COTTON
SUNFLOWER
TOBACCO
TEA
OIL SEEDS
SWEET POTATOES
POTATOES
CARROTS
CUCUMBER
CHILI
EGGPLANT
GREEN LEAFY VEGETABLES
OKRA / LADY FINGER
ONION
CAPSICUM
CABBAGE
CAULIFLOWER
BOTTLE GOURD
SPONGE GOURD
BITTER GOURD
GREEN BEANS
GARLIC
GINGER
PUMPKIN / ZUCHIMI
TOMATO
AVOCADO
GUAVA
MANGO
LEMON / LIME
ORANGE / TANGERINE
PAPAYA
MELON
LYCHEE
APPLE
BERRIES
BANANAS
SARSON
URAT DAL
MUSSOR DAL
ARHAR DAL
CHANA
OTHER (SPECIFY)
I21
What is the total quantity received?
I22
How much of the received ____was sold?
I23
What was the income from the sale of ___?
FOOD SECURITY
J01
How many meals did you eat yesterday during the day and night?
J02
How many meals did the adult members (18+) of your household eat yesterday during the day and night?
J03
How many meals did the children 6 to18 years in this household eat yesterday during the day and night?
J04
Over the last 7 days, how many days were the following food groups consumed by:
J05
YOU AND OTHER FEMALE MEMBERS OF THE HH
J05_1
Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
J05_2
Beans and peas, pulses groundnuts and cashew nuts`
J05_3
Vegetables (including leaves)
J05_4
Fruits
J05_5
Egg, meat, fish etc.
J05_6
Milk/yogurt/other dairy product
J05_7
Sugar or sugar products, honey
J05_8
Oils/fats/butter
J06
CHILDREN AGE 6-18 YRS.
J06_1
Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
J06_2
Beans and peas, pulses groundnuts and cashew nuts`
J06_3
Vegetables (including leaves)
J06_4
Fruits
J06_5
Egg, meat, fish etc.
J06_6
Milk/yogurt/other dairy product
J06_7
Sugar or sugar products, honey
J06_8
Oils/fats/butter
J07
OTHER MALE MEMBERS
J07_1
Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
J07_2
Beans and peas, pulses groundnuts and cashew nuts`
J07_3
Vegetables (including leaves)
J07_4
Fruits
J07_5
Egg, meat, fish etc.
J07_6
Milk/yogurt/other dairy product
J07_7
Sugar or sugar products, honey
J07_8
Oils/fats/butter
J08
What was the main source(s) of the food?
J08_1
Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_2
Beans and peas, pulses groundnuts and cashew nuts`
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_3
Vegetables (including leaves)
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_4
Fruits
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_5
Egg, meat, fish etc.
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_6
Milk/yogurt/other dairy product
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_7
Sugar or sugar products, honey
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
J08_8
Oils/fats/butter
OWN PRODUCTION
CASUAL LABOR
BORROWED
GIFT
PURCHASED
FOOD ASSISTANCE
BARTER
HUNTING/ GATHERING/ CATCHING
TAKE HOME RATION
MID-DAY MEAL
RATION SHOP
NOT CONSUMED IN THE LAST 7 days
COPING STRATEGY
K01
Usually, does your household has sufficient food available for the whole year?
Yes
No
K02
If no, in a year how many months / days, the household has insufficient food?
K03
In a year, how frequently do you have to do ________ because of insufficient food in the household
K03_1
Skip entire days without eating?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_2
Limit portion size at mealtimes?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_3
Reduce number of meals eaten per day?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_4
Borrow food or rely on help from friends or relatives?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_5
Rely on less expensive or less preferred foods?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_6
Purchase/borrow food on credit?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_7
Gather unusual types or amounts of wild food / hunt?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_8
Send household members to eat elsewhere?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_9
Send household members to beg?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K03_10
You or other female members eat less?
NEVER
SELDOM
SOMETIMES
OFTEN
DAILY
K04
Have you sold any household assets to buy food?
Yes
No
MALARIA
L01
Does your household have any mosquito nets that can be used while sleeping?
Yes
No
L02
How many mosquito nets does your household have?
L03
Has any of the mosquito nets been treated or sprayed with any kind of medicine in the last 12 months?
Yes
No
L04
How many mosquito nets have been treated or sprayed with medicine in the last one month?
L05
In the past 12 months were the interior walls of your dwelling sprayed against mosquitoes?
