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Household Template 20 -Form Fill
Interviewer Information
Q01
Code of the Interviewer
Q02
Name of the Interviewer
Q03
Start Time
Household information
A01
Block code
A02
Gram Panchayat code
A03
Village code
A04
Name of respondent
A05
Age of respondent
A06
Contact number
A07
Gender of the respondent
Male
Female
Others
A07A
Category/caste of the respondent
General
SC
ST
OBC
A07B
Religion of the respondent
Muslim
Hindu
Christian
Buddhist
Sarna
Sikh
Jainism
Others
A07C
Does the HH have a white card (BPL card)/ Antodya Card
Yes
No
A08
What all schemes (Departments) are applicable to the household?
Vaccination
Artificial Insemination Treatment
Milk Society Member
Animal treatment at government center
PMKY – Pradhan Mantri Kisan Samman Nidhi Yojana
PMFBY - Pradhan Mantri Fasal Bima Yojana
NHM- National Horticulture Mission
Maternal and child health program
Ayushman Bharat PM-JAY
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS)
Vector borne Disease control program
National TB Eradication program
National Program for control of Blindness
Rashtriya Bal Swasth Karyakram
ICDS scheme – Integrated Child Development Services
PMJDY - Pradhan Mantri Jan Dhan Yojana
APY - Atal Pension Yojana
PMJJBY – Pradhan Mantri Jeevan Jyoti Bima Yojana
PMSBY - Pradhan Mantri Suraksha Bima Yojana
MNREGA – Mahatma Gandhi National Rural Employment Guarantee Act
DDU-GKY – Deen Dayal Upadhyay Grameen Kaushal Yojana
R-SETI - Rural Self Employment Training Institute
NRLM – National Rural Livelihood Mission
NSAP – National Social Assistance pension
UPSDM
PMEGP
CMEGP
ODOP
Electric CHAAK
Beekeeping
PMSYM – Pradhan Mantri Shram Yogi Maan-dhan
Meri Sadak App
A09
Are you head of the household
Yes
No
A09A
What is the education level of the head of the household?
Upto class 8th
Upto class 10th
Upto class 12th
Graduation
Post-Graduation and above
Uneducated/ Didn’t attend school
Do not Know
A09B
What is the occupation of the head of the household?
Agriculture
Poultry and Livestock
Unskilled wage labour (agricultural labour, MGNREGA labour, construction work, brick kiln labour etc.)
Skilled worker(tailoring, masonry, electrician, plumbing, carpentry, welding, driving, etc.
Small business (kirana shops, dhabas, mobile shops, ferry shops etc.)
Enterprise in manufacturing sector
Govt. job
Private job
Contractual or task-based work ( ASHAs, CSPs, BC Agents, Tuitions, para-teachers etc
Old age/pensioner
Unemployed
Others (specify)
A10
Does the household have any secondary source of income?
Yes
No
A11
What is the secondary income source for your household?
Agriculture
Poultry and Livestock
Unskilled wage labour (agricultural labour, MGNREGA labour, construction work, brick kiln labour etc.)
Skilled worker(tailoring, masonry, electrician, plumbing, carpentry, welding, driving, etc.
Small business (kirana shops, dhabas, mobile shops, ferry shops etc.)
Enterprise in manufacturing sector
Govt. job
Private job
Contractual or task-based work ( ASHAs, CSPs, BC Agents, Tuitions, para-teachers etc
Old age/pensioner
Others (specify)
A12
What is the number of household members in each of the following category ?
A13
GPS coordinates
Department of Animal Husbandry and Dairying
B01
Did your household own any livestock in the last one year?
Yes
No
B02
If yes, what are the different types and number of livestock owned by the households in the last one year?
B02A
Livestock owned
B02A_1
bulls/oxen
Yes
No
B02A_2
buffalo
Yes
No
B02A_3
cow
Yes
No
B02A_4
goat
Yes
No
B02A_5
Sheep
Yes
No
B02A_6
horse
Yes
No
B02A_7
pig
Yes
No
B02B
Number
B02B_1
bulls/oxen
B02B_2
buffalo
B02B_3
cow
B02B_4
goat
B02B_5
Sheep
B02B_6
horse
B02B_7
pig
B03
Where did you consult for medical advice/ treatment in case of livestock diseases in the last one year?
