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Household Template 18 -Form Fill

IDENTIFICATION
Q01

State
Q02

District
Q03

Block
Q04

Village (Hamlet Name)
Q05

Household No.
Q06

Name of the household head
Q07

Gender/ Sex of Household head
Q08

Name of the respondent
Q09

Are you a member of any SHG
Q10

What is the name of your SHG?
Q11

Was your SHG formed by PRADAN/ Federation/ Other SHG leaders/ women from the area?
Q12

Religion of the respondent
Q13

Caste of the respondent
Q14

Interviewer
Q15

Date of interview
HOUSEHOLD COMPOSITION
A01

Please tell me the name of all the persons who live in your house, starting with your name
A02

Relation to respondent woman.
A03

Sex

A04

Age
A05

Education
A06

Marital status?
A07

Main Occupation
LAND OWNERSHIP; USE OF LAND FOR FARMINGAND IRRIGATION PRACTICES
B01

Does your household own any land?
B02

How much land does your household own?
B02A

Unit
B03

How much of this is cultivable?
B03A

Unit
B04

How much of your owned land do you cultivate?
B04A

Unit
B05

Have you also taken any land on lease from others?
B06

How much land have you leased in?
B06A

Unit
B07

Have you mortgaged or leased out your land to someone else?
B08

How much land have you leased/mortgaged out?
B08A

Unit
B09

Do you have any source of irrigation on your land/the land that you cultivate?
B10

What are the sources

B10_1

Farm pond (Hapa)
B10_2

Dugwell
B10_3

Lift/Flow irrigation

B10_4

Canal/River
B10_5

Earthern dam/Check dams
B10_6

Borewell
B11

How much of the the land area is irrigated
B11A

Unit
CROPS CULTIVATED AND PACKAGE OF PRACTICES ADOPTED
C01

Crop Code
C02

How much of the agricultural land was used in the cultivation of this crop?
C02A

Unit
C03

What is the total quantity produced? (Quantity in KG.)
C04

What was the average market rate you got for this crop? (price per kg)
C05

Where do you normally sell the crop?
C06

What was/would be the income from the sale of ___?
C07

First, please tell me the names of two crops that are mostly grown by you______?
C08

What type of seed was primarily used for production of ____?
C09

Do you treat the seeds in some way before planting?
C10

Do you raise nursery for the crop (raised bed , line sowing, use of fertilizer, Use of pesticide, net covering, irrigation)

C11

In how many days do you transplant the seedling?
C12

For this crop, are you mostly using line sowing/transplanting or do you broadcast the seeds in the main field or both?
C13

Did you apply fertilizer in the main field?
C14

How do you prepare the field before transplanting/sowing?
C15

Do you practice intercultural operations in the main field?
C16

How many times during the crop cycle do you practice intercultural operations?
C17

Do you use farm tools and implements (weeders, markers, sprayers etc) in this crop?
C18

Do you apply any control measures of insect and pest?
TRAININGS
D01

Have you or anyone else from your household ever received any training on agriculture, poultry or livestock related work?
D02

Did you or anyone else from your household ever receive training on_________?

D02_1

Crop planning
D02_2

Cropping practices

D02_3

Nursery raising
D02_4

Pest management
D02_5

Composting/Vermicompost
D02_6

Production of bio-pesticides like agniastra, neemastra
D02_7

Poultry
D02_8

Goat rearing

D02_9

Pig rearing
D02_10

Marketing of produce
D03

Who received the training?

D03_1

Crop planning
D03_2

Cropping practices

D03_3

Nursery raising
D03_4

Pest management
D03_5

Composting/Vermicompost
D03_6

Production of bio-pesticides like agniastra, neemastra
D03_7

Poultry
D03_8

Goat rearing

D03_9

Pig rearing
D03_10

Marketing of produce
ANIMAL OWNERSHIP AND PRODUCTION AND SALE OF ANIMAL PRODUCTS
E01

During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc?
E02

How many ______ did your household own in the past 12 months?

