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Household Template 17 -Form Fill
IDENTIFICATION
Q01
State
Q02
District
Q03
Block
Q04
Village (Hamlet Name)
Q05
Household No.
Q06
Name of the household head
Q07
Gender/ Sex of Household head
Male
Female
Q08
Name of the respondent
Q09
Are you a member of any SHG
Yes
No
Q10
What is the name of your SHG?
Q11
Was your SHG formed by PRADAN/ Federation/ Other SHG leaders/ women from the area?
Yes
No
Q12
Religion of the respondent
Muslim
Hindu
Christian
Buddhist
Sarna
Sikh
Other [specify]
Q13
Caste of the respondent
General
Scheduled caste
Scheduled tribe
Other backward class
Q14
Interviewer
Q15
Date of interview
HOUSEHOLD COMPOSITION
A01
Please tell me the name of all the persons who live in your house, starting with your name
A02
Relation to respondent woman.
Respondent woman
Husband
Son or daughter
Son in-law or daughter-in-law
Grandfather or grand mother
Grandson or granddaughter
Father or mother
Father in law or mother in law
Brother or sister
Brother in law or sister in law
Uncle or aunt
Other relatives (including cousins)
Foster/step/adopted children
Not related
A03
Sex
Male
Female
Transgender
A04
Age
A05
Education
Currently in class 1
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 class 10
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
A06
Marital status?
Unmarried
Married
Widowed
Divorced
Separated
Deserted by spouse
A07
Main Occupation
Farming/Agriculture (Crops)
NTFP Collection
Livestock (goats, poultry, piggery, fishery & dairy)
Unskilled wage labour (agricultural labour, MGNREGA labour, construction work, brick kiln labour etc.)
Skilled worker(tailoring, masonry, electrician, plumbing, carpentry, welding, driving, etc.)
Salaried worker (teachers, AWW, ANM, etc. )
Contractual or task based work ( ASHAs, CSPs, BC Agents, Tuitions, para-teachers etc.)
Micro-enterprises (kirana shops, dhabas, mobile shops, ferry shops etc.)
House Work
Unemployed
Old age/pensioner
Differently abled
Student
Child (age <5)
Other
LAND OWNERSHIP; USE OF LAND FOR FARMINGAND IRRIGATION PRACTICES
B01
Does your household own any land?
Yes
No
B02
How much land does your household own?
B02A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
B03
How much of this is cultivable?
B03A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
B04
How much of your owned land do you cultivate?
B04A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
B05
Have you also taken any land on lease from others?
Yes
No
B06
How much land have you leased in?
B06A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
B07
Have you mortgaged or leased out your land to someone else?
Yes
No
B08
How much land have you leased/mortgaged out?
B08A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
B09
Do you have any source of irrigation on your land/the land that you cultivate?
Yes
No
B10
What are the sources
B10_1
Farm pond (Hapa)
Yes
No
B10_2
Dugwell
Yes
No
B10_3
Lift/Flow irrigation
Yes
No
B10_4
Canal/River
Yes
No
B10_5
Earthern dam/Check dams
Yes
No
B10_6
Borewell
Yes
No
B11
How much of the the land area is irrigated
B11A
Unit
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Others Specify
CROPS CULTIVATED AND PACKAGE OF PRACTICES ADOPTED
C01
Crop Code
Paddy
Wheat
Maize
Millet
Sorghum
Barley
Oat
Groundnut
Mustard
Rapeseed
Nizer
Sunflower
Til
Pigeonpea
Blackgram
Chickpea
Greengram
Horsegram
Lentil
Lathyrus(Cheakling pea)
Potato
Tomato
Cabbage
Cauliflower
Chilli
Capsicum
Spongegourd
Bittergourd
Bottlegourd
Spinegourd
Snakegourd
Pointed gourd
Ridge gourd
Leafy vegetable
Sweet Potato
Brinjal
Cucumber
French bean
Green pea
Broccoli
Radish
Carrot
Coriander
Ladiesfinger
Coccinia (kundru)
Elephant foot yam
Colocasia (Kacchu)
Flat bean (Saim)
Drumstick
Pupmkin
cowpea
Bean
Kakri
Ashgourd
Guava
Mango
Lemon/Lime
Papaya
Water Melon
Onion
Garlic
Turmeric
Ginger
Arrrow root
Banana
Mulberry
C02
How much of the agricultural land was used in the cultivation of this crop?
C03
What is the total quantity produced? (Quantity in KG.)
C04
What was the average market rate you got for this crop? (price per kg)
C05
Where do you normally sell the crop?
Local market in the village
Middlemen
Retail market in block town
Wholesale market
C06
What was/would be the income from the sale of ___?