B03_1
bulls/oxen
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_2
buffalo
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_3
cow
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_4
goat
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_5
Sheep
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_6
horse
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B03_7
pig
At Home Govt. Veterinary centre
Govt. Veterinary hospital
Private Veterinary clinic
Govt. held screening and treatment camp
Did not consult or treat animal
B04
Has any of your livestock suffered from diseases in the last one year?
Yes
No
B05
What disease(s) did your livestock suffer from in the last one year?
B05_1
bulls/oxen
F&M
HS
PPR
Others
B05_2
buffalo
F&M
HS
PPR
Others
B05_3
cow
F&M
HS
PPR
Others
B05_4
goat
F&M
HS
PPR
Others
B05_5
Sheep
F&M
HS
PPR
Others
B05_6
horse
F&M
HS
PPR
Others
B05_7
pig
F&M
HS
PPR
Others
B06
Did your livestock receive any vaccination in the last one year?
Yes
No
B07
What all vaccines did your livestock receive in the last one year?
B07_1
bulls/oxen
F&M
HS
PPR
Others
B07_2
buffalo
F&M
HS
PPR
Others
B07_3
cow
F&M
HS
PPR
Others
B07_4
goat
F&M
HS
PPR
Others
B07_5
Sheep
F&M
HS
PPR
Others
B07_6
horse
F&M
HS
PPR
Others
B07_7
pig
F&M
HS
PPR
Others
B08
How many of the livestock owned by you have been eligible for insemination (Reproduction) in the last one year?
B09
How many of your livestock been inseminated in the last one year?
B10
Where/how was the animal inseminated?
B10_1
bulls/oxen
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_2
buffalo
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_3
cow
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_4
goat
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_5
Sheep
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_6
horse
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B10_7
pig
By AI technician at home
By Govt. AI technician at veterinary hospital/centre
Private sources
others (specify)
B11
Does any of your livestock produce milk?
Yes
No
B12
Do you sell the milk produced by your livestock?
Yes
No
B13
What has been your average monthly earnings from the sale of milk during the last 3 months?
B13_1
44256
B13_2
44287
B13_3
44317
B14
Where do you sell the milk?
Local trader
Market
Parag Dairy milk society
Neighbours
Amul milk society
Local bulk milk chillers
Others (Specify)
Department of Agriculture
C01
What are the assets (Agri machineries) provided to you by the agriculture department, in the last two cropping seasons, under the following categories?
C01A
Bought
Rotavator
Solar Pump
Power Sprayer
Others
No equipment taken
C01B
Rented
Rotavator
Solar Pump
Power Sprayer
Others
No equipment taken
C02
Which of the assets (Agri machinery) did you use for agricultural field operations during the last two cropping seasons?
C02A
Kharif (2020)
Rotavator
Solar Pump
Power Sprayer
Others
No equipment taken
C02B
Rabi (2020-2021)
Rotavator
Solar Pump
Power Sprayer
Others
No equipment taken
C03
Did you attend any training related on agricultural practices in the last year?
Yes
No
C04
What were the topics covered in the trainings?
Soil type and quality
Assessment of nutrients
Soil testing
Fertilizer types and usage
Quantity of fertilizers to be used
Others (specify)
C05
Have you enrolled yourself for the PMKSNY Pradhan Mantri Kisan Samman Nidhi scheme (financial assistance of Rs 6000/year)?
Yes
No
C06
When did you enrol for the PMKY scheme (financial assistance of Rs 6000/year) ?
C07
Have you started receiving any financial assistance (instalment of Rs 2000) since July 2020?
Yes
No
C08
Out of three, how many times have you received the financial assistance (three instalments of Rs. 2000) ?
Once
Twice
All three times
More than 3 times
None of the 3 times
Do not know
C09
How many times have you received the financial assistance (three instalments of Rs. 2000) in a timely manner?
Once
Twice
All three times
More than 3 times
None of the 3 times
Do not know
C10
Where did you approach/complaint for the delays in payment of PMKY assistance?
Gram Pradhan
GP Secretary
BDO office
Bank
Did not complain
Others
C11
Have you enrolled for PM Fasal Bima Yojna during the last two cropping seasons?
C11A
Kharif (2020)
Yes, all crops and land insured
Yes, Partial crops or land insured
No crops/land insured
C11B
Rabi (2020-2021)
Yes, all crops and land insured
Yes, Partial crops or land insured
No crops/land insured
C12
Did you pay the premium (2% of sum insured) for PMFBY during the last two cropping seasons?
