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Household Template 39 -Form Fill
HOUSEHOLD PRIMARY DETAILS
Q01
District Name
Q02
Block Name
Q03
Cluster Name
Q04
Structure number
Q05
Household ID
Q06
Interviewer ID
Q07
Supervisor ID
Q08
Date of visit
Q09
Result of 1st/ 2nd/3rd visit
Available for interview
Refused
HH migrated permanently
Not available for interview
HH temporarily away for longer time
Out of study period
HH not found
Q10
Name of the respondent
Q11
What is the sex of the respondent?
Male
Female
Transgender
Q12
Type of respondent
Head of the household
Other than above
Q13
Did respondent give consent for interview?
yes
no
Q14
What is the age of the head of household/respondent?
Q15
What is the highest educational qualification of the head of the household/respondent?
Never been to school
Class 1-5
Class 6-8
Class 9-10
Class 11-12
College or more
Refused
Q16
What is the occupation of the head of the household/respondent?
Unemployed
Homemaker
Service/Salaried worker
Agricultural labour
Cultivator
Farmer other than cultivator
Business/self employed
Labour
Other (specify)__
Q17
Is any usual member of this household covered by a health scheme or health insurance?
yes
no
Don't know
Q18
Observe the floor and code the main material of the floor
Mud/clay/earth
Bricks
Ceramic tiles
Other (specify)
Q19
look at the roof and code the main material of the roof
Thatch/palm leaf/reed/grass
Metal and galvanised iron
Asbestos sheets
Cement/concrete
RCC/RBC
Burnt brick
Other (specify)
Q20
look at the exterior walls and code the main material of the exterior walls
Cane/palm/trunks/bamboo
Mud
Bamboo with mud
Unburnt brick
Cement/concrete
Stone with lime/cement
Burnt bricks
Cement blocks
Other (specify)
Q21
look at the types of windows in the household
No windows
Windows with glass
Windows with screens
Windows with curtains or shutters
Other (specify)
Q22
Is the kitchen where food is cooked inside the house, or in a separate building, or outdoors?
In the house as separate room
In the house but not in separate room
In a separate building
Outdoors
Other (specify)
Q23
What type of fuel does your household mainly use for cooking?
Electricity
LPG/natural gas
Kerosene
Coal/lignite
Wood
Dung cakes
No food cooked in household
Other (specify)
Q24
What is the main source of lighting in this household?
Lantern
Kerosene lamp
Candle
Electric
LPG/battery
Solar energy
None
Other (specify)
Q25
Do you have drinking water available in your house or do you get it from a neighbour or some other source?
In own house
In own yard/plot
Elsewhere
Q26
What is the main source of drinking water for members of your household?
Piped water into dwelling
Government hand pump
Hand pump at home
Purified water cans
Other (specify)
Q27
What kind of toilet facility do members of your household usually use?
No facility/uses open space or field
Flush to septic tank
Flush to pit latrine
Dry toilet
Other (specify)
Q28
Do you share this toilet facility with other households?
yes
no
Refused to answer
Q29
Does any member of this household own any agricultural land?
yes
no
Don't know
Refused to answer
Q30
Does your household have the following items ………?
Q30_1
Electricity?
yes
no
Q30_2
A mattress?
yes
no
Q30_3
A pressure cooker?
yes
no
Q30_4
A chair?
yes
no
Q30_5
A cot or bed?
yes
no
Q30_6
A table?
yes
no
Q30_7
An electric fan?
yes
no
Q30_8
A radio or transistor?
yes
no
Q30_9
A black or white television?
yes
no
Q30_10
A colour television?
yes
no
Q30_11
A sewing machine?
yes
no
Q30_12
A mobile phone?
yes
no
Q30_13
Any other type of telephone?
yes
no
Q30_14
A computer?
yes
no
Q30_15
Internet?
yes
no
Q30_16
A refrigerator?
yes
no
Q30_17
A watch or clock?
yes
no
Q30_18
Air conditioner/cooler?
yes
no
Q30_19
Washing machine?
yes
no
Q30_20
A bicycle?
yes
no
Q30_21
A motorcycle or scooter?
yes
no
Q30_22
An animal drawn cart?
yes
no
Q30_23
A car?
yes
no
Q30_24
A water pump?
yes
no
Q30_25
A thresher?
yes
no
Q30_26
A tractor?
yes
no
Q31
Are there any male members who are 60 years or more of age in this household?
yes
no
Q31A
How many of male members who are 60 years or more of age in this household receive pension from any source – government or through previous employment?