C07
First, please tell me the names of two crops that are mostly grown by you______?
C08
What type of seed was primarily used for production of ____?
Improved seeds
Local seeds
Don’t know
C09
Do you treat the seeds in some way before planting?
Yes
No
C10
Do you raise nursery for the crop (raised bed , line sowing, use of fertilizer, Use of pesticide, net covering, irrigation)
Yes
No
C11
In how many days do you transplant the seedling?
8-14 days
15-30 days
More than 30
Don’t know
C12
For this crop, are you mostly using line sowing/transplanting or do you broadcast the seeds in the main field or both?
Line sowing
Transplanting
Broadcastings
Don’t know
C13
Did you apply fertilizer in the main field?
Organic
K (Potash)
P(Phosphate)
N (Nitrogen/ Urea)
Composite (DAP, NPK, Gromor etc.)
Organic and inorganic both
Other
None
Don’t know
C14
How do you prepare the field before transplanting/sowing?
Heavy tillage (sub-soiling) of field
Light tillage (ripping) of soil
Create planting basins/spots
Create ridges and furrows
Create multiple plots
Don’t know
C15
Do you practice intercultural operations in the main field?
Yes
No
C16
How many times during the crop cycle do you practice intercultural operations?
C17
Do you use farm tools and implements (weeders, markers, sprayers etc) in this crop?
Manual
Herbicide
Weeder
Don’t know
C18
Do you apply any control measures of insect and pest?
Use organic pesticides
Use inorganic pesticide
Do not use pesticides
Don’t know
TRAININGS
D01
Have you or anyone else from your household ever received any training on agriculture, poultry or livestock related work?
Yes
No
D02
Did you or anyone else from your household ever receive training on_________?
D02_1
Crop planning
Yes
No
D02_2
Cropping practices
Yes
No
D02_3
Nursery raising
Yes
No
D02_4
Pest management
Yes
No
D02_5
Composting/Vermicompost
Yes
No
D02_6
Production of bio-pesticides like agniastra, neemastra
Yes
No
D02_7
Poultry
Yes
No
D02_8
Goat rearing
Yes
No
D02_9
Pig rearing
Yes
No
D02_10
Marketing of produce
Yes
No
D03
Who received the training?
D03_1
Crop planning
You
Other female member of the household
Male member of the household
D03_2
Cropping practices
You
Other female member of the household
Male member of the household
D03_3
Nursery raising
You
Other female member of the household
Male member of the household
D03_4
Pest management
You
Other female member of the household
Male member of the household
D03_5
Composting/Vermicompost
You
Other female member of the household
Male member of the household
D03_6
Production of bio-pesticides like agniastra, neemastra
You
Other female member of the household
Male member of the household
D03_7
Poultry
You
Other female member of the household
Male member of the household
D03_8
Goat rearing
You
Other female member of the household
Male member of the household
D03_9
Pig rearing
You
Other female member of the household
Male member of the household
D03_10
Marketing of produce
You
Other female member of the household
Male member of the household
ANIMAL OWNERSHIP AND PRODUCTION AND SALE OF ANIMAL PRODUCTS
E01
During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc?
Yes
No
E02
Which all animals do you have?
E02_1
Cattle(buffalo/oxen/cow)
Yes
No
E02_2
Goat
Yes
No
E02_3
Sheep
Yes
No
E02_4
Pig
Yes
No
E02_5
Chicken/ Guinea fowl/Pigeons/Duck/ Hen/
Yes
No
E03
How many ______ did your household own in the past 12 months?
E03_1
Cattle(buffalo/oxen/cow)
E03_2
Goat
E03_3
Sheep
E03_4
Pig
E03_5
Chicken/ Guinea fowl/Pigeons/Duck/ Hen/
E04
How many ________ has your household sold in the last 12 months?
E04_1
Cattle(buffalo/oxen/cow)
E04_2
Goat
E04_3
Sheep
E04_4
Pig
E04_5
Chicken/ Guinea fowl/Pigeons/Duck/ Hen/
E05
How much did your household receive for the sale of these ___ in the last 12 months?
E05_1
Cattle(buffalo/oxen/cow)
E05_2
Goat
E05_3
Sheep
E05_4
Pig
E05_5
Chicken/ Guinea fowl/Pigeons/Duck/ Hen/
CONTRIBUTION OF WAGES, SERVICES, REMITTANCE AND NTFP COLLECTION TO HOUSEHOLD INCOME
F01
In the last one year did your family do this labour work for someone else?
