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Household Profile Template -Form Fill
Observation
Q01
NAME AND CODE OF DISTRICT WHERE SCHOOL IS LOCATED
Q02
NAME AND CODE OF TALUK WHERE SCHOOL IS LOCATED
Q03
NAME AND CODE OF VILLAGE WHERE SCHOOL IS LOCATED
Q04
NAME AND CODE OF SCHOOL
Q05
CHILD ID
Q06
QUESTIONNAIRE NUMBER
Q07
NAME AND CODE OF INTERVIEWER
Q08
DATE OF VISIT
Q09
RESULT CODE
COMPLETE
PARTIALLY COMPLETE
NOT AVAILABLE RESPONDENT
REFUSAL
OTHER (SPECIFY)
Q10
DATE
Q11
CODE AND FIRST NAME
Visit information
A01
Respondent Gender
A03
Relation with the child
Father
Mother
Guardian
A04
Household
Urban
Rural
A05
Time of visit
Socio - Economic Data
B01
Total no. of persons in the household
B02
Highest Education in the HH (Head of the Household)
Illiterate
Less than 5 years
5-9 years
10 or more years
B03
How many children in the age group of (6-10) are attending school?
B04
Occupation of the HH
Cultivation
Allied Agriculture
Daily wage labourer
Salaried but non- government employee
Govt. Employee
Agricultural wage labor
Non agriculture labor
Artisan\skill based independent work
Petty shop\other trade
Organised trade\business(large scale)
Pension\rent\dividend
Others specify
B05
Religion
Hindu
Muslim
Christian
Buddhist/Neo-Buddhist
Sikh
Others
B06
Castes\Tribes
General
Scheduled Castes
Scheduled Tribes
Other backward classes
Others
B07
Do you have an APL or BPL card?
BPL
APL
B08
What is the main source of drinking water for members of your household?
Piped water into the dwelling
Public tap
Well (Covered)
Well (Uncovered)
Hand pump
Tanker Truck
Cart with small tank
Surface water (river / dam / lake / pond / stream\irrigation channel\canal)
Bottled water
Rain water
Others
B09
Do you treat water to make it safer to drink?
Yes
No
B10
How do you treat your water to make it safer to drink?
Boil water
Add bleach
Add chlorine solution (in water)
Add chlorine tablets/pills (Aquatabs)
Filter with clean cloth
Sedimentation (leave it undisturbed)
Use ceramic filter
Use sand biofilter
Use electronic purifier
Does not do anything
Other (SPECIFY)
Dont know
B11
How do you store drinking water?
In uncovered containers
In covered containers
Tank on the roof
None
Others
B12
What kind of toilet facility does the household have?
Flushing toilet (to septic tank/pit/sewer)
Open Pit latrine
Latrine with septic tank
Pit with slab
Pit ventilated improved
No latrine/open space
Others (SPECIFY)
B13
Do you share this toilet facility with other households?
Yes
No
B14
How many households use this toilet facility?
No of households if less than 10
10 or more households
Does not know
B15
In this household, is food cooked on a stove, a chullah or on open fire?
Stove
Chualla
Open fire
Others Specify
B16
Is the cooking usually done in the house, in a separate building, or outdoors?
In the house
In the separate building
Outdoors
Others specify
B17
Do you have a separate room which is used as a kitchen?
Yes
No
B18
What type of fuel does the household mainly use for cooking?
Electricity
liquid petroleum gas / natural gas
Kerosene
Coal / Lignite
Charcoal
Wood
straw /shrub / grass
agricultural crop waste
dung cakes
biogas
others
B19
Is the house you live is owned or rented?
own
rent
free
others (specify)
B20
What is the total number of rooms in the home?
B21
Type of house
Kuchha
Pucca
Semi-Pucca
Others- Specify
B22
Main material of the floor.
Natural floor
Mud\Clay Earth
Sand
Dung
Rudimentary floor
Raw wood planks
Palm\Bamboo
Brick
Stone
Finished Floor
Polished wood
Ceramic tiles
Cement
Carpet
Polished stone\marble\granite
Others (specify)
B23
Is your house connected to electricity?
Yes
No
Does not know
B24
Does this household own any of the following?
Yes
No
Does not know
B24_1
Bullock cart
Yes
No
Does not know
B24_2
Does this household own or cultivate any agriculture land?
Yes
No
Does not know
B24_3
Bicycle
Yes
No
Does not know
B24_4
No. Of bycycles
Yes
No
Does not know
B24_5
Fan
Yes
No
Does not know
B24_6
Radio
Yes
No
Does not know
B24_7
Sewing machine
Yes
No
Does not know
B24_8
Tractor
Yes
No
Does not know
B24_9
Mobile phone
Yes
No
Does not know
B24_10
Land line Phone
Yes
No
Does not know
B24_11
Computer\lap top
Yes
No
Does not know
B24_12
Internet facility
Yes
No
Does not know
B24_13
Television (even not working one)
Yes
No
Does not know
B24_14
Refrigerator
Yes
No
Does not know
B24_15
Motor cycle (even not working one)
Yes
No
Does not know
B24_16
Water pump
Yes
No
Does not know
B24_17
Bedset
Yes
No
Does not know
B24_18
Wardobe or cabinet?
Yes
No
Does not know
B24_19
Car\Jeep (even if it is not working)
Yes
No
Does not know
B25
Do you have any animal in your house?
Yes
No
Does not know
B26
Which animal do you have ?
Cows
Bulls
Buffaloes
Goats
Sheep
Chicken
Dogs
Cats
Others
B27
Number
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