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Household Template 40 -Form Fill
HOUSEHOLD CHARACTERISTICS
Q01
Name of the respondent
Q02
What is the sex of the respondent?
Male
Female
Q03
What is the religion of the household?
Hindu
Muslim
Sikh
Christians
Others(specify)
Q04
Which caste do you belong to?
Schedule Caste
Schedule Tribe
OBC
General
Others(specify)
Q05
What is the type of your family?
Nuclear
Joint
Q06
Please specify whether you belong to APL/BPL?
APL
BPL
Don’t know/cant say
Q07
Please tell me the names of the persons who usually live in your household starting with the head of the household including you
Q08
What is the relationship of (NAME) to the head of the household?
head
wife or husband
son or daughter
son-in-law or daughter-in-law
grandchild
parent
brother or sister
other
Q09
Is (NAME) male or Female?
Male
Female
Q10
What is the age of (Name)?
Q11
What is the current marital status of (NAME)?
Currently married
Widowed
Divorced
Separated
Never Married
Other
Q12
Whether (NAME) has any kind of disability?
Physical
Mental
None
Q13
Whether (NAME) has any kind of chronic disease?
Physical
Mental
None
Q14
Can (NAME) read and write?
Yes
No
Q15
Has (NAME) ever Attended school?
Yes
No
Q16
What is the qualification of (NAME)?
Currently in class I
Completed class 1
Completed class 2
Completed class 3
Completed class 4
Completed class 5
Completed class 6
Completed class 7
Completed class 8
Completed class 9
Completed Secondary School
Completed Higher Secondary
BA/BSC pass/Fazil
BA/BSC honors/Fazil (Hons)
MA/MSC/Kamil & above
Hafezia/Kiratia/Nurani madrasa
Child less than 5 years
Never attended school
Currently in Aanganwadi/Pre-school Education
Q17
What is the Primary Occupation of (NAME)?
Agriculture
Local Labour
Migrant labour
Salaried
Petty Trader
Skilled worker
Unemployed
Student
Housewife
Child not attending school
Self-Employed
Others (if any)
Household Assets and Income
A01
Does your household own a house?
Yes
No
A02
What is the type of your house?
Pucca
Semi Pucca
Kuccha
A03
How many rooms in this house are used for sleeping?
A04
What is the main source of drinking water for members of your household?
Piped water in residence/yard/plot
Hand pump in residence/yard/plot
Well water in residence/yard/plot
Public hand pump
Public tap
Public well
Bore well
Canal
Other source (specify)
A05
Is the water available throughout the year?
Yes
No
A06
During which months of the year do you face scarcity of drinking water?
January
February
March
April
May
June
July
August
September
October
November
December
A07
What kind of toilet facility does your household have?
Open Defecation
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Ventilated improved pit biogas latrine
Pit latrine with slab
Pit latrine without slab/ open pit
Twin pit/composting toilet
Dry toilet
Others (specify)
A08
What is the main source of lighting for your household?
Electricity
Kerosene lamp
Gas lamp
Candle
Solar energy
Other (specify)
A09
What type of fuel does your household commonly use for cooking?
Wood
Crop residues
Dung cakes
Coal/ charcoal
Kerosene
Electricity
Liquid petroleum gas
Bio-gas
Other (specify)
A10
Does your household own any of the following items
A10_1
Electric connection
Yes
No
A10_2
Pressure cooker
Yes
No
A10_3
Mixer/grinder
Yes
No
A10_4
Motorcycle/scooter
Yes
No
A10_5
Car/Jeep
Yes
No
A10_6
Tractor and/ or other agril. Equipment (incl. power tiller)
Yes
No
A10_7
Bicycle
Yes
No
A10_8
Animal-drawn cart
Yes
No
A10_9
Chair
Yes
No
A10_10
Table
Yes
No
A10_11
Cot/ Bed
Yes
No
A10_12
Mattress
Yes
No
A10_13
Clock or watch
Yes
No
A10_14
Electric fan
Yes
No
A10_15
Water pump
Yes
No
A10_16
Thresher
Yes
No
A10_17
Radio/Transistor
Yes
No
A10_18
Sewing machine
Yes
No
A10_19
Refrigerator
Yes
No
A10_20
B & W television
Yes
No
A10_21
Colour television
Yes
No
A10_22
Telephone
Yes
No
A10_23
Computer
Yes
No
A10_24
Cell Phone
Yes
No
Household Income
B01
Did anyone in the household earn income from any of the following sources in the last 12 months?