F01_1
Agriculture operations
Yes
No
F01_2
Wage labour in watershed/other government program
Yes
No
F01_3
Masonry
Yes
No
F01_4
Carpentry
Yes
No
F01_5
Private construction labour
Yes
No
F01_6
Labour work in brick kiln
Yes
No
F01_7
Others
Yes
No
F02
How many months in the last 12 months did the HH members engage in this labour work ?
F02_1
Agriculture operations
F02_2
Wage labour in watershed/other government program
F02_3
Masonry
F02_4
Carpentry
F02_5
Private construction labour
F02_6
Labour work in brick kiln
F02_7
Others
F03
How many days in those months did the HH members engage ?
F03_1
Agriculture operations
F03_2
Wage labour in watershed/other government program
F03_3
Masonry
F03_4
Carpentry
F03_5
Private construction labour
F03_6
Labour work in brick kiln
F03_7
Others
F04
What was the daily wage rate?
F04_1
Agriculture operations
F04_2
Wage labour in watershed/other government program
F04_3
Masonry
F04_4
Carpentry
F04_5
Private construction labour
F04_6
Labour work in brick kiln
F04_7
Others
F05
Do you or any member of your family work as any of the following?
F05_1
ASHA/AWW
Yes
No
F05_2
Tuition
Yes
No
F05_3
Micro-enterprises
Yes
No
F05_4
CRP/CSP/Trainer/Secretary
Yes
No
F05_5
Govt. or Private Job
Yes
No
F06
Income in one month
F06_1
ASHA/AWW
F06_2
Tuition
F06_3
Micro-enterprises
F06_4
CRP/CSP/Trainer/Secretary
F06_5
Govt. or Private Job
F07
No of months in a year that the HH members work
F07_1
ASHA/AWW
F07_2
Tuition
F07_3
Micro-enterprises
F07_4
CRP/CSP/Trainer/Secretary
F07_5
Govt. or Private Job
F08
Does any member of your family live outside for work and sends you money?
Yes
No
F09
For how many months has each member of your household migrated in last one year?
F09A
Name
F09B
No. of months in last one year for migration
F10
Where do they work?
Brick kiln
Paper factory
Garments factory
Agriculture labour outside the village
Construction work
Mill/refinery
Other (specify)
F11
In the last 12 months, has anyone in your household received remittances from a member of the family or other person who is somewhere else in India or abroad?
Yes
No
F12
Who receives the remittance?
You
Other female member of the household
Male member of the household
F13
How often has your household received remittances in the last 12 months?
F14
On average, how much money did your household receive each time you received remittances in the last 12 months?
F15
How much did your household earn from NTFP selling (Mahua seeds, amla, honey, imli etc) in last 1 year?
F16
Does someone in the household receive pension?
Yes
No
F17
Who gets the pension?
You
Spouse
Other female member of the household
Other male member of the household
F18
What type of Pension?
Old age pension
Widow pension
Disability pension
Retirement pension
Others
F19
Amount received in last 12 months
FOOD CONSUMPTION SCORE, HOUSEHOLD FOOD SECURITY USING COPING STRATEGY INDEX
G01
Was yesterday a special day (celebration, feast day, or fasting) where anyone in the HH ate special foods or more or less than usual)?
Yes
No
G02
How many meals did you eat yesterday during the day and night?
G03
How many meals did the adult members (18+) of your household eat yesterday during the day and night?
G04
How many meals did the children 6 to18 years in this household eat yesterday during the day and night?
G05
Over the last 7 days, how many days did you consume following foods?
G05_1
Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G05_2
Beans and peas, groundnuts and cashew nuts
G05_3
Vegetables (including relish and leaves)
G05_4
Fruits
G05_5
Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G05_6
Milk/yogurt/other dairy product
G05_7
Sugar or sugar products, honey
G05_8
Oils/fats/butter
G06
Over the last 7 days, how many days did the children of 6 to18 years in this household consume following foods?
G06_1
Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G06_2
Beans and peas, groundnuts and cashew nuts
G06_3
Vegetables (including relish and leaves)
G06_4
Fruits
G06_5
Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G06_6
Milk/yogurt/other dairy product
G06_7
Sugar or sugar products, honey
G06_8
Oils/fats/butter
G07
Over the last 7 days, how many days did other household members consume following foods?
G07_1
Maize, maize porridge, daal Other cereal (rice, sorghum, millet, wheat etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
G07_2
Beans and peas, groundnuts and cashew nuts
G07_3
Vegetables (including relish and leaves)
G07_4
Fruits
G07_5
Beef, goat, or other red meat and pork, Poultry and eggs, Fish
G07_6
Milk/yogurt/other dairy product
G07_7
Sugar or sugar products, honey
G07_8
Oils/fats/butter
G08
What was the main source(s) of the food?
