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Household Template 15 -Form Fill

General Information of the Household Members
Q01

Name of the respondent

Q02

What is the sex of respondent

Q03

What is the religion of the household?
Q04

What is the caste of the household

Q05

Please specify the caste/Tribe
Q06

What is the type of your family

Q07

What type of ration card does your household currently possess?

Q08

Please tell me the names of the persons who usually live in your household starting with the head of the household
Q09

What is the relationship of (NAME) to the head of the household?
Q10

Is (NAME) male or female?
Q11

What is the age of (Name)?
Q12

What is the current marital status of (NAME)?
Q13

Whether (NAME) has any kind of disability?
Q14

Can (NAME) read and write?
Q15

Has (NAME) ever attended school?
Q16

What is the Highest level of formal education?
Q17

What is the Primary Occupation of (NAME)?
Q18

Does your household own this house or any other house?
Q19

What is the type of your house

Q20

What is the main source of drinking water for members of your household?

Q21

What kind of toilet facility does your household have?
Q22

Where do you defecate?
Q23

What is the main source of lighting for your household?
Q24

What type of fuel does your household commonly use for cooking?

Q25

Does your household own any of the following items:

Q25_1

Motorcycle/scooter
Q25_2

Car/Jeep
Q25_3

Tractor
Q25_4

Bicycle
Q25_5

Animal-drawn cart
Q25_6

Chair

Q25_7

Table
Q25_8

Cot/ Bed
Q25_9

Mattress
Q25_10

Clock or watch
Q25_11

Electric fan
Q25_12

Water pump
Q25_13

Thresher
Q25_14

Radio/Transistor
Q25_15

Sewing machine
Q25_16

Refrigerator
Q25_17

B & W television
Q25_18

Colour television
Q25_19

Telephone
Q25_20

Computer
Q25_21

Cell Phone
Q26

Do you have a bank account?
Q27

Does your household own livestock?
Q28

Does this household own any agricultural land?

Q29

How much agricultural land does this household own?
Q30

Out of this land, how much is irrigated?
Access to Education Institution (RTE & SSA) and Government Supported Schemes
A01

Are there any children in the HH of the school going age (6-13 years)?
A02

Go to Household Roster in Section I and write the line number, name, age and sex of children in the HH of 6-13 years

A02A

Child 1

A02A1

Line Number
A02A2

Name
A02A3

Age
A02A4

Sex
A02A5

Whether ever enrolled in school
A02A6

What is the type of School?
A02A7

Is (NAME) regular to school?
A02A8

How many days did (NAME) attend the school in the last month visited?
A02A9

On an average, how many days did (NAME) get mid-day meal in school in the last month visited?
A02A10

What is the reason for never enrolling the child in school?
A02A11

What is the reason for drop out?
A02B

Child 2

A02B1

Line Number
A02B2

Name
A02B3

Age
A02B4

Sex
A02B5

Whether ever enrolled in school
A02B6

What is the type of School?
A02B7

Is (NAME) regular to school?
A02B8

How many days did (NAME) attend the school in the last month visited?
A02B9

On an average, how many days did (NAME) get mid-day meal in school in the last month visited?
A02B10

What is the reason for never enrolling the child in school?
A02B11

What is the reason for drop out?
A02C

Child 3

A02C1

Line Number
A02C2

Name
A02C3

Age
A02C4

Sex
A02C5

Whether ever enrolled in school
A02C6

What is the type of School?
A02C7

Is (NAME) regular to school?
A02C8

How many days did (NAME) attend the school in the last month visited?
A02C9

On an average, how many days did (NAME) get mid-day meal in school in the last month visited?
A02C10

What is the reason for never enrolling the child in school?
A02C11

What is the reason for drop out?
A02D

Child 4

A02D1

Line Number
A02D2

Name
A02D3

Age
A02D4

Sex
A02D5

Whether ever enrolled in school
A02D6

What is the type of School?
A02D7

Is (NAME) regular to school?
A02D8

How many days did (NAME) attend the school in the last month visited?
A02D9

On an average, how many days did (NAME) get mid-day meal in school in the last month visited?
A02D10