Yes
No
L06
Has any member of your household been detected with malaria in the past 3 months?
Yes
No
L07
How many members of your household been ill with malaria in the past 3 months?
L08
Line No.
L09
Slept under mosquito net last night
Yes
No
L10
Slept under ITN last night
Yes
No
L11
Been ill with fever in the last 2 weeks
Yes
No
L12
If yes, was (s)he tested for malaria
Yes
No
L13
If yes, did (s)he test positive
Yes
No
L14
Was (s)he given any drugs for treatment
Yes
No
MATERNAL HEALTH
M01
During your pregnancy with [CHILD NAME], did you register the pregnancy?
Yes
No
M02
In which month of pregnancy was your pregnancy registered?
M03
During your pregnancy with [CHILD NAME], did you go to see anyone for antenatal checkup?
Yes
No
M04
During your pregnancy with [CHILD NAME], did anyone come to you for antenatal checkup?
Yes
No
M05
Who all did your antenatal checkups during your pregnancy with [CHILD NAME]?
GOVERNMENT DOCTOR
PRIVATE DOCTOR
STAFF NURSE
LHV
MALE HEALTH WORKER
ANM
OTHER HEALTH PERSONNEL
AWW
OTHER (SPECIFY)
M06
When you were pregnant with [CHILD NAME], how many times did you receive antenatal checkup?
M07
During your pregnancy, as part of your antenatal check-ups were you weighed?
Yes
No
M08
During your pregnancy, as part of your antenatal check-ups was your blood pressure measured?
Yes
No
M09
During your pregnancy, as part of your antenatal check-ups did you give a urine sample?
Yes
No
M10
During your pregnancy, as part of your antenatal check-ups was your blood checked for hemoglobin level?
Yes
No
M11
During your pregnancy, as part of your antenatal check-ups was your abdomen checked?
Yes
No
M12
During your pregnancy, as part of your antenatal check-ups was your ultrasound done?
Yes
No
M13
During your pregnancy with [CHILD NAME], were you given a TT injection?
Yes
No
M14
During your pregnancy with [CHILD NAME], how many times did you receive a tetanus injection?
M15
During your pregnancy with [CHILD NAME], did you receive any Iron Folic Acid (IFA) tablets or bottles?
Yes
No
M16
How many tablets or bottles did you receive in total during your whole pregnancy with [CHILD NAME]?
M17
During the whole pregnancy with [CHILD NAME], how many tablets or bottles did you consume?
M18
During the whole pregnancy, for how many days did you take the tablets or syrup?
M19
Did the ASHA come to meet you at your home during your pregnancy with [CHILD NAME]?
Yes
No
M20
How many times did the ASHA come to meet you at your home during your pregnancy with [CHILD NAME]?
M21
Was the delivery caesarean?
Yes
No
M22
Where did you deliver [CHILD NAME]?
HOME
GOVERNMENT HEALTH FACILITY
PRIVATE HEALTH FACILITY
OTHERS (SPECIFY)
M23
What type of a government health facility was it?
SUB-CENTER
PRIMARY HEALTH CENTER
COMMUNITY HEALTH CENTER
FIRST REFERAL UNIT
DISTRICT WOMEN HOSPITAL/DISTRICT HOSPITAL
OTHERS (SPECIFY)
M24
Did you receive a benefit for delivery care from the Government (Janani Suraksha Yojana)?
Yes
No
M25
How much was the payment received?
M26
How long after the delivery did you receive the financial payment/ assistance?
M27
Did the ASHA come to your home to check on you or [CHILD NAME] within 24 hours after your delivery?
Yes
No
CHILD HEALTH & NUTRITION
N01
Did you ever breastfeed [CHILD NAME]?
Yes
No
N02
How long after birth did you first put [CHILD NAME] to the breast?
N03
Did you feed [CHILD NAME] your first yellow thick milk (local term)?
Yes
No
N04
Are you still breastfeeding [CHILD NAME]?
Yes
No
N05
For how many months did you breastfeed [CHILD NAME]?
N06
How long did you exclusively breastfeed [CHILD NAME]?
N07
Have you breastfed [CHILD NAME] in the past 24 hours – either day time or night time?
Yes
No
N08
How many times did you breastfeed [CHILD NAME] in the past 24 hours – either day time or night time?
N09
Next I would like to ask you about some liquids that your child may have had yesterday during the day or at night.