B01_1
Agriculture labor
Yes
No
B01_2
Non-agriculture labor
Yes
No
B01_3
Skilled labor
Yes
No
B01_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
B01_5
Services
Yes
No
B01_6
Large scale business
Yes
No
B01_7
NTFP selling (Mohwa seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)
Yes
No
B01_8
Poultry
Yes
No
B01_9
Fisheries
Yes
No
B01_10
Other(specify)- excluding Agriculture and livestock as we will talk about agriculture and livestock later
Yes
No
B02
Whether engaged in the activity?
B02_1
Agriculture labor
Yes
No
B02_2
Non-agriculture labor
Yes
No
B02_3
Skilled labor
Yes
No
B02_4
Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
B02_5
Services
Yes
No
B02_6
Large scale business
Yes
No
B02_7
NTFP selling (Mohwa seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)
Yes
No
B02_8
Poultry
Yes
No
B02_9
Fisheries
Yes
No
B02_10
Other(specify)- excluding Agriculture and livestock as we will talk about agriculture and livestock later
Yes
No
B03
Who in the household earned income over last 12 months?
Men
Women
Both Men &Women
Children
All HH Members
B04
How much did the household earn from [activity] ______ over the past 12 months?
B05
Do you continue this acctivity during extreme weather conditions such as flood, drought, cyclone etc. ?
Yes
No
B06
Does your Household have a MGNREGA job card?
Yes
No
B07
In total how many number of job days did your households members receive through MGNREGS in the last 12 months?
B08
Do you practice regular savings?
Yes
No
B09
How regularly do you save?
Weekly
Fortnightly
Monthly
Once in 6 months
Once a year
Others
B10
Where do you save?
SHG
Cooperative
Bank
Post Office
At home
Others(specify)
B11
Do you have access to credit?
Yes
No
B12
Have you taken any loan in the last 12 months
Yes
No
B13
Where did you take the loan from?
SHG
Cooperative
Bank
Post Office
Family/ Relatives
Local money lender
others (specify)
B14
What was the purpose of taking the loan
Purchase agricultural inputs
Purchase agricultural machinery
Small business
Large business
Education
Personal (Wedding, Death, Buying food)
Medical purposes
Payment of old loans
Others(specify)
B15
Has there been any situation where you have not been able to repay the loan or pay the instalment for the loans taken in the last 12 months?
Yes
No
B16
What were the reasons for the failure?
Less Income due to absence of earning member
Other large expenditure
Reduction in income due to crop failure
Reduction in income due to Business failure
Payment of old loans
Others (specify)
B17
Does your houshold have access to insurance?
Yes
No
B18
What type of insurance does your household/ Crop/ Livestock have have?
Health
Accidental
Life
Vehicle
Regular Crop Insurance
Weather based crop insurance
No insurance
Others(specify)
B19
Does you receive remittance?
Yes
No
B20
How often has your household received remittances in the last 12 months?
Weekly
Fortnightly
Monthly
Once in 6 months
Once a year
Others
B21
On average, how much money did your household receive each time you received remittances in the last 12 months?
B22
In the last 12 months, has there been any unexpected incident that has adversely affected the economic situation of your household?
Yes
No
B23
What has been the event?
Death of income earning HH member
Death of other HH member
Disease or injury of income-earning HH member
Disease or injury of other HH member
Loss of employment of any HH member
Divorce by husband/wife
Loss of crop due to flooding
Loss of crop due to other reasons drought
Disease, injury, loss of cattle/ in fish pond
Damage to house or any productive assets (theft, fire, river erosion, cyclone etc.)
Storage crop damage/theft
Business failure
Conflict, dispute, legal problems
Land ownership and usage
C01
Does your household own any agricultural land?
Yes
No
C02
What is the size of the land on which you are currently cultivating?
C03
Does your household lease out any agricultural land?
Yes
No
C04
What is size of the agricultural land you lease out?
C05
Does your household lease in any agricultural land?
Yes
No
C06
What is size of the agricultural land you lease in?
C07
Does your household mortgage any agricultural land?
Yes
No
C08
What is size of the agricultural land you mortgage?