Q32
Can you tell me the type of government pension schemes that each male member is enrolled in?
Q32A
Name
Q32B
Age
Q32C
government pension schemes
Atal Pension Yojana (APY)
National Pension scheme (NPS)
Indira Gandhi National Old Age Pension Scheme (IGNOAPS)
Varishtha Pension Bima Yojana (VPBY)
Pradhan Mantri Vaya Vandana Yojana (PMVVY)
Other govt scheme
Reitred employee pension
Do not know the pension scheme
Q33
Are there any female members who are 50 years or more of age in this household?
yes
no
Q34
How many of female members who are 50 years or more of age in this household receive pension from any source – government or through previous employment?
Q35
Can you tell me the type of government pension schemes that each female member is enrolled with?
Q35A
Name
Q35B
Age
Q35C
government pension schemes
Atal Pension Yojana (APY)
National Pension scheme (NPS)
Indira Gandhi National Old Age Pension Scheme (IGNOAPS)
Varishtha Pension Bima Yojana (VPBY)
Pradhan Mantri Vaya Vandana Yojana (PMVVY)
Other govt scheme
Reitred employee pension
Do not know the pension scheme
Awareness regarding the need for birth and death registration
A01
Do you know within many days after a birth or death, should the birth/death be registered with the government?
yes
no
Refused to answer
A02
Do you know how many days after stillbirth, should the stillbirth be registered with the government?
yes
no
Refused to answer
No need to register
A03
In your opinion, where all can a birth or death be registered?
Public health facility
Block Development Office
Municipality office
Village Panchayat
Jan seva kendra
Other (specify)
Don’t know
Refused to answer
A04
Does the head of the household have a birth certificate?
yes
no
Don't know
Refused to answer
A05
Do you have a birth certificate for yourself?
yes
no
Don't know
Refused to answer
A06
How many birth certificates do you have?
A07
In your opinion, why is the birth certificate needed?
Useful government record to have
Needed for school admission
Useful as a proof of date of birth
Useful for employment
Useful for AADHAR card registration
For marriage
Others (specify)
Don’t know
A08
In your opinion, why is a death certificate needed?
Useful for government record
Useful for bank/postal settlements
Claim for property inheritance
Claim for any business or share
Claim for insurance or policy benefits
Claim for pension
For court cases
For agricultural land transfers
For job transfer
Useful for ration card
Useful for marriage/re-marriage
Don’t know
Other (specify)
A09_1
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Death of a 75 years old woman
Death of a 10 months old baby boy
Death of a 20 days old baby girl
Death of a 14 years old boy
Death of a 60 years old man
Death of a 1.5 years old girl
A09_2
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Death of a 60 years old man who was a pensioner
Death of a 45 years old housewife
Death of a 48 years old man who was in Government service
Death of a 28 years old man who was unemployed
Death of a 65 years old man who was not a pensioner
A09_3
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Death of a 36 years old man with life insurance policy
Death of a 27 years old woman who died during delivery
Death of a 60 years old housewife with no property on her name
Death of a 70 years old man with property on his name
Death of a 35 years old woman with property on her name
A09_4
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Death of a 17 years old married woman
Death of a 35 years old widow
Death of a 30 years old woman who is a divorcee
Death of a 27 years old unmarried girl
A09_5
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Baby who died immediately at birth
Baby who was born dead
Baby boy who died next day of birth
Baby girl who died 7 days after birth
A09_6
I will now give you a set of deaths. From each set, please tell me which of the deaths are most likely to be registered to get a death certificate.