N09_1
PLAIN WATER
Yes
No
N09_2
HONEY
Yes
No
N09_3
SUGAR WATER
Yes
No
N09_4
GHUTTI
Yes
No
N09_5
OIL TO CLEAN TONGUE
Yes
No
N09_6
TINNED / POWDERED MILK
Yes
No
N09_7
ANIMAL MILK
Yes
No
N09_8
RICE WATER
Yes
No
N09_9
DAL WATER
Yes
No
N09_10
ROTI MIXED IN MILK
Yes
No
N09_11
SATTU IN WATER/MILK
Yes
No
N09_12
THIN SUJI HALWA
Yes
No
N09_13
THIN KHICHDI
Yes
No
N09_14
JUICE
Yes
No
N09_15
OTHER LIQUIDS
Yes
No
N09_16
OTHER FOOD
Yes
No
N10
Do you have a mother and child protection card (immunization card)?
Yes
No
N11
COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. CODE ‘77’ IF CARD IS BLANK AND THEN SKIP TO N12. WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. CODE 0 IF DATE IS NOT MENTIONED & THE CARD DOES NOT SHOW THAT A VACCINE WAS GIVEN OR NOT. IF ONLY PART OF DATE IS SHOWN ON CARD, RECORD ‘99’ OR ‘9999’ FOR ‘DO NOT KNOW’ IN THE COLUMN FOR WHICH INFORMATION IS NOT GIVEN.
N11_1
BCG
N11_2
POLIO 0
N11_3
HEPATITIS B 0
N11_4
POLIO 1
N11_5
DPT 1
N11_6
HEPATITIS B 1
N11_7
PENTAVALENT 1
N11_8
POLIO 2
N11_9
DPT 2
N11_10
HEPATITIS B 2
N11_11
PENTAVALENT 2
N11_12
POLIO3
N11_13
DPT 3
N11_14
HEPATITIS B 3
N11_15
PENTAVALENT 3
N11_16
MEASLES
N11_17
DPT (16-24 MONTHS)
N11_18
POLIO (16-24 MONTHS)
N11_19
VITAMIN A (FIRST DOSE)
N11_20
VITAMIN A (SECOND DOSE)
N11_21
VITAMIN A (THIRD DOSE)
N12
Please tell me if [CHILD NAME] received any of the following vaccinations:
N12_1
A BCG vaccination against tuberculosis that is, an injection in the arm or shoulder that usually causes a scar?
Yes
No
N12_2
A Polio vaccine that is drop given in the mouth?
Yes
No
N12_3
How many times?
N12_4
Was the first polio vaccine received in the first two weeks after birth?
Yes
No
N12_5
Drops in the mouth as part of the Pulse Polio campaign?
Yes
No
N12_6
A DPT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?
Yes
No
N12_7
How many times?
N12_8
A Hepatitis B vaccination, that is, an injection given sometimes at the same time as DPT?
Yes
No
N12_9
How many times?
N12_10
A pentavalent vaccine given in place of DPT, HEP B and Hib in child’s thigh to protect from 5 diseases.
Yes
No
N12_11
How many times?
N12_12
An injection against measles at right arm/shoulder?
Yes
No
N12_13
Vitamin A that is given by a spoon?
Yes
No
N12_14
How many times?
N13
Do you give [CHILD NAME] any solid, semi-solid, mashed or soft foods to eat?
Yes
No
N14
Now I would like to ask you about the food [CHILD NAME] ate during the last 24 hours, either separately or combined with other foods.
N14_1
Porridge or gruel (Rice/Khichdi)
Yes
No
N14_2
Biscuit
Yes
No
N14_3
Commercially fortified baby food such as Cerelac or Farex
Yes
No
N14_4
Bread, roti, chapatti
Yes
No
N14_5
Daal (Foods made with lentils or beans)
Yes
No
N14_6
Pumpkin, carrots, or sweet potatoes that are yellow or orange inside
Yes
No
N14_7
Green leafy vegetables
Yes
No
N14_8
Ripe mangoes or ripe papayas
Yes
No
N14_9
Other fruits or vegetables (potatoes)
Yes
No
N14_10
Meat/chicken/fish
Yes
No
N14_11
Egg
Yes
No
N14_12
Nuts
Yes
No
N14_13
Salty purchased snacks foods (chips, kurkure, namkeen,)
Yes
No
N14_14
Sweet purchased snacks ( chocolate, candies)
Yes
No
N14_15
Other solids (SPECIFY)
Yes
No
N15
From what age did you start feeding [CHILD NAME] solid, semi-solid, mashed or soft foods?