E02_1

Cattle(buffalo/oxen/cow)
E02_2

Goat

E02_3

Sheep
E02_4

Pig
E02_5

Chicken/ Guinea fowl/Pigeons/Duck/ Hen
E03

How many ________ has your household sold in the last 12 months?

E03_1

Cattle(buffalo/oxen/cow)
E03_2

Goat

E03_3

Sheep
E03_4

Pig
E03_5

Chicken/ Guinea fowl/Pigeons/Duck/ Hen
E04

How much did your household receive for the sale of these ___ in the last 12 months?

E04_1

Cattle(buffalo/oxen/cow)
E04_2

Goat

E04_3

Sheep
E04_4

Pig
E04_5

Chicken/ Guinea fowl/Pigeons/Duck/ Hen
CONTRIBUTION OF WAGES, SERVICES, REMITTANCE AND NTFP COLLECTION TO HOUSEHOLD INCOME
F01

In the last one year did your family do this labour work for someone else?

F01_1

Agriculture operations
F01_2

Wage labour in watershed/other government program
F01_3

Masonry
F01_4

Carpentry
F01_5

Private construction labour
F01_6

Labour work in brick kiln
F02

How many months in the last 12 months did the HH members engage in this labour work ?

F02_1

Agriculture operations
F02_2

Wage labour in watershed/other government program
F02_3

Masonry
F02_4

Carpentry
F02_5

Private construction labour
F02_6

Labour work in brick kiln
F03

How many days in those months did the HH members engage ?

F03_1

Agriculture operations
F03_2

Wage labour in watershed/other government program
F03_3

Masonry
F03_4

Carpentry
F03_5

Private construction labour
F03_6

Labour work in brick kiln
F04

What was the daily wage rate?

F04_1

Agriculture operations
F04_2

Wage labour in watershed/other government program
F04_3

Masonry
F04_4

Carpentry
F04_5

Private construction labour
F04_6

Labour work in brick kiln
F05

Do you or any member of your family work as any of the following?

F05_1

ASHA/AWW
F05_2

Tuition
F05_3

Micro-enterprises
F05_4

CRP/CSP/Trainer/Secretary
F05_5

Govt. or Private Job
F06

Income in one month

F06_1

ASHA/AWW
F06_2

Tuition
F06_3

Micro-enterprises
F06_4

CRP/CSP/Trainer/Secretary
F06_5

Govt. or Private Job
F07

No of months in a year that the HH members work

F07_1

ASHA/AWW
F07_2

Tuition
F07_3

Micro-enterprises
F07_4

CRP/CSP/Trainer/Secretary
F07_5

Govt. or Private Job
F08

Does any member of your family live outside for work and sends you money?
F09

For how many months has each member of your household migrated in last one year?

F09_1

Name
F09_2

No. of months in last one year for migration
F10

Where do they work?
F11

In the last 12 months, has anyone in your household received remittances from a member of the family or other person who is somewhere else in India or abroad?
F12

Who receives the remittance?
F13

How often has your household received remittances in the last 12 months?
F14

On average, how much money did your household receive each time you received remittances in the last 12 months?

F15

How much did your household earn from NTFP selling (Mahua seeds, amla, honey, imli etc) in last 1 year?
F16

Does someone in the household receive pension?
F17

Who gets the pension?
F18

What type of Pension?
F19

Amount received in last 12 months
FOOD CONSUMPTION SCORE, HOUSEHOLD FOOD SECURITY USING COPING STRATEGY INDEX
G01

Was yesterday a special day (celebration, feast day, or fasting) where anyone in the HH ate special foods or more or less than usual)?
G02

How many meals did you eat yesterday during the day and night?
G03

How many meals did the adult members (18+) of your household eat yesterday during the day and night?
G04

How many meals did the children 6 to18 years in this household eat yesterday during the day and night?
G05

Over the last 7 days, how many days did you consume following foods?