C12A
Kharif (2020)
Yes, paid full premium
Yes, paid partial premium
No didn’t pay
C12B
Rabi (2020-2021)
Yes, paid full premium
Yes, paid partial premium
No didn’t pay
C13
Were you able to pay the premiums in a timely manner (before application end date)?
C13A
Kharif (2020)
Yes
No
C13B
Rabi (2020-2021)
Yes
No
C14
Did you claim the insurance benefits under PM Fasal Bima Yojna during the last two cropping seasons?
C14A
Kharif (2020)
Yes
No
C14B
Rabi (2020-2021)
Yes
No
C15
Did you receive the insurance amount claimed during the last two cropping seasons?
C15A
Kharif (2020)
Yes, Full Amount
Yes, Partial Amount
No
Do not know
C15B
Rabi (2020-2021)
Yes, Full Amount
Yes, Partial Amount
No
Do not know
C16
Were there any delays in payment of claim amount in the last two cropping seasons?
C16A
Kharif (2020)
Yes
No
C16B
Rabi (2020-2021)
Yes
No
C17
How many days did it take for the claim to be processed?
C18
How many days did it take for the amount to be disbursed?
C19
Did you attend any training related to horticulture practices in last one year?
Yes
No
C20
Who conducted the training?
Govt. officials from agriculture/horticulture department
NGOs/Pvt. organisations
Others
Do not know
C21
What were the topics covered in the training?
Organic manure/Vermi-composting
Pollination in vegetable crops
Disease and Pest management
Soil health management t
Nursery management
Use of improved varieties
Water use (micro/drip irrigation)
Post-harvest techniques
Others (specify)
C22
Have you engaged in Beekeeping and honey production business in the last 3 months?
Yes
No
C23
Did you receive bee boxes, in the last one year ?
Yes
No
C24
Did you participate in the Bee-keeping training programme in the last one year?
Yes
No
C25
Who conducted the training?
Govt. officials from agriculture/horticulture department
NGOs/Pvt. organisations
Others
Do not know
C26
What were the topics covered in the trainings?
Bee- Keeping Process
Tools and Equipment
Location of Bee-boxes/colony
Bee species identification
Knowledge of flowering plants
Seasonal variations in the Bee-keeping process
Extraction and Processing of honey
Protection/Diseases/Pest management
Packaging and Storage
Others (specify)
C27
Have you harvested the honey in last one year?
Yes
No
C28
How many times did you harvest the honeyproduce in the last one year (July 2020- Present) ?
C29
What was the average amount of honey harvested in one harvest cycle of 2-3 months, in the last one year (KG.)?
C30
What was your earning/income from selling the honey harvested during a single harvest cycle, in the last one year (Rs.)?
Department of Fisheries
D01
Have you received any support for Pisciculture/ fish cultivation?
Training
Pond construction
Provision of feed
Provision of fingerling
No support received
others
D02
Since when did you received support for pisciculture/fish cultivation
D03
What topics were covered during the pisciculture trainings?
Pond Preparation
Fish Food selection
Fish species selection
Fish rearing practices
Fish breeding
Fish harvesting practices
Others (specify)
D04
Have you been engaged in pisciculture in the last one year?
Yes
No
D05
Since when have you been engaging in pisciculture related activities?
D06
How many times did you harvest the fish produce in the last one year (July 2020- Present) ?
D07
What is the average quantity of fish harvested by you each time of harvest (Quintal)?
D08
What was your earnings from the sale of fish during the last harvest cycle (Rs.)?
D09
Where did you sell the fish harvest/produce?
Local Market
Traders
District market
Other villagers
Did not sell
Others
Department of Power
E01
Does your household have a metered electricity connection?
Yes
No
E02
Which type of connection do you have
Metered
Non-metered
E03
On an average how many days in a week do you face power outage/ power cuts?
Everyday
Once in 2 days/Alternate days
More than 3 days in a week
No power cuts
E04
On an average how many hours do these outages last?
0-2 hours
2- 4 hours
4-8 hours
More than 8 hours
E05
Which time of the day do the power outages take place mostly?
Morning (6-10)
Afternoon (10-2)
Evening (2-6)
Night (after 6)
Any Random time of the day
E06
Who do you approach in case of a power outage?