Own production
Casual labour
Borrowed
Gift
Purchases
Food assistance
Barter
Hunting/gathering/catching
PDS
Mid day Meal (MDM)
ICDS
G09
Normally, how many months does the food produced from your land suffice your household’s requirement?
G10
In the past four weeks
G10_1
In the past four weeks, did you worry that your household would not have enough food ?
Yes
No
G10_2
In the past four weeks, were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?
Yes
No
G10_3
In the past four weeks, did you or any household member have to eat a limited variety of foods due to a lack of resources?
Yes
No
G10_4
In the past four weeks, did you or any household member have to eat some foods that you really did not want to eat because of a lack of resources to obtain other types of food?
Yes
No
G10_5
In the past four weeks, did you or any household member have to eat a smaller meal than you felt you needed because there was not enough food?
Yes
No
G10_6
In the past four weeks, did you or any household member have to eat fewer meals in a day because there was not enough food?
Yes
No
G10_7
In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food?
Yes
No
G10_8
In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food?
Yes
No
G10_9
In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food?
Yes
No
G11
How often did this happen?
G11_1
In the past four weeks, did you worry that your household would not have enough food ?
Rarely
Sometimes
Often
G11_2
In the past four weeks, were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?
Rarely
Sometimes
Often
G11_3
In the past four weeks, did you or any household member have to eat a limited variety of foods due to a lack of resources?
Rarely
Sometimes
Often
G11_4
In the past four weeks, did you or any household member have to eat some foods that you really did not want to eat because of a lack of resources to obtain other types of food?
Rarely
Sometimes
Often
G11_5
In the past four weeks, did you or any household member have to eat a smaller meal than you felt you needed because there was not enough food?
Rarely
Sometimes
Often
G11_6
In the past four weeks, did you or any household member have to eat fewer meals in a day because there was not enough food?
Rarely
Sometimes
Often
G11_7
In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food?
Rarely
Sometimes
Often
G11_8
In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food?
Rarely
Sometimes
Often
G11_9
In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food?
Rarely
Sometimes
Often
WOMEN’S ACCESS TO CAPITAL AND CREDIT
H01
Does anyone in your household currently have any _____?
H01_1
Agricultural land
Yes
No
H01_2
Other land not used for agriculture
Yes
No
H01_3
Large livestock (e.g. oxen, cattle, buffalo, horse)
Yes
No
H01_4
Small livestock (e.g. goats, pigs, sheep)
Yes
No
H01_5
Chickens, ducks, turkeys, pigeons
Yes
No
H01_6
Fish pond or fishing equipment
Yes
No
H01_7
Farm equipment (non-mechanized)
Yes
No
H01_8
Farm equipment (mechanized e.g. tractor)
Yes
No
H01_9
Non farm business equipment
Yes
No
H01_10
House (and other structures)
Yes
No
H01_11
Large consumer durables (Fridge, TV, sofa)
Yes
No
H01_12
Small consumer durables (radio, cookware)
Yes
No
H01_13
Cell phone
Yes
No
H01_14
Means of transportation (bicycle, motorcycle, car)
Yes
No
H02
Do you own any of the ____?
H02_1
Agricultural land
Yes
No
H02_2
Other land not used for agriculture
Yes
No
H02_3
Large livestock (e.g. oxen, cattle, buffalo, horse)
Yes
No
H02_4
Small livestock (e.g. goats, pigs, sheep)
Yes
No
H02_5
Chickens, ducks, turkeys, pigeons
Yes
No
H02_6
Fish pond or fishing equipment
Yes
No
H02_7
Farm equipment (non-mechanized)
Yes
No
H02_8
Farm equipment (mechanized e.g. tractor)
Yes
No
H02_9
Non farm business equipment
Yes
No
H02_10
House (and other structures)
Yes
No
H02_11
Large consumer durables (Fridge, TV, sofa)
Yes
No
H02_12
Small consumer durables (radio, cookware)
Yes
No
H02_13
Cell phone
Yes
No
H02_14
Means of transportation (bicycle, motorcycle, car)
Yes
No
H03
Do you have a bank account?
Yes
No
H04
What type of bank account do you have? Individual or joint? If it is joint, with whom?
Individual
Joint with husband
Joint with SHG
Joint with others
H05
For how many years do you have this bank account?
H06
Who facilitated opening this account?
Bank mitra
SHG
No One
Sarpanch/Mukhia
Other (specify)
H07
What do you use your bank account for?
To receive payments from govt. schemes
To receive payments from MNREGA
To receive remittances
To save money
To request a loan
Other (Specify)
H08
Who operates your bank account?