G05_1

Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G05_2

Beans and peas, groundnuts and cashew nuts
G05_3

Vegetables (including relish and leaves)
G05_4

Fruits
G05_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G05_6

Milk/yogurt/other dairy product
G05_7

Sugar or sugar products, honey
G05_8

Oils/fats/butter
G06

Over the last 7 days, how many days did the children of 6 to18 years in this household consume following foods?

G06_1

Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G06_2

Beans and peas, groundnuts and cashew nuts
G06_3

Vegetables (including relish and leaves)
G06_4

Fruits
G06_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G06_6

Milk/yogurt/other dairy product
G06_7

Sugar or sugar products, honey
G06_8

Oils/fats/butter
G07

Over the last 7 days, how many days did other household members consume following foods?

G07_1

Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G07_2

Beans and peas, groundnuts and cashew nuts
G07_3

Vegetables (including relish and leaves)
G07_4

Fruits
G07_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G07_6

Milk/yogurt/other dairy product
G07_7

Sugar or sugar products, honey
G07_8

Oils/fats/butter
G08

What was the main source(s) of the food?

G08_1

Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G08_2

Beans and peas, groundnuts and cashew nuts
G08_3

Vegetables (including relish and leaves)
G08_4

Fruits
G08_5

Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G08_6

Milk/yogurt/other dairy product
G08_7

Sugar or sugar products, honey
G08_8

Oils/fats/butter
G09

Normally, how many months does the food produced from your land suffice your household’s requirement?
G10

In the past four weeks

G10_1

In the past four weeks, did you worry that your household would not have enough food?
G10_2

In the past four weeks, were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?
G10_3

In the past four weeks, did you or any household member have to eat a limited variety of foods due to a lack of resources?
G10_4

In the past four weeks, did you or any household member have to eat some foods that you really did not want to eat because of a lack of resources to obtain other types of food?
G10_5

In the past four weeks, did you or any household member have to eat a smaller meal than you felt you needed because there was not enough food?
G10_6

In the past four weeks, did you or any household member have to eat fewer meals in a day because there was not enough food?
G10_7

In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food?
G10_8

In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food?
G10_9

In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food?
G11

How often did this happen?

G11_1

In the past four weeks, did you worry that your household would not have enough food?
G11_2

In the past four weeks, were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?
G11_3

In the past four weeks, did you or any household member have to eat a limited variety of foods due to a lack of resources?
G11_4

In the past four weeks, did you or any household member have to eat some foods that you really did not want to eat because of a lack of resources to obtain other types of food?
G11_5

In the past four weeks, did you or any household member have to eat a smaller meal than you felt you needed because there was not enough food?
G11_6

In the past four weeks, did you or any household member have to eat fewer meals in a day because there was not enough food?
G11_7

In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food?
G11_8

In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food?
G11_9

In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food?
WOMEN’S ACCESS TO CAPITAL AND CREDIT
H01

Does anyone in your household currently have any _____?

H01_1

Agricultural land
H01_2

Other land not used for agriculture
H01_3

Large livestock (e.g. oxen, cattle, buffalo, horse)
H01_4

Small livestock (e.g. goats, pigs, sheep)
H01_5

Chickens, ducks, turkeys, pigeons
H01_6

Fish pond or fishing equipment
H01_7

Farm equipment (non-mechanized)
H01_8

Farm equipment (mechanized e.g. tractor)
H01_9

Non farm business equipment
H01_10

House (and other structures)
H01_11

Large consumer durables (Fridge, TV, sofa)
H01_12

Small consumer durables (radio, cookware)
H01_13

Cell phone

H01_14

Means of transportation (bicycle, motorcycle, car)
H02

Do you own any of the ____?