Helpline/Telephone number
GP Secretary
Pradhan/Sarpanch
Block office
Other Villagers
Electricity sub-station
Electricity office
Local representatives of electricity offices
Do not complaint/approach anyone
E07
Do you receive bills for your electric connection?
Yes
No
E08
What is the average monthly bill incurred by your household (Rs.)?
E09
Are there any delays in bill payments from your side?
Every month
Once in a few months
Never
E10
How do you pay the electric bill?
Online payment
Physical payment at electric office/kiosk
Pay through Sarpanch/GP Secretary
Pay to concerned official at block level
Pay cash to other villagers/neighbors who in turn make the payment
Never Paid
HWC Section
F01
Did you/any household member ever visit the _____HWC/Sub-center in your area, in the last one year?
Yes
No
F02
How often do you/any household member visit the HWC in your area to avail medical facilities?
Weekly (Once or more than once every week)
Monthly (once or more than once per month)
Bi-monthly (once every two months)
Quarterly (thrice in the last one year)
Bi-Annually (twice in the last one year)
Annually ( once in the last one year)
In need of medical assistance
In need of medical counselling
In need of referral services
When advised by ASHA worker or ANM.
F03
What were the medical services required by you, for which you/any household member visited the HWC in the last one year?
Care in pregnancy and childbirth
Neonatal and infant health care services
Family planning and other Reproductive Health Care services
Communicable diseases (Vector borne diseases, leprosy, TB)
Outpatient care for simple illnesses and minor ailments (Fever, cold, first aid etc.)
Non-Communicable diseases (Diabetes, hypertension, Cancer )
Common Ophthalmic and ENT problems
Basic Oral health care
Elderly and Palliative health care services (Cataract Operations)
Emergency Medical Services
Mental health ailments
Others (specify)
F04
Were the foresaid medical facilities available in your local HWC, when you visited the same?
Yes
No
F05
How far is the health and wellness center from your Home?
0-2.5 km. distance
2.5 – 5 km. distance
5 – 10 km. distance
more than 10 km. distance
F06
How satisfied are you with the services at HWC?
Highly Satisfied
Moderately Satisfied
Satisfied
Dissatisfied
Highly dissatisfied
TB Section (To be auto filled for relevant households)
G01
Is there any TB patient in house
Yes
No
G02
How/where was the TB patient diagnosed?
Active Case Finding/ home visit by ASHA worker
Patient’s visit to ANM/Sub-center
Patient’s visit to PHC/CHC
Patient’s visit to Govt. Hospital
Pvt. Hospital/clinic
Others
G03
Did the TB patient undergo the treatment after being diagnosed, in the last one year? e
Yes
No
G04
Where does the patient receive the treatment from ?
HWC/ Sub-center
PHC/CHC
Govt. Hospital
Private treatment
Others
G05
Is/was follow up on the TB patient done periodically ?
Yes
No
Pregnant women section (ASK ONLY TO WOMEN)
H01
Is/Was there any pregnant woman in your household in the last two years (2019-2021) ?
Yes
No
H02
In which year was/is the woman pregnant?
2019
2019-2020
2020
2020-2021
2021
H03
Which stage of pregnancy/ lactation is the woman in?
1st trimester (1-3 months)
2nd trimester (3-6 months)
3rd trimester (6-9 months)
Finished pregnancy period
H04
Where is/was the pregnant woman registered for checkups during the pregnancy?
HWC/ANM/CHO
PHC/CHC
Govt. Hospital
Private hospital/Clinic
Don’t know
H05
How many ANC checkups did the woman receive during the course of her pregnancy?
One
Two
Three
Four and more
H06
Did the pregnant woman receive the first ANC checkup, during her 1st trimester (1-3 months) ?
Yes
No
H07
Was the pregnancy classified as HRP )?
Yes
No
Lactating woman section
I01
Has any woman in your household given birth during the last one year?
Yes
No
I02
What was the type of delivery ?
Normal delivery
C Section
I03
What was the outcome of the childbirth process?
Child dead
Mother dead
Child critical but recovered later
Mother critical but recovered later
Child healthy
Mother healthy
I04
Where did the delivery take place?
HWC/ Sub-center
PHC/CHC
Govt. Hospital
Private hospital/clinic
Home
Others
I05
If delivered at Govt. facility, did you have the following cards during delivery?
JSY card
MCH card
Both
None of the above
Do not know
I06
Did you receive the cash benefit, after delivery at govt. institution (HWC/CHC/PHC/Govt. hospital) ?