N16
Excluding oil for cooking, did you add oil/ghee/butter to the food you gave [CHILD NAME] in the last 24 hours?
Yes
No
N17
How many times did [CHILD NAME] eat solid, semi-solid, mashed or soft foods other than liquids yesterday during the last 24 hours?
SELF-HELP GROUPS AND LEADERSHIP
O01
Are you a member of any Self-help group (SHG)?
Yes
No
O02
Is anyone in your household a member of any Self Help Group (SHG)?
Yes
No
O03
Are you a panchayat member?
Yes
No
O04
What position do you hold as a panchayat member?
SARPANCH
SECRETARY
WARD MEMBER
OTHERS (SPECIFY)
O05
Are you a member of any committee associated with Gram Panchayat?
Yes
No
O06
Which committees are you associated with?
VHSNC
MGNREGA
FRC
LAND RIGHTS COMMITTEE
ICDS
SCHOOL MANAGEMENT COMMITTEE
OTHERS (SPECIFY)
GENDER
P01
Did you engage in any income generating activities in last 12 months?
Yes
No
P02
Was it usually at home or away from home?
HOME
AWAY
P03
Was it usually throughout the year, seasonal or once in a while?
THROUGHOUT THE YEAR
SEASONALLY / PART OF THE YEAR
ONCE IN A WHILE
P04
Were you usually paid in cash or kind for this work?
CASH ONLY
CASH AND KIND
KIND ONLY
NOT PAID
P05
According to you, what share of household income do you contribute to?
LESS THAN HALF
HALF
MORE THAN HALF
P06
Who decided how to use the money you earn?
Self
Husband
Jointly
OTHERS (SPECIFY)
P07
Do you save any of the income that you earn?
Yes
No
P08
Where do you save?
SHG
GOVERNMENT BANK
COOPERATIVE BANK
PRIVATE BANK
POST OFFICE
FRIENDS / RELATIVES
AT HOME
OTHERS (Specify)
P09
Do you have any money of your own that you can decide how to spend?
Yes
No
P10
Does your household have any bank account?
Yes
No
P11
Who does the account belong to?
IN THE NAME OF MALE MEMBER
IN THE NAME OF BOTH MALE AND FEMALE MEMBER
IN THE NAME OF FEMALE MEMBER ONLY
P12
Is there an account in your name?
Yes
No
P13
If yes, have you operated it in the last 3 months?
Yes
No
P14
What is your role in buying or selling of land or other similar assets?
INFORMED OF THE PURCHASE/SALE TO BE MADE
INFORMED OF THE PURCHASE/SALE ALREADY MADE
CONSULTED ON THE PURCHASE/SALE
DECIDE THE PURCHASE/SALE
NO ROLE
P15
What is your role in buying, selling OR mortgaging of gold or other jewelry?
INFORMED OF THE PURCHASE/SALE TO BE MADE
INFORMED OF THE PURCHASE/SALE ALREADY MADE
CONSULTED ON THE PURCHASE/SALE
DECIDE THE PURCHASE/SALE
NO ROLE
P16
What is your role in buying or selling of livestock?
INFORMED OF THE PURCHASE/SALE TO BE MADE
INFORMED OF THE PURCHASE/SALE ALREADY MADE
CONSULTED ON THE PURCHASE/SALE
DECIDE THE PURCHASE/SALE
NO ROLE
P17
What is your role in buying or selling of farm produce?
INFORMED OF THE PURCHASE/SALE TO BE MADE
INFORMED OF THE PURCHASE/SALE ALREADY MADE
CONSULTED ON THE PURCHASE/SALE
DECIDE THE PURCHASE/SALE
NO ROLE
P18
How easy it is for you to go to the following places?
P18_1
To go out and work
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_2
Ration Shop
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_3
Paternal Home
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_4
Weekly Market
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_5
Government Offices
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_6
Banks
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_7
Gram Sabha
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_8
Jati Panchayat
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_9
Police Station
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_10
Meeting/training in the village
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P18_11
Meeting / training outside village
NOT ALLOWED TO GO ALONE
ALLOWED TO GO WITH OTHER FAMILY MEMBERS / FRIENDS
ALLOWED TO GO ONLY WITH SPOUSE
ALLOWED TO GO ALONE AFTER SEEKING PERMISSION
DO NOT NEED ANY PERMISSION
OTHERS (SPECIFY)
P19
Do you usually go to the local market place?
