Surveypoint

Q01

GPS Coordinates 

Q02

State

Andhra Pradesh

Telangana

Bihar

Uttar Pradesh

Q03

District Name

Q04

Mandal/Block Name

Q05

GP Name  

Q06

Village name 

Q07

Interviewer code 

Q08

Interviewer Name 

Q09

Supervisor Name 

Q10

Date of Interview 

Q11

Interview Start Time 

Q12

Interview End Time 

A01

Name of the respondent  

A02

Respondent’s phone number 

A03

What is the gender of the respondent? 

Female 

Male 

Transgender 

A04

What is your age? (in completed years) 

A05

How many members are there in your household? 

Male above 60 Years  

Female above 60 Years 

Males between 14-60 years 

Females between 14-60 years 

Children aged 14 years or less 

A06

What is the highest level of education that you have completed?  

No formal education 

Has attended primary school (up to grade 6) 

Has attended up to grade 10 

Matriculate (10th pass) 

Passed school (10+2) 

Graduate  

Postgraduate  

ITI/ Diploma/ similar vocational course 

Others (Specify) 

A07

Which ID is used to verify the identity of the respondent? 

Aadhar Card 

Ration Card 

Others (Specify) 

A08

Please specify which card you have. 

Above Poverty Line (APL) 

Below Poverty Line (BPL)  

Antyodaya Anna Yojana (AAY)  

Don’t know/can’t say 

A09

What is your social category? 

Scheduled caste (SC)  

Scheduled tribe (ST)  

Backward caste (BC)  

Minority (Muslim, Christian, Jain etc.) 

General caste 

Others  

A10

What is your household’s main source of income?  

Farming (on own land)  

Farming on leased or rented-in land 

Wage or salaried work (agricultural)  

Wage or salaried work (non-agricultural) 

Agri-business  

Non-agri-business 

Others (Specify) 

A11

What is your annual income range? 

Less than 50,000 

50-100,000 

100,000 -200,000 

200,00 – 350,000 

350,000 – 500,000 

More than 500, 000 

Don’t want to share 

A11A

Are you or any of your family members currently a member of any SHG? 

Yes, myself 

Yes, family member 

No  

A12

Have you taken any credit facilities? 

Yes

No  

Don’t know  

A13

For what purpose have you taken loan?

Business expansion

Asset purchase

Education expense

Health related expense

Marriage expense

Agriculture

Animal Husbandry

Others (Specify)

A14

If yes, then what is the source of that credit facility? 

Formal banking institutions (banks, cooperatives, Private banks) 

Informal banking institutions (SHGs, JLGs, etc.) 

Private lenders/Pawn brokers 

Personal network (Neighbourhood) 

Others (Specify) 

Don’t want to reveal 

B01

Do you have access to a toilet?

Yes

No  

B02

What kind of toilet do you use?

Private, within the vicinity of your home

Semi-private/ Shared Toilet

Community Toilet

B03

Does your house have an electricity connection?

Yes

No  

B04

What is the average duration of electricity supply?

0-8 Hours

8-16 Hours

16- 24 Hours

24 Hours

B05

What type of drinking water source does your household primarily use?

Tap

Well

Hand Pump

Bottled / Tanker

Tubewell / Borewell

Surface water

Others (Specify)

B06

How far is the nearest source of safe drinking water from your household?

Within 100 meters

100-500 meters

More than 500 meters

Don’t know

C01

How do you dispose of solid waste generated in your household?

Municipal Collection

Local Waste Collectors

Leave it at the local dumping ground

Others (Specify)

C02

What is the frequency of waste collection in your area?

Daily

Weekly

Fortnightly

Irregular

Never

C03

Do you segregate your household waste before disposal?

Yes

No  

C04

In what categories do you segregate your waste?

Biodegradable

Non-Biodegradable

Recyclable

Hazardous

C05

Do you engage in composting?

Yes

No  

C06

If yes, how do you compost?

Personal Composting

Community Composting

D01

Have you participated in any waste management awareness campaigns or training sessions?

Yes

No  

D02

If yes, who imparted the training?

Implementing Agency

Government officials

PRI members

Others (Specify)

D03

How often do you attend Awareness campaigns for Waste Management?

Multiple times a month

Once a Month

At least once in 2-3 months

At least once in 3-6 Months

At least once in 6 months to a year

D04

How would you rate the efficiency of awareness campaigns on behaviour modification?