Herself
Husband
Other family/ SHG members
Self and spouse
H09
Did you make any transaction from your bank account in the past three months? (depositing money or withdrawing money)
Yes
No
H10
What are the reasons for not having a bank account?
I have no money/little money to put in account
There is no bank in this area
Benefits were received only in cash so far, hence did not open account
Too many charges are there for opening a bank account
Tried to open but was refused
Lengthy process for opening account
Having a bank account is not important
Anticipated rejection from bank staff
Other (specify)
H11
Has anyone in your household taken any loans or borrowed cash/in-kind from _____ in the past 12 months?
H11_1
Non-governmental organization (NGO)
Yes, cash
Yes, in-kind
Yes, cash and in-kind
No
Don’t know
H11_2
Money lender
Yes, cash
Yes, in-kind
Yes, cash and in-kind
No
Don’t know
H11_3
Formal lender (direct credit from bank/financial institution)
Yes, cash
Yes, in-kind
Yes, cash and in-kind
No
Don’t know
H11_4
Friends or relatives or neighbours
Yes, cash
Yes, in-kind
Yes, cash and in-kind
No
Don’t know
H11_5
Self - Help Group
Yes, cash
Yes, in-kind
Yes, cash and in-kind
No
Don’t know
H12
Who made the decision to borrow from
H12_1
Non-governmental organization (NGO)
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H12_2
Money lender
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H12_3
Formal lender (direct credit from bank/financial institution)
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H12_4
Friends or relatives or neighbours
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H12_5
Self - Help Group
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H13
Who makes the decision about what to do with the money/item borrowed from _____ most of the time?
H13_1
Non-governmental organization (NGO)
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H13_2
Money lender
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H13_3
Formal lender (direct credit from bank/financial institution)
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H13_4
Friends or relatives or neighbours
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H13_5
Self - Help Group
Self
Spouse
Self and spouse
Other male hh member
Other female hh member
Self and other hh member
Spouse and other household member(s)
Self, spouse and other hh member(s)
Someone (or group of people) outside the household
Self and other outside non hh people
Spouse and other non hh people
H14
Has such a situation ever occurredwhere you wanted to take loan but you couldn’t take?
H14_1
Non-governmental organization (NGO)
Yes
No
H14_2
Money lender
Yes
No
H14_3
Formal lender (direct credit from bank/financial institution)
Yes
No
H14_4
Friends or relatives or neighbours
Yes
No
H14_5
Self - Help Group
Yes
No
SELF HELP GROUPS & GROUP COHESION
I01
Do you currently belong to a self-help group?
Yes
No
I02
When you expressed desire to become SHG member, did you have to face any challenges?
Yes
No
I03
What challenges did you have to overcome to become SHG member?
I04
For how long have you belonged to the self-help group to which you belong?
I05
Are you an active member of this group, meaning that you participate in meetings, for example? Are you attending meeting regularly?
Yes
No
I06
Have you participated in meetings conducted in last 3 months?
Yes
No
I07
Have you participated in meetings conducted in last 1 months?
Yes
No
I08
Does your self-help group have savings and credit activities?
Yes
No
I09
Do you personally participate in these savings and credit activities?
Yes
No
I10
Are you currently a portfolio-holder?
Yes
No
I11
Which position do you hold?
President
Treasurer
Secretary
Other (specify)
I12
What issues are discussed in the self-help group meeting ?
Livelihoods/socio-economic problems in the community
Agriculture problems
Education problems
Health and nutrition problems
Gender dynamics in society
Violence against women
Rights and entitlements
Savings and loans
Sanitation
Other
I13
Which organization started or supports this self-help group?
PRADAN
Other NGO
Government
Federation
Don’t know
Other (Specify)
I14
Name of the NGO
I15
Has a representative from this NGO visited you and talked about agricultural practices?
Yes
No
I16
Has the NGO conducted any training on livelihood practices?
Yes
No
I17
How often does your group meet for discussions or activities in a month?
Weekly
Bimonthly
Monthly
Occasionally
Never met so far
I18
How often do you participate in group meetings in a month?
Weekly
Bi-monthly
Monthly
Occasionally
Never met so far
I19
When was the last time that you participated in a group meeting?
I20
Did you attend the most recent meeting of your group?
Yes
No
I21
Do you save money in SHG?
Yes
No
I22
How much money do you save in each meeting? (average amount – in Rs.)
I23
How often do you save?
