Please Wait...
Back Check Template 3 -Form Fill
Village Information
Q01
state name
Q02
state code
Q03
district name
Q04
district code
Q05
block name
Q06
block code
Q07
village name
Q08
village code
Q09
hamlet
Q10
structure no.
Q11
HH no.
Q12
UID
Q13
Name of Supervisor
Q14
Name of Investigator
Q15
Investigator Code
Q16
Date of Interview
Respondent Information
A01A
Name of the head of the household
A01B
Respondent category
Women with children age 0-5 months
Women with children age 6-11 months
Women with children age 12-23 months
Women with children age 24-59 months
Women with children studing in 5th standard
Women with adolescent girl child aged 10-19 years
A01C
Name of the respondent
A02
What is your religion?
HINDU
MUSLIM
CHRISTIAN
SIKH
BUDDHIST/NEO-BUDDHIST
JAIN
JEWISH
PARSI/ZOROASTRIAN
NO RELIGION
SARNA
OTHER (SPECIFY)
A03
Which caste do you belong to?
A04
Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CASTE
GENERAL
OTHER (SPECIFY)
A05
Does your household own this house or any other house?
YES
NO RELIGION
DO NOT KNOW
A06
LOOK AT THE FLOOR AND CODE THE MAIN MATERIAL OF THE FLOOR
MUD/CLAY/EARTH
SAND
DUNG
RAW WOOD PLANKS
PALM/BAMBOO
BRICK
STONE
PARQUET OR POLISHED WOOD
VINYL OR ASPHALT
CERAMIC TILES
CEMENT
CARPET
POLISHED TONE/MARBLE/GRANITE
OTHER (SPECIFY)
A07
LOOK AT THE ROOF AND CODE THE MAIN MATERIAL OF THE ROOF
NO ROOF
THATCH/PALM LEAF/REED/GRASS
MUD
SOD/MUD AND GRASS MIXTURE
PLASTIC/POLYTHENE SHEETING
RUSTIC MAT
PALM/BAMBOO
RAW WOOD PLANKS/TIMBER
UNBURNT BRICK
LOOSELY PACKED STONE
METAL/GI
WOOD
CALAMINE/CEMENT FIBER
ASBESTOS SHEETS
RCC/RBC/CEMENT/CONCRETE
ROOFING SHINGLES
TILES
SLATE
BURNT BRICK
OTHER (SPECIFY)
A08
LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS
NO WALLS
CANE/PALM/TRUNKS/BAMBOO
MUD
GRASS/REEDS/THATCH
BAMBOO WITH MUD
STONE WITH MUD
PLYWOOD
CARDBOARD
UNBURNT BRICK
RAW WOOD/REUSED WOOD
CEMENT/CONCRETE
STONE WITH LIME/CEMENT
BURNT BRICKS
CEMENT BLOCKS
WOOD PLANKS/SHINGLES
GI/METAL/ASBESTOS SHEETS
OTHER (SPECIFY)
A09
Does your household have a toilet?
YES
NO
ACCESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
B01
Does anyone in your household have a MGNREGA job card? If yes, please show me.
YES, SEEN
YES, REPORTED BUT NOT SEEN
NO
B02
Does your household have a ration card?
YES
NO
B03
Is your name included in the ration card?
YES
NO
B04
Does anyone in your household have a bank account opened under the Pradhan Mantri Jan Dhan Yojana?
YES
NO
DO NOT KNOW
LAND OWNERSHIP AND USE OF LAND FOR FARMING
C01
Does any your household own, lease in any agricultural land?
YES
NO
C02
Does your household engage in agricultural activities?
YES
NO
C03
How much agricultural land does your household presently have access to:
C03A
OWNED LAND
C03A1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C03B
LEASED LAND
C03B1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C04
Out of this land how much is irrigated or rainfed?
C04A
IRRIGATED LAND
C04A1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C04B
RAINFED LAND
C04B1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C04C
Leased land
C04C1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C04D
IRRIGATED LAND
C04D1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
C04E
RAINFED LAND
C04E1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
MALARIA
D01
Does your household have any mosquito nets that can be used while sleeping?
YES
NO
DO NOT KNOW
D02
How many mosquito nets does your household have?
D03
Has any member of your household been detected with malaria in the past 3 months?
YES
NO
DO NOT KNOW
MATERNAL HEALTH
E01
Was the delivery caesarean?
YES
NO
E02
Where did you deliver [CHILD NAME]?
HOME
GOVERNMENT HEALTH FACILITY
PRIVATE HEALTH FACILITY
OTHERS (SPECIFY)
E03
During your pregnancy with [CHILD NAME], were you given a TT injection?
YES
NO
DO NOT KNOW
E04
During your pregnancy with [CHILD NAME], did you receive any Iron Folic Acid (IFA) tablets or bottles?
YES
NO
DO NOT KNOW
CHILD HEALTH & NUTRITION
F01
Did you ever breastfeed [CHILD NAME]?
YES
NO
F02
Are you still breastfeeding [CHILD NAME]?
YES
NO
F03
Have you breastfed [CHILD NAME] in the past 24 hours – either day time or night time?
YES
NO
F04
Do you have a mother and child protection card (immunization card)?
YES, SEEN
YES, NOT SEEN
NO
F05
COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. CODE ‘77’ IF CARD IS BLANK AND THEN SKIP TO N12. WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. CODE 0 IF DATE IS NOT MENTIONED & THE CARD DOES NOT SHOW THAT A VACCINE WAS GIVEN OR NOT. IF ONLY PART OF DATE IS SHOWN ON CARD, RECORD ‘99’ OR ‘9999’ FOR ‘DO NOT KNOW’ IN THE COLUMN FOR WHICH INFORMATION IS NOT GIVEN.
F05_1
BCG
F05_2
POLIO 0 (POLIO GIVEN AT BIRTH)
F05_3
HEPATITIS B 0 (HEPATITIS B GIVEN AT BIRTH)
F05_4
POLIO
F05_5
DPT 1
F05_6
HEPATITIS B 1
F05_7
PENTAVALENT 1
F05_8
POLIO 2
F05_9
DPT 2
F05_10
HEPATITIS B 2
F05_11
PENTAVALENT 2
F05_12
POLIO3
F05_13
DPT 3
F05_14
HEPATITIS B 3
F05_15
PENTAVALENT 3
F05_16
MEASLES
F05_17
DPT (16-24 MONTHS)
F05_18
POLIO (16-24 MONTHS)
F05_19
VITAMIN A (FIRST DOSE)
F05_20
VITAMIN A (SECOND DOSE)
F05_21
VITAMIN A (THIRD DOSE)
SELF-HELP GROUPS AND LEADERSHIP
G01
Are you a member of any Self-help group (SHG)?
YES
NO
G02
Is anyone in your household a member of any Self Help Group (SHG)?
YES
NO
G03
Are you a panchayat member?
YES
NO
G04
Did you engage in any income generating activities in last 12 months?
YES
NO
Dear user, please upgrade your plan to access this feature
See Plans
Please Wait