Excellent

Good

Average

Poor

D05

What all, according to you is the purposes of the Mohalla Committee?

Spreading awareness about Waste Management

Managing the functions of local waste collectors

Address all matters of public health and hygiene

D06

How would you rate the efficiency of your local Mohalla Committee with regards to SWM related activities?

Excellent

Good

Average

Poor

D07

Have you noticed any changes in the cleanliness of your surroundings since the implementation of the solid waste management system?

Cleanliness has increased significantly

Cleanliness has increased moderately

Cleanliness has remained constant

Cleanliness has depleted

D08

Do you believe that the solid waste management system has led to a reduction in littering and illegal dumping in your community?

Significantly

Moderately

No change

D09

Do you feel that the solid waste management system has contributed to a sense of community involvement and responsibility towards environmental conservation?

Significantly

Moderately

No change

E01

How often does a member of your household visit a healthcare facility?

E02

Why do the members of your household visit the doctor/ healthcare facility, usually?

Regular check-ups

Illness

Vaccinations

Others (Specify)

E03

How much is your monthly household healthcare expenditure?

Rs. 0-1000

Rs. 1000 – 3000

Rs. 3000 – 5000

More than Rs. 5000

E04

Do you face any challenges in accessing healthcare services?

Yes

No

E05

How many times did cases of Communicable diseases (cholera, typhoid, dysentery etc.) occur in your household, last year ?

0-5

5-10

10-15

More than 15

E06

Have you experienced any changes in your healthcare expenditure since engaging in Waste management practices?

Increased Significantly

Decreased significantly

No change

Swm Quantitative Template -Form Fill

GPS Coordinates

State

District Name

Mandal/Block Name

GP Name

Village name

Interviewer code

Interviewer Name

Supervisor Name

Date of Interview

Interview Start Time

Interview End Time

Name of the respondent

Respondent’s phone number

What is the gender of the respondent?

What is your age? (in completed years)

How many members are there in your household?

What is the highest level of education that you have completed?

Which ID is used to verify the identity of the respondent?

Please specify which card you have.

What is your social category?

What is your household’s main source of income?

What is your annual income range?

Are you or any of your family members currently a member of any SHG?

Have you taken any credit facilities?

For what purpose have you taken loan?

If yes, then what is the source of that credit facility?

Do you have access to a toilet?

What kind of toilet do you use?

Does your house have an electricity connection?

What is the average duration of electricity supply?

What type of drinking water source does your household primarily use?

How far is the nearest source of safe drinking water from your household?

How do you dispose of solid waste generated in your household?

What is the frequency of waste collection in your area?

Do you segregate your household waste before disposal?

In what categories do you segregate your waste?

Do you engage in composting?

If yes, how do you compost?

Have you participated in any waste management awareness campaigns or training sessions?

If yes, who imparted the training?

How often do you attend Awareness campaigns for Waste Management?

How would you rate the efficiency of awareness campaigns on behaviour modification?

What all, according to you is the purposes of the Mohalla Committee?

How would you rate the efficiency of your local Mohalla Committee with regards to SWM related activities?

Have you noticed any changes in the cleanliness of your surroundings since the implementation of the solid waste management system?

Do you believe that the solid waste management system has led to a reduction in littering and illegal dumping in your community?

Do you feel that the solid waste management system has contributed to a sense of community involvement and responsibility towards environmental conservation?

How often does a member of your household visit a healthcare facility?

Why do the members of your household visit the doctor/ healthcare facility, usually?

How much is your monthly household healthcare expenditure?

Do you face any challenges in accessing healthcare services?

How many times did cases of Communicable diseases (cholera, typhoid, dysentery etc.) occur in your household, last year ?

Have you experienced any changes in your healthcare expenditure since engaging in Waste management practices?

GPS Coordinates 

GP Name  

Village name 

Interviewer code 

Interviewer Name 

Supervisor Name 

Date of Interview 

Interview Start Time 

Interview End Time 

Name of the respondent  

Respondent’s phone number 

What is the gender of the respondent? 

What is your age? (in completed years) 

How many members are there in your household? 

What is the highest level of education that you have completed?  

Which ID is used to verify the identity of the respondent? 

Please specify which card you have. 

What is your social category? 

What is your household’s main source of income?  

What is your annual income range? 

Are you or any of your family members currently a member of any SHG? 

Have you taken any credit facilities? 

If yes, then what is the source of that credit facility? 