Weekly
Bi-monthly
Monthly
Occasionally
Never saved so far
I24
How much do you agree or disagree with the following statements
I24_1
I can count on fellow SHG members if I need to borrow money
Agree
Neither agree nor disagree
Disagree
I24_2
I can count on fellow SHG members to talk about my problems
Agree
Neither agree nor disagree
Disagree
I24_3
SHG members worry about themselves only
Agree
Neither agree nor disagree
Disagree
I24_4
I can count on fellow SHG members to help me address the problems I am unable to solve on my own. (E.g. Violence)
Agree
Neither agree nor disagree
Disagree
I25
Do you think the activities of your SHG or federation has resulted in a positive change in
I25_1
You
Yes
No
I25_2
Members of your group
Yes
No
I25_3
Members of other groups in your village
Yes
No
I25_4
People who are not members
Yes
No
I26
How much do you think the activities of your SHG or federation have contributed to a positive change in
I26_1
You
Not at all
Somewhat
Very much
Completely
I26_2
Members of your group
Not at all
Somewhat
Very much
Completely
I26_3
Members of other groups in your village
Not at all
Somewhat
Very much
Completely
I26_4
People who are not members
Not at all
Somewhat
Very much
Completely
WOMEN’S STATUS
J01
Do you currently live with your partner or husband?
Yes
No
J02
At what age did you get married?
J03
At what age did you first get pregnant?
J04
Do you have your own money that you can use for what you want to use it?
Yes
No
J05
Do you talk to someone when you have any problem?
Yes
No
J06
If yes, whom do you talk to in case of any problem?
SHG members
VO members
Friends
Relatives
Husband
Neighbours
J07
How often do you see or talk to somebody from your own family other than the one who live in the same house?
Several times per week
About once per week
About once per month
Several times per month
More than once a year
About once per year or less
Never
No Response
J08
How often can you visit the following spaces freely?
J08_1
To the market?
Yes
No
J08_2
To a friend or family member’s house less than one hour away?
Yes
No
J08_3
To the temple, church or mosque?
Yes
No
J08_4
To a public village meeting?
Yes
No
J08_5
To a meeting of any association of which you are a member including a self-help group?
Yes
No
J08_6
Outside your village?
Yes
No
J08_7
To see a health care provider for your own treatment?
Yes
No
J08_8
Going to a movie
Yes
No
J08_9
Buying new clothes for yourself
Yes
No
J08_10
Taking child to health care center
Yes
No
J08_11
Shopping within the village
Yes
No
J08_12
Shopping outside the village
Yes
No
J08_13
Attending a religious festival/social function within the village
Yes
No
ACCESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
K01
Have you ever heard about_______?
K01_1
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
Yes
No
K01_2
Antyodaya Anna Yojana
Yes
No
K01_3
Swachh Bharat Abhiyan
Yes
No
K01_4
ICDS
Yes
No
K01_5
Janani Suraksha Yojana (JSY)
Yes
No
K01_6
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
K01_7
Social Security Pension
Yes
No
K01A
If yes, from whom or where?
K01A_1
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_2
Antyodaya Anna Yojana
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_3
Swachh Bharat Abhiyan
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_4
ICDS
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_5
Janani Suraksha Yojana (JSY)
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_6
Janani Shishu Suraksh Karykaram (JSSK)
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K01A_7
Social Security Pension
Family member
Friends/neighbors
Media (TV, radio, newspaper, etc.)
Government officials
PRADAN
Other NGO
Members of my SHG
Mukhiya/Sarpanch
Street Plays
Other
K02
Is your household / anyone in your household eligible for this scheme?
K02_1
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
Yes
No
K02_2
Antyodaya Anna Yojana
Yes
No
K02_3
Swachh Bharat Abhiyan
Yes
No
K02_4
ICDS
Yes
No
K02_5
Janani Suraksha Yojana (JSY)
Yes
No
K02_6
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
K02_7
Social Security Pension
Yes
No
K03
Has anyone in your household ever availed this scheme?
K03_1
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
Yes
No
K03_2
Antyodaya Anna Yojana
Yes
No
K03_3
Swachh Bharat Abhiyan
Yes
No
K03_4
ICDS
Yes
No
K03_5
Janani Suraksha Yojana (JSY)
Yes
No
K03_6
Janani Shishu Suraksh Karykaram (JSSK)
Yes
No
K03_7
Social Security Pension
Yes
No
K04
When was the last time someone in your household used this scheme?
K04_1
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
K04_2
Antyodaya Anna Yojana
K04_3
Swachh Bharat Abhiyan
K04_4
ICDS
K04_5
Janani Suraksha Yojana (JSY)
K04_6
Janani Shishu Suraksh Karykaram (JSSK)
K04_7
Social Security Pension
K05
Does your household have a MGNREGA job card? If yes, please show me.