Yes
No
I07
Did you have to pay for any of the following expenses, after delivery at govt. institution (HWC/CHC/PHC/Govt. hospital) ?
I07_1
Drugs and consumables
Yes
No
I07_2
Diagnostics and tests
Yes
No
I07_3
Blood wherever required
Yes
No
I07_4
Diet for 3-7 days
Yes
No
I07_5
Transport from home to institution and back home
Yes
No
I08
How many Post Natal checkups did you receive after giving birth?
First checkup Within 24 hours
3rd day after delivery
7th day after delivery
14th day after delivery
42nd day after delivery
No Post Natal checkups
I09
Where did you receive the Post Natal checkups?
VHSND
HWC
PHC/CHC
Govt. Hospital
Private hospital/clinic
Home
Others
Vaccination Section
J01
Do you/your household have any child aged (0-6) (0-1) years ?
Yes
No
J02
When was the child born ?
J03
Does the child have an immunization card?
Yes
No
J04
Was the child vaccinated at birth?
Yes
No
J05
What all vaccinations did the child receive at birth?
BCG
HEP B
OPV(0)
J06
Where was the child vaccinated post birth?
VHSND
HWC
PHC/CHC
Govt. Hospital
Private hospital/clinic
Home
Didn’t get vaccinated post birth
J07
What all vaccinations did the child receive post birth?
J07_1
OPV-1
Yes
No
J07_2
PENTA-1
Yes
No
J07_3
ROTA-1
Yes
No
J07_4
PCV-1
Yes
No
J07_5
IPV-1
Yes
No
J07_6
OPV -2
Yes
No
J07_7
PENTA-2
Yes
No
J07_8
ROTA-2
Yes
No
J07_9
OPV-3
Yes
No
J07_10
PENTA-3
Yes
No
J07_11
ROTA-3
Yes
No
J07_12
PCV-2
Yes
No
J07_13
IPV-2
Yes
No
J07_14
MR-1
Yes
No
J07_15
JE-1
Yes
No
J07_16
VITAMIN A-1
Yes
No
J07_17
PCV BOOSTER
Yes
No
COVID Section
K01
Did you/any household member suffer from COVID-19 in the last one year?
Yes
No
K02
How many members suffered from COVID-19 in the last one year ?
K03
Did you/the household member get tested for COVID-19 in the last one year ?
Yes
No
K04
Was the testing facility for COVID-19 available nearby?
At village level
At GP level
At block level
At district level
Not available
K05
Did you/any household member get Vaccinated for COVID-19 in the last one year
Yes
No
K06
How many doses of vaccination did you receive?
K06A
DOSE 1
Yes
No
K06B
DOSE 2
Yes
No
Women and child development
L01
Did the pregnant woman have her Hb tested during the course of her pregnancy?
Yes
No
L02
Where did the woman get her Hb tested?
VHSND
HWC/Sub-center
PHC/CHC
Govt. Hospital
Private hospital/clinic
L03
Was the pregnant woman identified as anemic/ severely anemic?
Yes
No
L04
What services did you/pregnant woman receive by the AWW from the local AWC?
Information and counselling on nutritional intake of mother
Information and counselling on nutritional intake of child
Provided supplementary nutrition (take home rations) during pregnancy
IFA tablets
Provided supplementary nutrition (take home rations) after pregnancy
None of the above
L05
How many tablets were you provided with, and how many did you consume?
IFA Tablets provided
IFA Tablets consumed
Malnutrition Section
M01
Does the household have any child (0-6 yrs.) ?
Yes
No
M02
Have they been monitored for height, weight (malnourishment) by the AWW ?
Yes
No
M03
Was the child classified under any of the following categories?
SAM
MAM
Do not know
NO
M04
Was the child sent to NRC for treatment?
Yes
No
M05
Did the child complete the full stay at NRC as required (21 days) ?
Yes
No
M06
For how many days did the child stay at NRC?
M07
Has the child been given supplement nutrition (THR or cooked meal) by/at AWC?
Yes
No
M08
Do they go to AWC for preliminary education? (3-6years)
Yes
No
Adolescent Girls
N01
Does your household have any adolescent girl (11-14 year)?
Yes
No
N02
Was the adolescent girl provided with information/training on nutrition, hygiene and health by the AWW from the local AWC, in the last one year?
Yes
No
N03
Where was the girl screened for anemia, in the last one year?