C09
Do you use irrigation on your land?
Yes
No
C10
Out of this land, how much is irrigated? (Investigator Note: Please use the local conversion unit in acres)
C11
What is the source used for irrigating this land?
Tube well
Well
Canal
Drip Irrigation
Borewell
Lift irrigation
Others (specify)
C12
Do you fallow your land?
Yes
No
C13
How long do you fallow your land?
Less than6 months
A year
More than a year
Others (specify)
C14
What all do you do to fallow your land?
Plough
Grow fallowing plants
Grow nothing
Add fertilizers
Others (specify)
Climatic changes
D01
In the past 20 years , have you noticed any changes or variability in the climatic patterns?
Yes
No
D02
In the last 20 years have you noticed any changes or variability in the rainfall patterns?
Yes
No
D03
Has the intensity of rainfall decreased or increased?
Increased
Decreased
D04
Comparing the 1980s with the recent past 20 years i.e. 2000s, have you noticed any changes or variability in the temperature patterns?
Yes
No
D05
Has the temperature decreased or increased?
Increased
Decreased
D06
Have you observed drought (as a result of increase in temperature/decrease in rainfall) in the last 20 yearss?
Yes
No
D07
On average, how many times/years have you observed drought in the last 20 years?
D08
Among all, how many times you have observed major drought impacts in the last 20 years?
D09
How severe was the loss in terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
D10
Have you observed floods in the past 2 decades?
Yes
No
D11
On average, how many times/years have you observed floods in the last 20 years?
D12
Among all, how many times you have observed major flood impacts in the last 20 years?
D13
How severe was the lossin terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
D14
Have you observed cyclone in the past 2 decades?
Yes
No
D15
On average, how many times/years have you observed cyclone in the past 2 decades?
D16
Among all, how many times you have observed major cyclone impacts in the past two decades?
D17
How severe was the lossin terms of crop failure?
75% to 100 % failure
50% to 75% failure
Less than 50% failure
D18
Have you observed cold wave in the past 2 decades?
Yes
No
D19
On average, how many times/years have you observed cold wave in the past 2 decades?
D20
Among all, how many times you have observed major cold wave impacts in the past two decades?
D21
How severe was the lossin terms of crop failure?
75% to 100 % failure
50% to 75% failure
20 to 50% failure
Less than 20% failure
D22
Have you observed heat wave in the last 20 years?
Yes
No
D23
On average, how many times/years have you observed heat wave in the past 2 decades?
D24
Among all, how many times you have observed major heat wave impacts in the past two decades?
D25
How severe was the lossin terms of crop failure?
75% to 100 % failure
50% to 75% failure
20 to 50% failure
Less than 20% failure
Farming Practices
E01
Do you currently produce ______?
Yes
No
E02
What type of seed was primarily used for production of ____?
Improved
Local
Hybrid
Don’t Know
E03
What type of fertilizer was used on the land during production of _______?
Organic
K (Potash)
P(Phosphate)
N (Nitrogen/ Urea)
Composite (DAP, NPK, Gromor etc.)
Mixture of different types of fertilizers
Other(specify)
None
E04
Was any pesticide used during cultivation of ________?
Organic
Chemical
Integrated
None
E05
For this crop, are you mostly using line planting/ transplanting or do you broadcast the crop in the main field or both?
Line planting/ transplanting
Broadcast crop
Both
Don’t know
E06
Do you practice hoeing in fields where you grow _____?
Yes
No
E07
What is the total quantity produced? (Quantity in KG.)
E08
How much of the harvested was sold?
E09
At what rate was the produce sold (INR/kg) the income from the sale of ___?
E10
Where do you sell your products?
Local Market/haat
Vendor/Middleman
sCooperatives
Wholesale Market
E11
Out of all the crops you mentioned, which crop is the most water- intensive?
Rice
Wheat
Maize
Sorghum
Millets
Buckwheat
Barley
Groundnut
Soybeans
Lent
Arhar
Green gram
black garm
Mustard
Peas
Chickpeas
Beans
Sugarcane
Cotton
Sunflower
Tobacco
Tea
Oil seeds
Sweet potatoes
Potatoes
Carrots
Cucumber
Chili
Eggplant
Green leafy vegetables
Okra/Lady Finger
Onion
Capsicum
Cabbage
Cauliflower
Bottle gourd
Sponge gourd
Bitter gourd
Green Beans
Garlic
Ginger
Pumpkin/Zuchini
Tomato
Avocado
Guava
Mango
Lemon/Lime
Orange/Tangerine
Papaya
Melon
Lychee
Apple
Berries
Bananas
Grapes
Sapota
Pomegranate
Others
E12
How many times in a year do you cultivate this crop?