What is the reason for never enrolling the child in school?
A02D11

What is the reason for drop out?
A02E

Child 5

A02E1

Line Number
A02E2

Name
A02E3

Age
A02E4

Sex
A02E5

Whether ever enrolled in school
A02E6

What is the type of School?
A02E7

Is (NAME) regular to school?
A02E8

How many days did (NAME) attend the school in the last month visited?
A02E9

On an average, how many days did (NAME) get mid-day meal in school in the last month visited?
A02E10

What is the reason for never enrolling the child in school?
A02E11

What is the reason for drop out?
A03

Satisfaction on MDM

A03_1

Quality of food served in mid-day meal
A03_2

Quantity of food served in mid-day meal
A03_3

Regularity of meals provided in mid-day meal
A03_4

Adoption of hygienic practices in cooking/serving mid-day

A04

In your opinion, is there any discrimination / irregularities in implementation of mid-day meal in school?
A05

Did your child ever experience any discrimination with respect to mid-day meal in school
A06

Have you ever raised a complaint about discrimination/irregularities in MDM?
A07

If yes, with whom did you complain?
A08

What was the affect of the complaint?
A09

Have you encountered any of the following situations?

A09_1

Is there a Separate seating arrangement for your child

A09_2

Are there different timings to serve mid-day meal to your child
A09_3

Reduced quantity of mid-day meal served to your child

A09_4

Inferior quality of mid-day meal served to your child

A09_5

Separate arrangement for drinking water
A09_6

Separate arrangement for keeping utensils
A10

Are you aware of the social background (caste and religion) of the cook for mid day meal in the school?
A11

Does the caste and religion of cook affect the decision of consumption of mid day meal by children in school?
A12

Are you aware of the scholarship/stipend scheme?
A13

Does _____________ receive the scholarship/stipend under the scheme?
A14

What amount does he/she receive under the scheme?
A15

If no, why does he she not receive scholarship under the scheme?
A16

In your opinion, are there any irregularities/discrimination in implementation of the scholarship schemes?

A17

Have you ever experience any irregularities in the implementation of the scholarship scheme?

A18

Have you ever raised a complaint about discrimination/irregularities?
A19

If yes, with whom did you complain?
A20

What was the affect of the complaint?
A21

Have you faced any of the following situations in the context of this scheme?

A21_1

Delay in payment of the scholarships in comparison to other children
A21_2

Amount paid less than the provisioned amount
A22

Are you aware of the Mukhyamantri Balika Poshak Yojna in which money is provided every year to purchase two pairs of dresses to girl children?
A23

List the girl children in the household studying class VI to VIII in government schools. Use the family chart for reference

A23A

Child 1

A23A_1

Name of the Child
A23A_2

Line Number in the Family Chart

A23A_3

Age

A23A_4

Class

A23B

Child 2

A23B_1

Name of the Child
A23B_2

Line Number in the Family Chart

A23B_3

Age

A23B_4

Class

A23C

Child 3

A23C_1

Name of the Child
A23C_2

Line Number in the Family Chart

A23C_3

Age

A23C_4

Class

A23D

Child 4

A23D_1

Name of the Child
A23D_2

Line Number in the Family Chart

A23D_3

Age

A23D_4

Class

A24

Has your child received the benefits of this scheme?
A25

If yes, what was the amount provided under the scheme? _________Rs

A26

If no (even for any one of the child), why in your opinion did your child not get the benefits?
A27

In your opinion, are there any irregularities in implementation of Mukhyamantri Balika Poshak Yojna?

A28

Have you ever experience any irregularities in the implementation of the scholarship scheme?

A29

Have you ever raised a complaint about discrimination/irregularities?
A30

If yes, with whom did you complain?
A31

What was the affect of the complaint?
A32

Have you experienced any of the following situations?

A32_1

Less amount of money reimbursed than provisioned

A32_2

Delayed in receiving benefits
A32_3

Money paid in installments
A32_4

Refused to give the provisions under the scheme
A33

Are you aware of the Mukhyamantri Balika cycle Yojna in which girls are supported to buy a cycle to all girl children registered in the 9th standard.
A33A

Has your child received the benefits under this scheme?
A34

If yes, what was the amount provided under the scheme?
A35

If no, why in your opinion did your child not get the cycle?
A36

In your opinion, is there any irregularity/discrimination in implementation of Mukhyamantri Balika cycle Yojna?

A37

Have you ever experience any irregularities in the implementation of the scholarship scheme?
A38

Have you ever raised a complaint about discrimination/irregularities?
A39

If yes, with whom did you complain?
A40

What was the affect of the complaint?
A41

Have you experienced any of the situations mentioned below?