School
Home
VHSND
AWC
HWC/PHC/CHC
Govt. hospital
Pvt. Hospital/clinic
Others
Not screened
N04
Was the adolescent girl identified as anemic ?
Yes
No
N05
Was the adolescent girl provided with IFA tablets by the AWW from the local AWC?
Yes
No
N06
Did the adolescent girl consume all the IFA tablets provided to them?
Yes
No
N07
Was the adolescent girl provided with deworming tablet?
Yes
No
Department of Drinking water and sanitation.
O01
Does your household have access to toilet?
Yes
No
O02
What kind of toilet facility does your household have access to?
Individual toilets constructed using SBM allowance
Individual toilets constructed by own investment
Individual toilets constructed using SBM allowance plus own investment
Community toilets
Neighbor or Relative
O03
Do all the members of your household (including yourself) use toilets for the following purposes?
O03A
Urination
Always (Every time by each member)
Sometimes (As per the wish of household members)
Never
O03B
Defecation
Always (Every time by each member)
Sometimes (As per the wish of household members)
Never
O04
Do any member of your household practice open defecation ?
Yes, each member of the household
Yes, some/few members of the household
No member of the household
O05
Where/how do you dispose of your household waste/garbage?
A specified dumping area in your village
Any open land area
Landfills
Burning
Village pond/water bodies
Using Dustbins
Others
O06
Where do you dispose of child/infant faeces?
A specified dumping area in your village
Any open land area
Landfills
Burning
Village pond/water bodies
Not applicable/no child
Others
Household Toilet
O07
Where does the household wastewater end up ?
Closed drain
Open drain
Open drain leading into the street
Open drain leading into water bodies
Do not know
Others (specify)
O08
Is there any stagnant water spot near your house?
Yes
No
Department of Financial services
P01
Have you/any household member heard about PMJDY accounts?
Yes
No
P02
Do you/any household member have an active PMJDY account?
Yes
No
P03
How often do you/any other member use the PMJDY account for ?
Daily
Weekly
Fortnightly
Monthly
Quarterly
Bi-Annually
Annually
Never
According to need
P04
When was the last time you did a financial transaction (transfer, deposit or withdrawal) with your PMJDY account?
APY (Atal Pension Yojana) section
R01
Have you heard about APY?
Yes
No
R02
Have you/any member enrolled for APY ?
Yes
No
R03
What frequency did you/eligible household member choose for depositing APY premiums?
Monthly
Quarterly
Bi-Annually
Do Not Know
Annually
R04
Do you have the scope of changing the premium payment frequency as per your convenience?
Yes
No
R05
Which account have you used to opt for APY scheme?
PMJDY account
Savings account in private bank
Savings account in public bank
Do not know
R06
What is the monthly premium amount paid by you/eligible household member (Rs.)?
R07
Are you able to pay the premiums on due date every time?
Yes, every time as per the frequency
No. delay in payment sometimes
No, never able to pay the premiums on time
Do Not know
R08
What is the monthly pension amount opted by you/eligible household member under the APY?
Rs. 1000
Rs. 2000
Rs. 3000
Rs. 4000
Rs. 5000
Do not know
R09
Does any member of your household receive pensions under the APY?
Yes
No
R10
Do they receive the monthly pensions in a timely manner?
Yes
No
R11
Where do you approach/complain for delay in payment of APY pensions?
Gram Pradhan
GP Secretary
BDO office
Bank
Did not complaint
Others
PMJJBY Section
S01
Have you heard about the PMJJBY insurance scheme (life insurance) ?
Yes
No
S02
Has any person in your household enrolled under the PMJJBY insurance scheme (life insurance) in the last one year (1st June 2020- 31st May 2021)?
Yes
No
S03
Were you able to pay the PMJJBY premium on time, in the last one year (1st June 2020- 31st May 2021)?
Yes
No
S04
Were you able to pay the full premium amount, in the last one year (1st June 2020- 31st May 2021) ?
Yes
No
S05
Which account have you used to opt for PMJJBY insurance?
PMJDY account
Savings account in private bank
Savings account in public bank
Do not know
S06
Have you claimed the PMJJBY insurance amount in the last one year (1st June 2020- 31st May 2021)?
Yes
No
S07
Has your PMJJBY claim been settled within 60 days from the submission of the claim form?
Yes
No
S08
How many days did it take for the claim to be processed?