H02_1

Agricultural land
H02_2

Other land not used for agriculture
H02_3

Large livestock (e.g. oxen, cattle, buffalo, horse)
H02_4

Small livestock (e.g. goats, pigs, sheep)
H02_5

Chickens, ducks, turkeys, pigeons
H02_6

Fish pond or fishing equipment
H02_7

Farm equipment (non-mechanized)
H02_8

Farm equipment (mechanized e.g. tractor)
H02_9

Non farm business equipment
H02_10

House (and other structures)
H02_11

Large consumer durables (Fridge, TV, sofa)
H02_12

Small consumer durables (radio, cookware)
H02_13

Cell phone

H02_14

Means of transportation (bicycle, motorcycle, car)
H03

Do you have a bank account?
H04

What type of bank account do you have? Individual or joint? If it is joint, with whom?
H05

For how many years do you have this bank account?
H06

Who facilitated opening this account?
H07

What do you use your bank account for?
H08

Who operates your bank account?

H09

Did you make any transaction from your bank account in the past three months?
H10

What are the reasons for not having a bank account?

H11

Has anyone in your household taken any loans or borrowed cash/in-kind from _____ in the past 12 months?

H11_1

Non-governmental organization (NGO)
H11_2

Money lender
H11_3

Formal lender (direct credit from bank/financial institution)
H11_4

Friends or relatives or neighbours
H11_5

Self - Help Group
H12

Who made the decision to borrow from _____most of the time?

H12_1

Non-governmental organization (NGO)
H12_2

Money lender
H12_3

Formal lender (direct credit from bank/financial institution)
H12_4

Friends or relatives or neighbours
H12_5

Self - Help Group
H13

Who makes the decision about what to do with the money/item borrowed from _____ most of the time?

H13_1

Non-governmental organization (NGO)
H13_2

Money lender
H13_3

Formal lender (direct credit from bank/financial institution)
H13_4

Friends or relatives or neighbours
H13_5

Self - Help Group
H14

Has such a situation ever occurredwhere you wanted to take loan but you couldn’t take?

H14_1

Non-governmental organization (NGO)
H14_2

Money lender
H14_3

Formal lender (direct credit from bank/financial institution)
H14_4

Friends or relatives or neighbours
H14_5

Self - Help Group
SELF HELP GROUPS & GROUP COHESION
I01

Do you currently belong to a self-help group?
I02

When you expressed desire to become SHG member, did you have to face any challenges?

I03

What challenges did you have to overcome to become SHG member?

I04

For how long have you belonged to the self-help group to which you belong?
I05

Are you an active member of this group, meaning that you participate in meetings, for example? Are you attending meeting regularly?
I06

Have you participated in meetings conducted in last 3 months?
I07

Have you participated in meetings conducted in last 1 months?
I08

Does your self-help group have savings and credit activities?
I09

Do you personally participate in these savings and credit activities?
I10

Are you currently a portfolio-holder?
I11

Which position do you hold?
I12

What issues are discussed in the self-help group meeting ?
I13

Which organization started or supports this self-help group?
I14

Name of the NGO
I15

Has a representative from this NGO visited you and talked about agricultural practices?
I16

Has the NGO conducted any training on livelihood practices?
I17

How often does your group meet for discussions or activities in a month?
I18

How often do you participate in group meetings in a month?

I19

When was the last time that you participated in a group meeting?
I20

Did you attend the most recent meeting of your group?
I21

Do you save money in SHG?
I22

How much money do you save in each meeting?
I23

How often do you save?
I24

Have you participated in the maintenance of SHG financial records?
I25

How responsible do you feel for achieving the objectives of your group?
I26

How much do you agree or disagree with the following statements

I26_1

I can count on fellow SHG members if I need to borrow money
I26_2

I can count on fellow SHG members to talk about my problems
I26_3

SHG members worry about themselves only

I26_4

I can count on fellow SHG members to help me address the problems I am unable to solve on my own. (E.g. Violence)
I27

Do you think the activities of your SHG or federation has resuled in a positive change in:

I27_1

You
I27_2

Members of your group

I27_3

Members of other groups in your village

I27_4

People who are not members

I28

How much do you think the activities of your SHG or federation have contributed to a positive change in

I28_1

You
I28_2

Members of your group

I28_3

Members of other groups in your village

I28_4

People who are not members

WOMEN’S STATUS
J01

Do you currently live with your partner or husband?
J02

At what age did you get married?
J03

At what age did you first get pregnant?
J04

Do you have your own money that you can use for what you want to use it?
J05

Do you talk to someone when you have any problem?
J06

If yes, whom do you talk to in case of any problem?
J07

How often do you see or talk to somebody from your own family other than the one who live in the same house?
J08

How often can you visit the following spaces freely?