Yes
No
P20
Was any Gram Sabha meeting held during the last one year?
Yes
No
P21
How many Gram Sabha meetings were held in the last one year?
P22
Did you attend any of the Gram Sabha meetings that were held in the last one year?
Yes
No
P23
How many meetings did you attend in the last one year?
P24
Did you raise any issue in the meetings that you attended?
Yes
No
P25
Were your issues deliberated and considered while arriving at decisions?
Yes
No
P26
Was any Jati Panchayat meeting held during the last one year?
Yes
No
P27
How many Jati Panchayat meetings were held in the last one year?
P28
Did you attend any of the Jati Panchayat meetings that were held in the last one year?
Yes
No
P29
How many meetings did you attend in the last one year?
P30
Did you vote in any of the elections in last 5 years?
Yes
No
P31
Who decides who will you cast your vote to?
SELF
HUSBAND
ELDER FAMILY MEMBER
INFLUENTIAL PEOPLE IN THE VILLAGE
REPRESENTATIVES OF POLITICAL PARTIES
OTHERS (SPECIFY)
P32
Have you ever wathched TV in the last one year?
Yes
No
P33
How often do you watch TV?
DAILY
2 TO 6 DAYS IN A WEEK
ONCE A WEEK
ONCE EVERY FORTNIGHT
ONCE A MONTH
RARELY
P34
Have you ever listened to the radio in the last one year?
Yes
No
P35
How often do you listen to the radio?
DAILY
2 TO 6 DAYS IN A WEEK
ONCE A WEEK
ONCE EVERY FORTNIGHT
ONCE A MONTH
RARELY
P36
Do you think that girls should be given equal opportunities for employment outside the house or may be to work in another village as boys?
NOT AGREE
PARTIALLY AGREE
AGREE
P37
What do you think should be ideal age for girls to get married?
Awareness, responsiveness, and participation in Gram Sabha
R01
Are you aware about the Gram Sabha?
Yes
No
R02
Who are the members that constitute a Gram Sabha?
All male voters in the village
All Female voters in the village
All Male and Female voters in the village
Only the members of the Gram Panchayat
None of the above
Others (Specify)
Do Not Know
R03
How frequently are the Gram Sabha Meetings conducted?
Once Every Month
Once every 2 months
Once every 3 months
Once every 6 months
Once a year
In lesser frequency
Do not know
Other (Specify)
R04
Did you participate in the last GS meeting?
Yes
No
R05
When was the last GS meeting held?
R06
Have you participated in any of the Gram Sabha meetings in the last one year?
Yes
No
R07
What was discussed in the last Gram Sabha meeting that you attended?
Information / news about new programs / schemes
Updation about previous programs / schemes
Income and expenditure on programs / schemes
Allotment / allocation to beneficiaries
None of the above
Other (Specify)
R08
Were these minutes of the Gram Sabha meeting documented?
Yes
No
R09
Where were these minutes documented?
In meeting register & signed by members at the meeting
Documented & signed by members later
Documented before the meeting and signed after the meeting
Others (Specify)
Do not know
R10
Did you read the minutes before signing these documents?
Yes
No
R11
Were these minutes reflective of the discussion?
Yes
No
R12
What according to you are the key functions of the GS?
Institute solving of disputes of villagers
Promotion of education, health, agriculture and communication facilities in the village
Represent the voice & opinion of the village at the GP, block & district level
Conduct regular meetings
Keep records of various departments
Other (Specify)
Do Not Know
R13
Are you familiar with the term quorum in GS meetings?
Yes
No
R14
What according to you is the quorum for the GS meeting?
Half of the total members to be present
One-third of the total members to be present
One-fifth of the total members of be present
One-Fourth of the total members to be present
Other (Specify)
R15
Are you aware of the fact that there is a separate quorum for women?
Yes
No
R16
What according to you is the quorum for women?
Half of the general quorum
One-third of the general quorum
One-fifth of the general quorum
One-Fourth of the general quorum
Other (Specify)
R17
What happens in the absence of a quorum?
GS meeting is postponed
Decisions taken in the meeting are considered void
All of the above
None of the above
Others (Specify)
Do Not Know
R18
Are you aware of the activities undertaken by the Gram Sabha?