S09
How many days did it take for the amount to be disbursed?
S10
Where did you approach/complaint for the delay in payments?
Gram Pradhan
GP Secretary
BDO office
Bank
Did not complaint
Others
S11
Have you received the claim amount (Rs 2 lakhs) entitled to you under PMJJBY?
Yes, received fully
Yes, received partially
No, didn’t receive at all
PMSBY Section
T01
Have you heard about PMSBY insurance scheme (accident insurance) ?
Yes
No
T02
Does any person in your household have an insurance policy under the PMSBY insurance scheme (accident insurance) in the last one year (1st June 2020- 31st May 2021)?
Yes
No
T03
Were you able to pay the PMSBY premium on time, in the last one year (1st June 2020- 31st May 2021)?
Yes
No
T04
Were you able to pay the full premium amount, in the last one year (1st June 2020- 31st May 2021) ?
Yes
No
T05
Which account have you used to opt for PMSBY insurance?
PMJDY account
Savings account in private bank
Savings account in public bank
Do not know
T06
Have you claimed the PMSBY insurance amount in the last one year (1st June 2020- 31st May 2021)?
Yes
No
T07
Has your PMJJBY claim been settled within 60 days from the submission of the claim form?
Yes
No
T08
How many days did it take for the claim to be processed?
T09
How many days did it take for the amount to be disbursed?
T10
Where did you approach/complaint for the delay in payments?
Gram Pradhan
GP Secretary
BDO office
Bank
Did not complaint
Others
T11
Have you received the claim amount entitled to you under PMSBY?
Yes, full amount (Rs 2 lakh) for total loss
Yes, partial amount (Rs 1 lakh) for partial loss
No, didn’t receive
MNREGA Section
U01
Does your household have MNREGA job card?
Yes
No
U02
How many times have you/ any HH member applied for work under MNREGA with Rojgar sevak in the last one year?
U03
How many times did you/ any HH member receive the work under MNREGA in the last one year, whenever you have applied for it?
U04
For how many days did you receive the work under MNREGA in the last one year?
U05
Did you usually receive the work within 15 days of application?
Yes
No
U06
In case the work was not provided to you within 15 days, did you receive unemployment allowance, in the last one year?
Yes
No
U07
Did you turn up for work within 15 days of receiving it, in the last one year?
Yes
No
Sometimes
Never received the work
U08
Did you receive the complete wages for your work under MNREGA, in the last one year?
Yes, received in cash
Yes, received in bank account
No, not received
Do not know
U09
Were there any delays in payment (more than 15 days after finishing the work) under MGNREGA, in the last one year?
Yes
No
U10
In case of delay in payment of wages (exceeding 15 days), did you receive the due compensation (0.05% of the unpaid wages), in the last one year ?
Yes
No
U11
Have you used MGNREGA work to create any individual/household asset, in the last one year?
Yes
No
U12
What individual/household assets have you created under MGNREGA?
Work on agriculture land (bunds, farm ponds, irrigation channels etc.)
Construction of house under awaas Yojana
Vermicompost pit
Cattle and poultry shed
CC road in front of the house
Toilet
Others (specify)
U13
How often do you use the individual/household assets created under MGNREGA?
U13_1
Work on agriculture land (bunds, farm ponds, irrigation channels etc.)
Every Day
Sometimes
Never
U13_2
Construction of house under awaas Yojana
Every Day
Sometimes
Never
U13_3
Vermicompost pit
Every Day
Sometimes
Never
U13_4
Cattle and poultry shed
Every Day
Sometimes
Never
U13_5
CC road in front of the house
Every Day
Sometimes
Never
U13_6
Toilet
Every Day
Sometimes
Never
DDU GKY, R-SETI section (includes state department indicators)
V01
Have you/any household member been trained under DDU-GKY, R SETI or UPSDM, in the last one year?
DDU-GKY
R SETI
UPSDM
None of the above
V02
How many household members have received the training?
V03
When was the last time you/any household member received the training?
V03_1
DDU-GKY
V03_2
R SETI
V03_3
UPSDM
V04
Did you/the trained household member(s) get placed in any job /started an enterprise after the training(s), in the last one year?
Got employed
Started business
None of the above
V05
What type of job did you/ the household member get placed in, after receiving the training(s), in the last one year?