J08_1

To the market?
J08_2

To a friend or family member’s house less than one hour away?
J08_3

To the temple, church or mosque?
J08_4

To a public village meeting?
J08_5

To a meeting of any association of which you are a member including a self-help group?
J08_6

Outside your village?
J08_7

To see a health care provider for your own treatment?
J08_8

Going to a movie
J08_9

Buying new clothes for yourself

J08_10

Taking child to health care center

J08_11

Shopping within the village
J08_12

Shopping outside the village
J08_13

Attending a religious festival/social function within the village

ACCESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
K01

Have you ever heard about_______?

K01_1

Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)

K01_2

Antyodaya Anna Yojana
K01_3

Swachh Bharat Abhiyan(SBA)
K01_4

ICDS

K01_5

Janani Suraksha Yojana (JSY)
K01_6

Janani Shishu Suraksh Karykaram (JSSK)
K01_7

Social Security Pension
K02

Is your household / anyone in your household eligible for this scheme?

K02_1

Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)

K02_2

Antyodaya Anna Yojana
K02_3

Swachh Bharat Abhiyan(SBA)
K02_4

ICDS

K02_5

Janani Suraksha Yojana (JSY)
K02_6

Janani Shishu Suraksh Karykaram (JSSK)
K02_7

Social Security Pension
K03

Has anyone in your household ever availed this scheme?

K03_1

Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)

K03_2

Antyodaya Anna Yojana
K03_3

Swachh Bharat Abhiyan(SBA)
K03_4

ICDS

K03_5

Janani Suraksha Yojana (JSY)
K03_6

Janani Shishu Suraksh Karykaram (JSSK)
K03_7

Social Security Pension
K04

When was the last time someone in your household used this scheme?

K04_1

Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)

K04_2

Antyodaya Anna Yojana
K04_3

Swachh Bharat Abhiyan(SBA)
K04_4

ICDS

K04_5

Janani Suraksha Yojana (JSY)
K04_6

Janani Shishu Suraksh Karykaram (JSSK)
K04_7

Social Security Pension
K05

Does your household have a MGNREGA job card? If yes, please show me.
K06

In the past year, how many days did members of your household work for MGNREGA?

K07

Do you know what is the daily wage rate for male workers working under MGNREGA? If yes, please specify.
K08

Do you know what is the daily wage rate for female workers working under MGNREGA? If yes, please specify.
K09

Have you faced any such situation in past 1 year when you demanded to work under MGNREGA but did not receive any work?
K10

Are you aware of the unemployment allowance provided under MGNREGA?
K11

Are you aware of the Integrated Watershed Management Program?
K12

Is there a Watershed Committee in your village?
K13

Are you a member of Watershed Committee?
K14

Is there any User Group formed under IWMP in your village?
K15

Are you a member of any User group?
K16

Have any assests been created in your village under watershed development program/scheme?
K17

Does anybody in the household have an Aadhar card?
K18

Does your household have a ration card?
K19

Which card do you have?
K20

In the past 30 days, did you buy anything from a fair price shop?
K21

Which items did you buy from the fair price shop in the last 30 days and in what quantity?

K21_1

Rice

K21_2

Wheat

K21_3

Sugar

K21_4

Kerosene

K21_5

Cooking oil

K21_6

Salt

K21_7

Cloth

K22

Quantity Purchased

K22_1

Rice

K22_2

Wheat

K22_3

Sugar

K22_4

Kerosene

K22_5

Cooking oil

K22_6

Salt

K22_7

Cloth

K23

Do you feel that fair price shops help your household be food secure?
K24

Did you or any member of your household ever receive any food from Anganwadi centre in the past 1 year?
K25

Who received food from an Anganwadi centre
K26

Do you know how much money the beneficiary is supposed to get under the JSY scheme?

