Surveypoint

Q01

District Name

Q02

District Code

Q03

Block Name

Q04

Block Code

Q05

Panchayat Name

Q06

Panchayat Code

Q07

Ward Name

Q08

Ward Code

Q09

Name of the EWR

Q10

Contact number

Q11

EWR ID

Q12

Designation of the Respondent in representing Panchayat

Mukhiya of Gram Panchayat

Ward Member

A01

Interviewer Name

A02

Interviewer ID

A03

Date of Visit

A04

Result Code

INTERVIEW COMPLETED

VISIT RESCHEDULED

INTERVIEW INCOMPLETE

REFUSED

HOUSEHOLD NOT LOCATED

RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD

RESPONDENT IS TEMPORARILY AWAY

OTHER (SPECIFY)

B01

How old were you at your last birthday?

B02

What is your caste or tribe?

No caste or tribe

BRAHMIN

RAJPUT/THAKUR

BHUMIHAR

KAYASTH/SRIVASTAVA/LALA

CHAMAR

DUSADH/PASWAN

MUSAHAR

PASI

DHOBI

BHUIYA

CHAUPAL

BANTAR

RAJWAR

YADAV

VAISHYA/BANIA

KURMI

SHAH

OTHER CASTE OR TRIBE (SPECIFY)

Do not know

B03

Have you ever attended school?

YES

NO

B04

What is the highest standard or class you completed?

B05

Other than being a Panchayat member, what is your occupation, that is, what other kind of work do you mainly do?

Farmer

Agricultural day labor

Herding animals

Non agricultural day labor

Maid servant

Cook

Child Care Provider

Service/Salaried Worker

Small/Cottage Industry

Business/Trader

Other Self-Employment

Skilled Worker

Other (specify)

B06

What is your current marital status?

Currently married

Married, guana not performed

Widowed

Divorced

Separated

Deserted

Never married

C01

How many times have you been elected?

C02

Was your current Panchayat position reserved for a female candidate?

YES

NO

Do not know

C03

Was your current Panchayat position reserved for an SC/ST candidate?

YES

NO

C04

Since becoming a Panchayat member in the most recent election cycle, have you received any training/orientation?

YES

NO

C05

Did you receive any training on health rights and entitlements?

YES

NO

D01

How many antenatal check-ups is a woman supposed to receive over the course of her pregnancy?

D02

Are you aware of any programs that are supposed to provide money or other types of support to pregnant women who deliver in a facility?

YES

NO

D03

What programs are you aware of?

Janani Suraksha Yojana

Janani Sishu Suraksha Karyakram

Other (specify)

D04

How much money are women who have an institutional delivery supposed to receive through these programs?

D05

How many postpartum home visits are women supposed to receive from an ASHA/AWW/ANM?

D06

If a woman would like to terminate a pregnancy, is it legal to do so?

YES

NO

Do not know

D07

If a woman would like to find out the sex of her fetus, is it legal to do so?

YES

NO

Do not know

E01

Are you aware of VHSNDs being organized in your village?

YES

NO

E02

How many times, if any, have you met with the ASHA to discuss her role in providing health services in the last 6 months?

E03

How many times, if any, have you met with the AWW to discuss her role in providing health services in the last 6 months?

E04

How many times, if any, have you met with the ANM to discuss her role in providing health services in the last 6 months?

E05

In the last 6 months, has there been a ward sabha meeting in your ward?

YES

NO

E06

In the last 6 months, has there been a Gram Sabha meeting in your Panchayat?

YES

NO

Do not know

E07

Have you heard of VHSNCs?

YES

NO

E08

Are you a member of the VHSNC in your village?

YES

NO

F01

Do you feel like you have the skills, information, and knowledge needed to perform your responsibilities as a Panchayat member, or do you feel you need more skills, information, and knowledge?

I have the skills, information, and knowledge needed to perform my duties

I need additional skills, information, and knowledge kills

Do not know

F02

Do you face any special problems in discharging your duties because you are a woman?

YES

NO

Back Check Template 2 -Form Fill

District Name

District Code

Block Name

Block Code

Panchayat Name

Panchayat Code

Ward Name

Ward Code

Name of the EWR

Contact number

EWR ID

Designation of the Respondent in representing Panchayat

Interviewer Name

Interviewer ID

Date of Visit

Result Code

How old were you at your last birthday?

What is your caste or tribe?

Have you ever attended school?

What is the highest standard or class you completed?

Other than being a Panchayat member, what is your occupation, that is, what other kind of work do you mainly do?

What is your current marital status?

How many times have you been elected?

Was your current Panchayat position reserved for a female candidate?

Was your current Panchayat position reserved for an SC/ST candidate?

Since becoming a Panchayat member in the most recent election cycle, have you received any training/orientation?

Did you receive any training on health rights and entitlements?

How many antenatal check-ups is a woman supposed to receive over the course of her pregnancy?

Are you aware of any programs that are supposed to provide money or other types of support to pregnant women who deliver in a facility?

What programs are you aware of?

How much money are women who have an institutional delivery supposed to receive through these programs?

How many postpartum home visits are women supposed to receive from an ASHA/AWW/ANM?

If a woman would like to terminate a pregnancy, is it legal to do so?

If a woman would like to find out the sex of her fetus, is it legal to do so?

Are you aware of VHSNDs being organized in your village?

How many times, if any, have you met with the ASHA to discuss her role in providing health services in the last 6 months?

How many times, if any, have you met with the AWW to discuss her role in providing health services in the last 6 months?

How many times, if any, have you met with the ANM to discuss her role in providing health services in the last 6 months?

In the last 6 months, has there been a ward sabha meeting in your ward?

In the last 6 months, has there been a Gram Sabha meeting in your Panchayat?

Have you heard of VHSNCs?

Are you a member of the VHSNC in your village?

Do you feel like you have the skills, information, and knowledge needed to perform your responsibilities as a Panchayat member, or do you feel you need more skills, information, and knowledge?

Do you face any special problems in discharging your duties because you are a woman?