A41_1

Less amount of money reimbursed than provisioned.
A41_2

Delayed in receiving benefits
A41_3

Money paid in installments
A41_4

Refused to give the provisions under the scheme
ACCESS TO SOCIAL SECURITY SCHEMES
B01

Are you aware of the widow pension schemes, under which a monthly pension is issued?
B02

Is ________ registered as one of the beneficiaries?
B03

If no, why is she not registered as a beneficiary?
B04

How much amount is provided to you as benefit every month?
B05

Do you think there are any discrimination/irregularities in the implementation of the scheme?
B06

Have you experienced any discrimination/irregularity in the implementation of scheme?
B07

Have you ever raised a complaint about discrimination/irregularities?
B08

If yes, with whom did you complain?
B09

What was the affect of the complaint?
B10

Have you experienced any of the following, while accessing the benefits of the scheme

B10_1

Amount paid as benefit less than the prescribed amount
B10_2

Delay in release of pension
B10_3

Release of pension in instalments
B10_4

Demand of bribes/facilitation money
B11

Are you aware of the Old age pension schemes, under which a monthly pension is issued?
B12

Is ________ registered as one of the beneficiaries?
B13

If no, why is _______ not registered as a beneficiary?
B14

Are you aware of the amount that should be provided under the scheme?
B15

How much amount is provided to you as benefit every month?
B16

Do you think there is any discrimination/irregularities in the implementation of the scheme?
B17

Have you ever experience any irregularities in the implementation of the scheme?

B18

Have you ever raised a complaint about discrimination/irregularities?
B19

If yes, with whom did you complain?
B20

What was the affect of the complaint?
B21

Have you experienced any of the following, while accessing the benefits of the scheme

B21_1

Amount paid as benefit less than the prescribed amount
B21_2

Delay in release of pension
B21_3

Release of pension in instalments
B21_4

Demand of bribes/facilitation money
B22

Are you aware of the pension scheme for the disabled, under which a monthly pension is issued?
B23

Is ________ registered as one of the beneficiaries?
B24

If no, why is _______ not registered as a beneficiary?
B25

Are you aware of the amount that should be provided under the scheme?
B26

What is the amount/benefit provided every month under the scheme?
B27

Do you think there is any discrimination/irregularities in the implementation of the scheme?
B28

Have you ever experience any irregularities in the implementation of the scholarship scheme?

B29

Have you ever raised a complaint about discrimination/irregularities?
B30

If yes, with whom did you complain?
B31

What was the affect of the complaint?
B32

Have you experienced any of the following, while accessing the benefits of the scheme

B32_1

Amount paid as benefit less than the prescribed amount
B32_2

Delay in release of pension
B32_3

Release of pension in instalments
B32_4

Demand of bribes/facilitation money
B33

Are you aware of the artisan card scheme, under which a loan can be accessed?
B34

Does ________ have an artisan card
B35

Have you / card holder derived any benefits by using this card?
B36

If yes, what are the benefits accessed by ____________ from the card?
B37

If no, why has _______ not accessed any benefits?
B38

Do you think there is any discrimination/irregularities in the implementation of the scheme?
B39

Have you ever experience any irregularities in the implementation of the scholarship scheme?

B40

Have you ever raised a complaint about discrimination/irregularities?
B41

If yes, with whom did you complain?
B42

What was the affect of the complaint?
B43

Have you experienced any of the following, while accessing the benefits of the scheme

B43_1

Amount paid as benefit/loan less than the prescribed amount
B43_2

Long delay in release of loan amount
B43_3

Release of loan amount in instalments
B43_4

Demand of bribes/facilitation money
B44

Are you aware of the insurance scheme for artisans, under which the artisan and their family members can assess health services?
B45

Does ________ have the health insurance?
B46

Have any benefits been accessed by using this scheme?
B47

If no, why is _______ not accessed any benefits?
B48

If yes, what are the benefits accessed by ____________ from the card?
B49

Do you think there is any discrimination/irregularities in the implementation of the scheme?
B50

Have you ever experience any irregularities in the implementation of the scheme?