Yes, seen
Yes, reported but not seen
No
K06
In the past year, how many days did members of your household work for MGNREGA?
K07
Do you know what is the daily wage rate for male workers working under MGNREGA? If yes, please specify.
K08
Do you know what is the daily wage rate for female workers working under MGNREGA? If yes, please specify.
K09
Have you faced any such situation in past 1 year when you demanded to work under MGNREGA but did not receive any work?
Yes
No
K10
Are you aware of the unemployment allowance provided under MGNREGA?
Yes
No
K11
Have any assests been created in your village under watershed development program/scheme?
Yes
No
K11A
The assets related to watershed development have been created under which scheme?
MGNREGA
IWMP
Others specify
K12
Is there a Watershed Committee in your village?
Yes
No
K13
Are you a member of Watershed Committee?
Yes
No
K14
Does anybody in the household have an Aadhar card?
Yes
No
K15
Does your household have a ration card?
Yes
No
K16
Which card do you have?
Antyodhya Anna Yojna
ANNAPURNA
BPL
Other (specify)
Don’t know
K17
In the past 30 days, did you buy anything from a fair price shop?
Yes
No
K18
Which items did you buy from the fair price shop in the last 30 days and in what quantity?
K18A
Whether purchased
K18A_1
Rice
Yes
No
K18A_2
Wheat
Yes
No
K18A_3
Sugar
Yes
No
K18A_4
Kerosene
Yes
No
K18A_5
Cooking oil
Yes
No
K18A_6
Salt
Yes
No
K18A_7
Cloth
Yes
No
K19
Quantity Purchased
K19_1
Rice
K19_2
Wheat
K19_3
Sugar
K19_4
Kerosene
K19_5
Cooking oil
K19_6
Salt
K19_7
Cloth
K20
Do you feel that fair price shops help your household be food secure?
Yes
No
K21
Did you or any member of your household ever receive any food from Anganwadi centre in the past 1 year?
Yes
No
K22
Who received food from an Anganwadi centre
Pregnant woman in the household
Lactating woman in the household
Child 6 to 24 months of age
Child 2 to 5 years of age
Don’t know
Other (specify)
K23
Do you know how much money the beneficiary is supposed to get under the JSY scheme?
PARTICIPATION IN SOCIAL SPHERE
L01
Is your SHG part of any Village Organisation (VO) forum?
Yes
No
L02
Do you participate in meetings of the VO?
Yes
No
L03
Is your SHG part of any Cluster/ Block level Federation (BLF)?
Yes
No
L04
Do you represent your SHG in Cluster/ BLF meetings?
Yes
No
L05
Have you ever raised voice for any concern or issue in the community?
Yes
No
L06
Have you ever participated in any mass events like rallies, campaigns, vigils, etc. for social change or to demand something (for ex. Against alcoholism)?
Yes
No
L07
If yes, for what?
Demand for MNREGA
Demand for PDS/ration card
Demand for opening bank account
Supply of safe drinking water
Supply of sufficient water for household purposes
Supply of sanitation services e.g. latrine facilities/construction of toilets
Preparation of village development plans
Demand for better school facilities
Demand for better angandwadi facililties
Addressing liquor consumption issues in village
Forest protection
Any other event (specify)
L08
In your house who decides to vote and to whom?
Self
Husband
Elder family member
Village level influential
Others specify
DK/CS
L09
Do you have voter identification card?
Yes
No
L10
Did you vote in the last election?
Yes
No
L11
Why did you vote?
My husband had asked me to do so
It is my right
Political party requested to cast vote
Political party distributed incentives to cast vote
I believe in the manifesto the party presented
Others specify
L12
Why did not you vote?
Do not feel this to be necessary
Stopped from going by husband/family members
Fearful
Not aware of the process
Others specify
DK/CS
L13
Have you or any other woman from any SHG in your village contested in the recent elections?
Yes
No
L14
Have you ever participated in gram sabha meeting?
Yes
No
L15
Did you attend last gram sabha meeting?
Yes
No
L16
What was the reason to attend Gram sabha meeting?
I was given incentive to attend the meeting
To keep myself updated with the political happening
It is my right to share my views and concern vius
Issue to be discussed was of interest to me
Issue to be discussed was of interest to my SHG/federation
To share about the problems faced
Other, Specify
L17
What was the reason for not attending gram sabha meeting?
I did not get information about the meeting
Date or time was not convenient
Gram Sabha is not of interest to me
Issue to be discussed in the meeting was not of interest to me
Other (specify)
L18
Have you ever raised any concern or given your opinion in any gram sabha meeting?