E13
Have you ever shifted to less-water intensive crop cultivation?
Yes
No
E14
How do you store your crops?
At home
Village level godown facilities
Government godown facilities
Others(specify)
E15
Do you think current storage facility available is adequate?
Yes
No
E16
Does your HH have access to cold storages for storing your crops?
Yes
No
E17
Has your HH utilized coldstorage facility in the past 12 months?
Yes
No
E18
Is the cold storage facility available whenever required?
Yes
No
IMPACT OF CLIMATE CHANGE ON CROP
F01
Crops grown
Rice
Wheat
Maize
Sorghum
Millets
Buckwheat
Barley
Groundnut
Soybeans
Lent
Arhar
Green gram
black garm
Mustard
Peas
Chickpeas
Beans
Sugarcane
Cotton
Sunflower
Tobacco
Tea
Oil seeds
Sweet potatoes
Potatoes
Carrots
Cucumber
Chili
Eggplant
Green leafy vegetables
Okra/Lady Finger
Onion
Capsicum
Cabbage
Cauliflower
Bottle gourd
Sponge gourd
Bitter gourd
Green Beans
Garlic
Ginger
Pumpkin/Zuchini
Tomato
Avocado
Guava
Mango
Lemon/Lime
Orange/Tangerine
Papaya
Melon
Lychee
Apple
Berries
Bananas
Grapes
Sapota
Pomegranate
Others
F02
By which hazard is your crop affected the most?
Flood
Drought
Hail
Cyclone
Heat Wave
Cold Wave
F03
Which stage of the crop is affected?
Pre-sowing
Seedling
Vegetative
Flowering/Tillering
Maturity
Others(specify)
F04
How severe is the loss or crop failure?
75% to 100 % failure
50% to 75% failure
20 to 50% failure
Less than 20% failure
Rearing
G01
Does your household own livestock?
Yes
No
G02
Did you rear any of these in the last 12 months?
G02_1
Bullocks
Yes
No
G02_2
Cow
Yes
No
G02_3
Cross bred cow
Yes
No
G02_4
Buffalo
Yes
No
G02_5
Goats/Lambs
Yes
No
G02_6
Poultry
Yes
No
G02_7
Fisheries
Yes
No
G02_8
Other (Specify)
Yes
No
G03
Does your HH has access to veterinary services?
Yes
No
G04
In the past 12 months, has your HH ever utilize veterinary health services?
Yes
No
Production
H01
Now we would like some information on your household's production and selling of animal products. Please only consider the previous 12 months.
H02
Did you produce any ___ during the last 12 months?
H02_1
Animal meat/offal
Yes
No
H02_2
Poultry meat/offal
Yes
No
H02_3
Milk (including that produced for milk products)
Yes
No
H02_4
Eggs
Yes
No
H02_5
Fisheries
Yes
No
H03
Did your household sell any of the ___ produced?
H03_1
Animal meat/offal
Yes
No
H03_2
Poultry meat/offal
Yes
No
H03_3
Milk (including that produced for milk products)
Yes
No
H03_4
Eggs
Yes
No
H03_5
Fisheries
Yes
No
H04
Where do you sell your products?
H04_1
Animal meat/offal
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
H04_2
Poultry meat/offal
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
H04_3
Milk (including that produced for milk products)
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
H04_4
Eggs
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
H04_5
Fisheries
Local Market/haat
Vendor/Middleman
Cooperatives
Wholesale Market
H05
How much did you sell?
H05_1
Animal meat/offal
H05_2
Poultry meat/offal
H05_3
Milk (including that produced for milk products)
H05_4
Eggs
H05_5
Fisheries
H06
What was the unit price? (INR)
H06_1
Animal meat/offal
H06_2
Poultry meat/offal
H06_3
Milk (including that produced for milk products)
H06_4
Eggs
H06_5
Fisheries
Migration
I01
In the last 12 months, have any adults (people aged at 15 years or more than 15 years) in your household migrated?