B51

Have you ever raised a complaint about discrimination/irregularities?
B52

If yes, with whom did you complain?
B53

What was the affect of the complaint?
B54

Have you experienced any of the following, while accessing the benefits of the scheme

B54_1

Long delay in release of reimbursed amount
B54_2

Refusal of providing services by empanelled hospitals
B54_3

Release of reimbursed amount in instalments
B54_4

Demand of bribes/facilitation money
Health Seeking Behaviour and Access to Schemes
C01

When members of your household get sick, where do they generally go for treatment?
C02

How far is this facility from your house?
C03

How much time do you take to reach this facility?
C04

Why don't members of your household generally go to a government facility when they are sick?

C05

What are the reasons for preferring them?
C06

Please rate your last experience to the government health service facility on the identified parameters.

C06_1

Availability of health service providers
C06_2

Availability of drugs, medicines and other consumables
C06_3

Cleanliness of the facility
C06_4

Behaviour of the service provider
C07

Do you know where the Anganwadi centre in your village / ward is located?
C08

How far is the centre from your home?
C09

Do you know who the Anganwadi worker in your village / ward is?

C09A

If yes then probe for the name.
C10

Are you aware of the main functions of the anganwaadi worker?
C11

What according to you are the main functions of the Anaganwaadi?
C12

In the last one year, have you / your household members used any of the services provided by the anganwaadi?
C13

If yes, what service have you/your household members used in the last one year?
C14

Please refer to the Household Roster and complete the table if the household has children in the age of 6 to 35 months

C14_1

Name
C14_2

Age
C14_3

Sex
C14_4

Whether registered at AWC
C14_5

Did (NAME) get supplementary nutrition from AWC?
C14_6

How many days’ supplementary nutrition was given for (NAME) in last month?
C15

In your opinion is there any discrimination in the services provides under the anaganwaadi?
C16

Have you experienced any discrimination in accessing the services offered by the anaganwaadi?
C17

Did you ever complain about the discrimination?
C18

If yes, with whom did you complain?
C19

What was the affect of the complaint?
C20

Please indicate if you have faced any of the following while seeking services from the anaganwaadi.

C20_1

Refused the service
C20_2

Not provided the right quantity of the nutrition supplements
C20_3

Irregular supply of supplements
C20_4

Made to sit separately
C20_5

Made to wait for the services
C20_6

Irregular immunization
C20_7

Referral services not offered
C20_8

Irregular growth monitoring of children
C21

Do you know who the ANM for your village is?
C22

Are you aware of the services that the ANM provides?
C23

Can you tell us about the services provided by the ANM?
C24

What is the frequency of the visit of the ANM to the village?
C25

Have you / your household members used any of the services offered by the ANM in the last one year?
C26

If yes, which services offered by the ANM did you / your household member acess?
C27

In your opinion is there discrimination in the services provided by the ANM?
C28

Have you experienced any discrimination in accessing the services offered by the ANM?
C98

If yes, have you ever registered a complaint against it?
C99

If yes, then with who did you lodge the complaint?
C29

What was the effect of the complaint?
C30

Please indicate if you have faced any of the following while seeking services from the ANM.

C30_1

Refused services required/demanded
C30_2

Made to wait for the services
C30_3

Refused to visit the tola
C31

Do you know the ASHA worker in the village?
C32

If yes, can you tell us her name?
C33

Are you aware of the main functions of the ASHA?
C34

In your opinion what are the functions of ASHA?
C35

In the last one year, have you / your household members accessed the services of ASHA?
C36

Which services did you / your household members access?
C37

In your opinion is there discrimination in the services provided by the ASHA?
C38

Have you faced any discrimination in the services of the ASHA?
C39

If yes, have you ever registered a complaint against it?
C40

If yes, then with who did you lodge the complaint?
C41

Please indicate if you have faced any of the following while seeking services from the ANM.

C41_1

Refused Services
C41_2

Not provided with the benefits of the schemes sush as JSY
C41_3

Demanded facilitation money/bribes/tips
C42

Are you aware of the Primary Health Centre?
C43

Can you provide the name/address of the PHC?
C44

How far is the PHC from your house?
C45

What health services are available at the PHC?
C46

Have you / your household members accessed the services offered by the PHC in past 12 months?
C47

If yes, which services were received by you / your household member?
C48

If no, why have you not accessed any of the services offered by the PHC?
C49

Are you aware of the JSY scheme which encourages delivery in hospitals and also pays cash for getting the child delivered in the hospital?