Baby who died due to Covid-19 without other illnesses
Death of a 28-year-old man due to Covid-19 without any other illness
Death of a 30 years old housewife due to Covid-19 without any other illness
Death of 60 years old man due to Covid-19 who had also chronic disease
A10
I will now quote a few statements, and I would like to know your opinion about that statement. Please respond as correct or incorrect as per your opinion.
A10A
Maternal death is the death of a woman
A10A_1
who dies during childbirth.
Correct
Incorrect
Don’t know
Refused to answer
A10A_2
who dies after delivery.
Correct
Incorrect
Don’t know
Refused to answer
A10A_3
who dies during childbirth or within 42 days of delivery.
Correct
Incorrect
Don’t know
Refused to answer
A11
In your opinion, is it important to register death of a woman who ………………?
A11_1
Woman who died during delivery
yes
no
cannot say
A11_2
Woman died later
yes
no
cannot say
A12
Do you know of any woman personally or a case where a woman had died during childbirth or after delivery?
Yes, know personally
Yes, have heard of a case
no
A14
In your opinion, is it important to register death due to ……
A14_1
Suicide
yes
no
cannot say
A14_2
Drowning of an adult
yes
no
cannot say
A14_3
Drowning of a child
yes
no
cannot say
A14_4
Snake bite of an adult
yes
no
cannot say
A14_5
Snake bite of a child
yes
no
cannot say
A14_6
Dog bite of an adult
yes
no
cannot say
A14_7
Dog bite of a child
yes
no
cannot say
A14_8
Road accident
yes
no
cannot say
A14_9
Burns
yes
no
cannot say
A14_10
Violence
yes
no
cannot say
A15
It is more important to register the babies who survive than the babies who die after birth.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A16
It is more important to register the babies who are born alive than those who are born dead.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A17
It is important to register births of baby boys than baby girls who are born alive.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A18
It is more important to register death of a male member who has property on his name than a male member who does not have property on his name.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A19
It is more important to register death of a female member who has property on her name than a female member who does not have property on her name.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A20
It is more important to register death of an old member who has property on his/her name than an old member who does not have property on his/her name.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A21
It is more important to register death of a young member who has property on his/her name than of young member who does not have property on his/her name.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A22
It is more important to register death of a male member who has pension on his name than someone who does not.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A23
It is more important to register death of a female member who has pension on her name than someone who does not.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A24
It is more important to register death of a married woman than someone who was not married or was a widow.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
A25
Do you believe that the family should know the medical cause of death when a household member dies?
yes
no
cannot say
Refused to answer
A26
Why do you think so?
A27
The numbers of births and deaths available with the government are incomplete in UP. One of the reasons is that information of a birth/death in village is not available immediately.
ASHA
ANM
Village Sarpanch
Dai /RMP
AWW
Other (specify)
Don’t know
Refused to answer
A28
In your opinion, can ….. be a resource person for keeping records of births and deaths in the community?
A28_1
ASHA
yes
no
cannot say
A28_2
AWW
yes
no
cannot say
A28_3
ANM
yes
no
cannot say
A28_4
Dai
yes
no
cannot say
A28_5
Village Sarpanch/Panchayat Sachive/Village pradhan
yes
no
cannot say
A28_6
RMP
yes
no
cannot say
A28_7
Nagar nigam/Nagar palika parishad/Nagar panchayat
yes
no
cannot say
A28_8
Other (specify)
yes
no
cannot say
A29
Sometimes people want to register birth/death in their family. But they cannot because of many reasons such as less knowledge about what do and where to register. Are there any other reasons why people are unable to register birth/death?
Facilities to register are far
Time consuming
People ask for money
Forms not easy to understand
People do not know where to go
Illiterate people cannot complete forms
Too many documents are asked
Have to go many times to get one certificate
Other (specify)
A30
Record the total number of interviews to be conducted in this household based on enumeration details provided.
A31
Please let the respondent know that you will confirm the number of births and deaths in this household.
A31_1
Name of baby/deceased
A31_2
Type of interview
A31_3
Confirm the type of interview with the respondent
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