PARTICIPATION IN SOCIAL SPHERE
L01

Is your SHG part of any Village Organisation (VO) forum?
L02

Do you participate in meetings of the VO?
L03

Is your SHG part of any Cluster/ Block level Federation (BLF)?
L04

Do you represent your SHG in Cluster/ BLF meetings?
L05

Have you ever raised voice for any concern or issue in the community?
L06

Have you ever participated in any mass events like rallies, campaigns, vigils, etc. for social change or to demand something (for ex. Against alcoholism)?
L07

If yes, for what?
L08

In your house who decides to vote and to whom?
L09

Do you have voter identification card?
L10

Did you vote in the last election?
L11

Why did you vote?
L12

Why did not you vote?
L13

Have you or any other woman from any SHG in your village contested in the recent elections?
L14

Have you ever participated in gram sabha meeting?
L15

Did you attend last gram sabha meeting?
L16

What was the reason to attend Gram sabha meeting?
L17

What was the reason for not attending gram sabha meeting?
L18

Have you ever raised any concern or given your opinion in any gram sabha meeting?
L19

Has ever yourconcern or suggestion resulted in resolution being adopted at gram sabha?
L20

Does gram Panchayat take action to address a complaint or suggestion raised collectively by women/SHGs?

L21

Do you feel comfortable speaking up in public to help decide on infrastructure (like small wells, roads, water supplies) to be built in your community?
L22

Do you feel comfortable speaking up in public to ensure proper payment of wages for public works or other similar programs?
L23

Do you feel comfortable speaking up in public to protest the misbehavior of authorities or elected officials?
L24

How confident do you feel speaking your opinion in any training or SHG meeting?
L25

How confident do you feel when you have to talk to a bank officer/manager/teacher/AWW?

L26

How confident do you feel when you have to talk to Sarpanch/Pradhan / Ward members?
HOUSEHOLD CHARACTERISTICS
M01

Does your household own this house or any other house?
M02

LOOK AT THE FLOOR AND CODE THE MAIN MATERIAL OF THE FLOOR
M03

LOOK AT THE ROOF AND CODE THE MAIN MATERIAL OF THE ROOF
M04

LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS
M05

How many rooms in this house are used for sleeping?
M06

Do you have a separate room for cooking?
M07

Do you have a window in your house?
M08

Type of window
M09

Do you have a homestead?
M10

What type of toilet facility do you have?
M11

What is the main source of lighting
M12

What type of fuel does your household mainly use for cooking?
M13

Does your household own any of the following items

M13_1

Mattress
M13_2

Pressure cooker
M13_3

Chair
M13_4

Cot/ Bed
M13_5

Table
M13_6

Electric fan
M13_7

Almirah
M13_8

Radio/Transistor
M13_9

Sewing machine
M13_10

Clock or watch
M13_11

Bicycle
M13_12

Animal-drawn cart/Bullock Cart
M13_13

Black & White television
M13_14

Colour television
M13_15

Mobile Phone
M13_16

Landline Phone
M13_17

Water pump
M13_18

Thresher
M13_19

Power Tiller
M13_20

Spray Machine/Sprayer
M13_21

Refrigerator

M13_22

Air conditioner / Cooler
M13_23

Washing Machine
M13_24

Internet
M13_25

Computer

M13_26

Motorcycle/scooter
M13_27

Car/Jeep
M13_28

Tractor
M14

For each of the following seasons, what is the main source of drinking water for members of your household?

M14A

Summer

M14B

Monsoon

M14C

Winter

M15

How long does it take to go to the water source, get water, and come back during the rainy season?

M16

How long does it take to go to the water source, get water, and come back during the dryseason?