C50

If yes, In your opinion what are provisions under the scheme?
C51

Is there any woman in the household who has delivered a child after January 2012?
C52

Women Delivered in last 2 years

C52_1

Name
C52_2

Was the delivery done in hospital?
C52_3

Did (NAME) register under JSY during the pregnancy?
C52_4

Did (NAME) received the cash benefit under JSY?
C52_5

Amount received under JSY? (In rupees) JSY
C53

In your opinion are there any discrimination/irregularities in the implementation of the JSY scheme
C54

Did you experience any discrimination in accessing this scheme
C55

Did you ever register a complaint against discrimination/irregularities?
C56

If yes, with whom?
C57

What was the impact of the complaint?
C58

Have you encountered any of the following situations

C58_1

Discrimination by ASHA in providing conselling and support
C58_2

Demand of tips/ Facilitation money by Asha or hospital functionaries
C58_3

Delay in receipt of cash incentive
C58_4

Discrimination or bad behavior by health functionaries
C59

Are you aware of the RSBY scheme (smart card), under which cashless hospitalization facilities are provided?
C60

Are you enrolled under the RSBY scheme?
C61

Are you aware of the name of the hospitals that are empanelled under the scheme
C62

Did you face any of the following situations while enrolling for the card

C62_1

Refusal for enrollment
C62_2

Were you made to stand in a separate queue for enrollment
C62_3

Facilitation money/bribe was demanded

C63

Are you Currently Pregnant?
C64

Can you tell us about the number of pregnancies that you have had in the past?
C65

Has there ever been a pregnancy that has resulted into miscarriage, abortion or still-birth?
C66

Has there been any incidence where a pregnant woman has died during / immediately after giving birth to a child in last 12 months?
C67

Was any of you child born alive but died before completing the age of one year?
C68

Can you please provide the details of any such incidence?

C68_1

BOYS

C68_2

GIRLS

C69

How many living children do you presently have?

C69_1

BOYS

C69_2

GIRLS

C70

During which month did you come to know about last pregnancy which ended in a LIVE birth of [NAME OF THE REF CHILD]?
C71

Did you register your last pregnancy?
C72

With whom did you register you pregnancy?
C73

How many times you received antenatal check-up(s) during last pregnancy?
C74

Why did you not go for an antenatal check-up?
C75

During which month of pregnancy, did you receive your first ante-natal check-up?
C76

From where did you receive antenatal check-up(s) for last pregnancy?
C77

During (any of) your antenatal visit, did you receive advice on any of the following at least once?
C78

During last pregnancy, how many IFA tablets did you receive?

C79

During last pregnancy, how many IFA tablets you consumed?
C80

Why did you not consume any IFA tablets?
C81

From where did you get IFA tablets?
C82

During last pregnancy how many times did you get tetanus injections?
C83

Why did you not take 2 tetanus injections?
C84

Where did your last delivery take place?
C85

What are the reasons for not going to health facility for delivery?
C86

Who conducted the last delivery?
C87

Did a qualified health worker check your health or your youngest child's health following the birth?
C88

How long after delivery did the first check take place?
C89

What was the weight of [CHILD NAME]?
C90

What is the date of birth of the child?
C91

Has the child been ever vaccinated?
C92

Why was the child not immunized?
C93

Do you have the vaccination card where vaccination details of the child are recorded?
C94

Did you ever have a vaccination card?
C95

Record the vaccination details from the card or as reported by the parent.

C95_1

BCG
C95_2

POLIO O
C95_3

DPT 1
C95_4

DPT 2
C95_5

DPT 3
C95_6

POLIO 1
C95_7

POLIO 2
C95_8

POLIO 3
C95_9

MEASLES
C95_10

VITAMIN A
C96

Where was the child vaccinated?
C97

Has the child been given a Hepatitis B injection
For All
D01

Are there any CBOs in your village?
D02

Are you a member of any CBO?

D03

Which type of CBO are you a member of?
D04

Are you aware of Gram Panchayats?
D05

Have you participated in Gram Sabha/Aam Sabha in the last one year?
D06

If no, why have you not participated in the Gram Sabha?
D07

What in your opinion are the functions of the gram sabha?
D08

Are you aware of the Village Health Sanitation and Nutrition committee?
D09

Have you attended a meeting of the VHSNC?
D10

In your opinion what are the key roles of VHSNC?
D11

In your opinion who are the members of the VHSNC?