Captive Placement (trained and placed by the employer itself)
Placements in private company with regular monthly wages
Placement in govt. organizations involved in public service delivery
Foreign Placements
Others (Specify)
Do not know
V06
What type of business did you/ the household member start after receiving the training(s), in the last one year?
Tailor/weaver/sewer
Mechanic
Carpentry/masonry
Teacher/tutor
Plumber
Electrician
Poultry
Sericulture
Apiculture
Others (Specify)
NRLM Section (ASK TO WOMEN SHG MEMBERS)
W01
Is any member of your household an SHG member?
Yes
No
W02
What is your/her position in the SHG?
President
Treasurer
Secretary
Member
Others (specify)
W03
Does SHG have bank account?
Yes
No
W04
Has your SHG lent any money in the last three months?
Yes
No
W05
What is the monthly loan amount disbursed by your SHG in the last 3 months?
W05_1
44256
W05_2
44287
W05_3
44317
W06
Does the SHG have any enterprise of its own?
Yes
No
W07
What type of enterprise does the SHG have?
Tailoring
Sewing and weaving
Handicrafts
Small case manufacturing
Manufacturing unit for private enterprises
Others (specify)
W08
Have you taken any loan from CCL/SHG savings in the last one year?
Yes
No
W09
How much loan did you take from the SHG in the last one year (Rs.)?
W10
What did you use the loan for?
Start a new enterprise
Invest in new equipment/raw materials
Strengthen operations and Management of the enterprize
None of the above
Others (specify)
Social assistance/welfare section
X01
Do you/any household member receive the pensions under NSAP program?
Divyang pension
Widow pension
Old age pension
None
Not eligible
Do not know
X02
What is the frequency of the pension payment received by you?
Monthly
Bi-monthly (every other month)
Quarterly
Bi-annually
Annually
X03
How many months in the last year, did you receive your pension on time (a specified day of each month)?
X04
What is the mode of payment by which you receive the NSAP pension?
In Person/cash
Via Post office
Direct transfer to bank account
X05
Which bank account do you use for receiving NSAP pensions?
PMJDY account
Savings account in private bank
Savings account in public bank
Do not know
X06
Whom do you approach/complaint about the delays in NSAP pension payments?
Gram Pradhan
GP Secretary
BDO office
Bank
Did not complaint
No delays in payment
Others
Department of MSME. (includes state department indicators)
Y01
Did you/any household member receive a loan/financial assistance for enterprise development, in the last one year ?
Yes
No
Y02
Under what scheme have you received the loan/financial assistance?
PMEGP
CMEGP
ODOP
Other govt. schemes (specify)
Loan from bank/financial institution
Loan from pvt. sources
Others (specify)
Do not know
Y03
Have you started any enterprises using the loan/financial assistance, in the last one year?
Yes
No
Y04
In what sector did you start the business in?
Manufacturing Sector
business/service sector
Y05
What was the size/scale of business, in terms of loan amount invested?
0-5 Lakhs
5-10 Lakhs
10-25 Lakhs
Y06
What has been the average monthly income from the business/enterprise, in the last 3 months?
Y06_1
44256
Y06_2
44287
Y06_3
44317
Y07
Is your household involved in pottery making ?
Yes
No
Y08
Did you receive electric chaak, in the last one year ?
Yes
No
Y09
What has been the average income from pottery, in the last 3 months ?
Y09_1
44256
Y09_2
44287
Y09_3
44317
Y10
Where do you sell the pottery items made by your household?
At local market
At district market
To trader
To other villagers
Others (specify)
Department of Labour and Employment.
Z01
Have you heard about PMSYM scheme?
Yes
No
Z02
Does any member of your household have a PMSYM account?
Yes
No
Z03
Did you enroll for the PMSYM scheme in the last one year?
Yes
No
Z04
Do you contribute to the monthly premium for PMSYM scheme?
Yes
No
Z05
How many months in the last year, did you pay your premium on time (a specified day of each month)?
State Department
1101
Have you heard about the meri sadak app?
Yes
No
1102
Have you used the meri sadak app to register complaint/grievance in the last one year?
Yes
No
1103
How frequently do you use the meri sadak app to register complaint/grievance ?
Daily
Weekly
Fortnightly
Monthly
Quarterly
Bi-Annually
Annually
Never
When required
1104
How many times do you receive a response to the complaint registered by you on the Meri Sadak App?
Every time
Sometimes
Never
1105
How was your experience of using the Meri Sadak app, based on the following factors?
1106
End Time
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