Yes
No
R19
What according to you are some of the key activities of a Gram Sabha?
Peace maintenance and dispute resolution
Plan and take action on farming related activities
Land management and related activities
Planning and management of water resources
Management of irrigation
Planning for labour force
Accounting of birth, death etc
Management of minor forest produce
Conduct social audits
Other (Specify)
R20
Are you aware who chairs the Gram Sabha meeting?
Yes
No
R21
Who according to you chairs the GS meeting?
Sarpanch
Secretary
Assistant Secretary
Ward Member
None of the above
Other (Specify)
R22
Are you familiar with the term Social Audit?
Yes
No
R23
Are you aware of the social audit process?
Yes
No
R24
Please describe the social audit process
R25
According to you what is the importance of social audits?
R26
Have you been a part of any Social Audit?
Yes
No
R27
For which scheme have you been a part of the Social Audit?
MGNREGA
FRA
Mid-Day Meal
JSY
RSBY
Other (Specify)
R28
Do you consider GS meetings to be a platform for raising your issues and concerns?
Yes
No
R29
Do you give your opinion in the discussions at the Gram Sabha meetings?
Yes
No
R30
Is your opinion deliberated and considered while arriving at decisions?
Yes
No
R31
Are you or any member of your household, member of any village level committee?
Village Education Committee
Forest Rights Committee
Mother’s committee
Village Health Sanitation & Nutrition Committee VHND
None
Others (Specify)
ANTHROPOMETRY
S01
Name of index child
S02
Sex
MALE
FEMALE
TRANSGENDER
S03
RECORD DATE OF BIRTH
S04
RECORD AGE OF [CHILD NAME]
S05
Name of mother
S06
Age of mother
S07
RECORD WHETHER WEIGHT WAS TAKEN OR NOT AND REASON WHY NOT
MEASURED
CHILD ABSENT
CHILD REFUSED
MOTHER REFUSED
CHILD DEFORMED
CHILD ILL
OTHER (SPECIFY)
S08
RECORD WEIGHT (G) OF THE MOTHER AND CHILD
S08A
FIRST MEASUREMENT
S08B
SECOND MEASUREMENT
S09
RECORD WHETHER MOTHER’S WEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
MEASURED
MOTHER ABSENT
MOTHER REFUSED
MOTHER DEFORMED
MOTHER ILL
OTHER (SPECIFY)
S10
RECORD WEIGHT (G) OF THE MOTHER
S10A
FIRST MEASUREMENT
S10B
SECOND MEASUREMENT
S11
RECORD WHETHER CHILD’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
MEASURED
CHILD ABSENT
CHILD REFUSED
MOTHER REFUSED
CHILD DEFORMED
CHILD ILL
OTHER (SPECIFY)
S12
RECORD HEIGHT (cm)
S12A
FIRST MEASUREMENT
S12B
SECOND MEASUREMENT
S13
RECORD WHETHER MOTHER’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
MEASURED
MOTHER ABSENT
MOTHER REFUSED
MOTHER DEFORMED
MOTHER ILL
OTHER (SPECIFY)
S14
RECORD HEIGHT (cm)
S14A
FIRST MEASUREMENT
S14B
SECOND MEASUREMENT
S15
Is there a girl of age 10-19 years in this household?
Yes
No
S16
What is the name of the adolescent girl?
S17
What is the age of the adolescent girl?
S18
RECORD WHETHER ADOLESCENT GIRL’S WEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
MEASURED
ADOLESCENT GIRL’S ABSENT
ADOLESCENT GIRL’S REFUSED
MOTHER/FAMILY MEMBERS REFUSED
ADOLESCENT GIRL’S DEFORMED
ADOLESCENT GIRL’S ILL
OTHER (SPECIFY)
S19
RECORD WEIGHT (KG)
S19A
FIRST MEASUREMENT
S19B
SECOND MEASUREMENT
S20
RECORD WHETHER ADOLESCENT GIRL’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
MEASURED
ADOLESCENT GIRL’S ABSENT
ADOLESCENT GIRL’S REFUSED
MOTHER/FAMILY MEMBERS REFUSED
ADOLESCENT GIRL’S DEFORMED
ADOLESCENT GIRL’S ILL
OTHER (SPECIFY)
S21
RECORD HEIGHT (cm)
S21A
FIRST MEASUREMENT
S21B
SECOND MEASUREMENT
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