Surveypoint

Q01

Village

Q02

District

Q03

Block

Q04

State

Q05

Project/Comparison area

Project

Comparison

Q06

Structure Type

Residential

Non-residential

Q07

Structure No.

Q08

Household No.

Q09

Unique Reference ID

Q10

Name of Household Head

Q11

Religion

Hindu

Muslim

Christian

Sikh

Buddhist/Neo-Buddhist

Jain

Jewish

Parsi/Zoroastrian

Sarna

No Religion

Others

Q12

Caste

Schedule Caste

Schedule Tribe

Other Backward Caste(OBC)

General

others

Q13

Result of visit

Complete

Refused

HH Migrated

HH temporarily away

No female respondent of age present to respond

Q14

Investigator’s code

Q15

Date

Q16

Mobile no.

Q17

Are there any boys/girls aged 5-20 years who usually live in this household?

Yes

No

Q18

Are there any girls aged 10-19 years who usually live in this household?

Yes

No

Q19

Is there any child studying in standard 5 in this household?

Yes

No

Q20

How many children of this household are studying in 5th standard?

Q21

Are there any boys/girls aged 0-4 years who usually live in this household?

Yes

No

Q22

Please name all the boys/girls who usually live in this household and are aged between 0-4 years, starting from the youngest to the oldest.

Q23

Line No. of the mother

Q24

Name of the mother (married+15-49 yrs+having a child of 0-4 years)

Q25

Line no. of the child

Q26

Name of child

Q27

Sex of boy/girl

BOY

GIRL

TRANSGENDER

Q28

Is DOB of child known?

Yes

No

Q29

DOB

Q30

Age in completed months

Q31

Is the mother available for interview in next 2 weeks

Yes

No

Q32

Any other child of the same mother?

Yes

No

Household Listing Template 4 -Form Fill