Surveypoint

Q01

NAME OF DISTRICT

Q02

CODE OF DISTRICT

Q03

NAME OF BLOCK

Q04

CODE OF BLOCK

Q05

VILLAGE/URBAN AREA NAME

Q06

CLUSTER CODE

Q07

NAME OF HOUSEHOLD HEAD

A01

What is your religion?

A02

Do you own this house?

Yes

No

A03

Does your family have a below poverty line (BPL) card?

Yes, Card Seen

Yes, Card Not Seen

No

Don’t Know

A04

Respondent category

Women with child age 0-3 months

Women with child age 4-6 months

Women with child age 34-38

Women with child age 39-44 months

Women with child age 45-50 months

Women with child age 51-56 months

Women with child age 57 and above

Women with child age 7-9 months

Women with child age 10-12 months

Women with child age 13-18 months

Women with child age 19-24 months

Women with child age 25-30 months

Women with child age 31-33 months

A05

Have you ever attended school?

Yes

No

A06

Total number of living children as of now

A07

Was this pregnancy registered?

Yes

No

A08

Until what age should a child be breastfed in addition to other food?

A09

How soon after birth did you breastfeed your child ?

With an hour

After 1-2 hours

A10

Has (NAME) taken any drug or syrup to get rid of intestinal worms in the past 6 months?

Yes

No

A11

Do you know about anemia?

Yes

No

A12

Does (name) attend any organized learning or early childhood education programme, such as a private or government facility like anganwadi centre, including kindergarten or community child care?

Yes

No

A13

Do you ever leave your child alone or with someone for taking care when you have to leave the house to go shopping, washing clothes clothes, or for other reasons.

A13_1

left alone for more than an hour?

Yes

No

A13_2

left in the care of another child, that is, someone less than 10 years old, for more than an hour?

Yes

No

A14

Has your child ever received any vaccinations since birth?

Yes

No

A15

Are you a member of Mother’s collective or support group?

Yes

No

A16

Do you have bank account?

Yes

No

A17

Do you support Aanganwadi centres or services provided by them?

Yes

No

A18

In the last 12 months, have you received any training?

Yes

No

A19

Are you a member of any SHG

Yes

No

Back Check Template 1 -Form Fill