Yes
No
L19
Has ever your concern or suggestion resulted in resolution being adopted at gram sabha?
Yes
No
L20
Does gram Panchayat take action to address a complaint or suggestion raised collectively by women/SHGs?
Yes
No
L21
Do you feel comfortable speaking up in public to help decide on infrastructure (like small wells, roads, water supplies) to be built in your community?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
L22
Do you feel comfortable speaking up in public to ensure proper payment of wages for public works or other similar programs?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
L23
Do you feel comfortable speaking up in public to protest the misbehavior of authorities or elected officials?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
L24
How confident do you feel speaking your opinion in any training or SHG meeting?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
L25
How confident do you feel when you have to talk to a bank officer/manager/teacher/AWW?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
L26
How confident do you feel when you have to talk to Sarpanch/Pradhan / Ward members?
No, not at all comfortable
Yes, but with a great deal of difficulty
Yes, but with a little difficulty
Yes, mostly comfortable
Yes, very comfortable
HOUSEHOLD CHARACTERISTICS
M01
Does your household own this house or any other house?
Yes
No
M02
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 phuh
Cement/RCC flesa
Carpet
Polished stone/marble/granite
Other (specify)
M03
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
Country made tiles
Other (specify)
M04
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)
M05
How many rooms in this house are used for sleeping?
M06
Do you have a separate room for cooking?
Yes
No
M07
Do you have a window in your house?
Yes
No
M08
Type of window
Window without glass, shutter, curtain or screen
Windows with glass
Windows with screens
Windows with curtains or shutters
M09
Do you have a homestead?
Yes
No
M10
What type of toilet facility do you have?
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Flush, don't know where
Ventilated improved pit (VIP)/Biogas Latrine
Pit latrine with slab
Pit latrine without slab/ open pit
Twin pit/Composting toilet
Dry toilet
No facility/uses open space or field
Other (specify)
M11
What is the main source of lighting
Lantern
Kerosene lamp
Candle
Electric
LPG/Battery
Solar Energy
None
Others (Specify)
M12
What type of fuel does your household mainly use for cooking?
Electricity
LPG
Natural gas
Biogas
Kerosene
Charcoal
Coal
Wood / straw/leaves
Animal dung
Other (specify)
M13
Does your household own any of the following items:
M13_1
Mattress
Yes
No
M13_2
Pressure cooker
Yes
No
M13_3
Chair
Yes
No
M13_4
Cot/ Bed
Yes
No
M13_5
Table
Yes
No
M13_6
Electric fan
Yes
No
M13_7
Almirah
Yes
No
M13_8
Radio/Transistor
Yes
No
M13_9
Sewing machine
Yes
No
M13_10
Clock or watch
Yes
No
M13_11
Bicycle
Yes
No
M13_12
Animal-drawn cart/Bullock Cart
Yes
No
M13_13
Black & White television
Yes
No
M13_14
Colour television
Yes
No
M13_15
Mobile Phone
Yes
No
M13_16
Landline Phone
Yes
No
M13_17
Water pump
Yes
No
M13_18
Thresher
Yes
No
M13_19
Power Tiller
Yes
No
M13_20
Spray Machine/Sprayer
Yes
No
M13_21
Refrigerator
Yes
No
M13_22
Air conditioner / Cooler
Yes
No
M13_23
Washing Machine
Yes
No
M13_24
Internet
Yes
No
M13_25
Computer
Yes
No
M13_26
Motorcycle/scooter
Yes
No
M13_27
Car/Jeep
Yes
No
M13_28
Tractor
Yes
No
M14
For each of the following seasons, what is the main source of drinking water for members of your household?
M14_1
Summer
Piped water into dwelling
Piped water into yard/plot
Public tap/standpipe
Own Tube well/borehole / handpump
Protected spring
Unprotected
Surface water (river/canal/lake)
Protected dug well
Unprotected dug well
Rainwater collection
Public handpump
Other (specify)
M14_2
Monsoon
Piped water into dwelling
Piped water into yard/plot
Public tap/standpipe
Own Tube well/borehole / handpump
Protected spring
Unprotected
Surface water (river/canal/lake)
Protected dug well
Unprotected dug well
Rainwater collection
Public handpump
Other (specify)
M14_3
Winter
Piped water into dwelling
Piped water into yard/plot
Public tap/standpipe
Own Tube well/borehole / handpump
Protected spring
Unprotected
Surface water (river/canal/lake)
Protected dug well
Unprotected dug well
Rainwater collection
Public handpump
Other (specify)
M15
How long does it take to go to the water source, get water, and come back during the rainy season?
M16
How long does it take to go to the water source, get water, and come back during the dryseason?
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