Yes
No
I02
What was/were the reason(s) for migration?
Temporary work/job
Permanent work/job
Entire family relocation
No land for agriculture
Cannot do agriculture cultivation anymore
No income generating activity at village
Other (specify)
Don’t know
I03
How often do they migrate for work?
Each month
Many times a year
Twice a year
Once a year
Permanently migrated
Others (specify)
Support and Trainings
J01
Have you or your HH member met with any agricultural/livestock/fisheries NGO extension worker in the past 12 months?
Yes
No
J02
What all topics did you discuss?
Agricultural practices
Seed subsidies
crop/livestock/fisheries Insurance
Farm machineries
Agro-chemicals and fertilizers
Irrigation
Others (specify)
J03
How many times have you met with any agricultural/livestock/fisheries government extension worker in the past 12 months?
J04
What all topics did you discuss?
Agricultural practices
Seed subsidies
crop/livestock/fisheries Insurance
Farm machineries
Agro-chemicals and fertilizers
Irrigation
Others (specify)
J05
Did your household use any of the following items during the 12 months?
J05_1
Improved Farm tools (e.g., wheel hoe, weeders, broad casters)
Yes
No
J05_2
Mechanized tools (e.g., thresher, harvester)
Yes
No
J05_3
Pesticides
Yes
No
J05_4
Herbicides
Yes
No
J05_5
Packaged animal feed
Yes
No
J05_6
Animal drugs/vaccines
Yes
No
J06
Have you or anyone else from your household ever received any training on agriculture, poultry or livestock related work?
Yes
No
J07
Did you or anyone else from your household ever receive training on_________ in the last 12 months?
J07_1
Agriculture and Livestock Training
Yes
No
J07_2
Field crop selection or rotation
Yes
No
J07_3
Improved seeds or crop varieties
Yes
No
J07_4
Pest management
Yes
No
J07_5
Soil improvement
Yes
No
J07_6
Poultry
Yes
No
J07_7
Livestock
Yes
No
J08
Who provided the training?
Government
NGO
Business groups
Community organizations
Family members/friends
Others (specify)
J09
Have you (yourself) or any of your household members been on an exposure visit related to agriculture practices in the past 12 months?
Yes
No
J10
How many times have you or your household member been on agriculture related exposure visit in the past 12 months?
J11
Where did you or your household member go for agriculture related exposure visit in the past 12 months?
Within village
Neighbouring village
Block
KVK within district
KVK outside district
Others (specify)
J12
Have you ever heard about farmer support centres?
Yes
No
J13
Have you or your household member ever accessed services from farmer support centre?
Yes
No
J14
Where is the nearest farmer support centre you or your family member have accessed?
Within village
Neighbouring village
Block
district
Others (specify)
J15
Are you currently availing any government or NGO facilitated agricultural schemes?
Government
NGO
Government and NGO
Not availing
Don’t Know
J16
Do you access agriculture related information from any other sources such as Mobile, Radio or TV?
Yes
No
SHG and Community Membership
K01
Are you or any of your HH member part of any SHG?
Yes
No
K02
Are you an active member of this group, (meaning that you participate in meetings, for example)?
Yes
No
K03
Does you self-help group have savings and credit activities?
Yes
No
K04
Do you personally participate in these savings and credit activities?
Yes
No
K05
Do you discuss any of the following in the self-help group?
K05_1
Livelihoods/socio-economic problems in the community
Yes
No
K05_2
Agriculture problems
Yes
No
K05_3
Education problems
Yes
No
K05_4
Health and nutrition problems
Yes
No
K06
Has any household member ever gone for any exposure visit as part of the SHG?
Yes
No
K07
Where have you gone for the exposure visit?
Neighbouring village
Nearest town
Block town
Neighbouring district
Outside state
Others
K08
Does your village have community welfare group?
Yes
No
K09
Are you a member of any community welfare group?
Yes
No
K10
What all activities do the group engage in?
Agriculture
Aquaculture
Poultry
Micro enterprise
Credit and savings
Others (specify)
K11
Have you received any kind of support from the group in the past 12 months?
Yes
No
K12
What kind of support do you receive from the group?
credit
Grain banks
Aid (both cash and kind)
Employment
Access to market
Others (specify)
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