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Clf Template 2 -Form Fill
Identification Information
Q01
District Name
Q02
District Code
Q03
Block Name
Q04
Block Code
Q05
Name of the CLF
Q06
UID
Q07
Type of Area
Comparison
Project
Survey Information
A01
Name of the respondents
A02
Designation of the respondent
President
Vice-President
Secretary
Treasurer
Bookkeeper
Others (Specify)
A03
Respondent identification code
A04
FIRST VISIT
A04_1
Interviewer name
A04_2
Interviewed code
A04_3
Date of the interview
A04_4
Result of the interview
Interview complete
Visit rescheduled
Interview incomplete
Refused
Respondent is out of station for extended period
Respondent is temporarily away
Other (specify)
A04_5
Record time when you start the interview
A05
SECOND VISIT
A05_1
Interviewer name
A05_2
Interviewed code
A05_3
Date of the interview
A05_4
Result of the interview
Interview complete
Visit rescheduled
Interview incomplete
Refused
Respondent is out of station for extended period
Respondent is temporarily away
Other (specify)
A05_5
Record time when you start the interview
A06
THIRD VISIT
A06_1
Interviewer name
A06_2
Interviewed code
A06_3
Date of the interview
A06_4
Result of the interview
Interview complete
Visit rescheduled
Interview incomplete
Refused
Respondent is out of station for extended period
Respondent is temporarily away
Other (specify)
A06_5
Record time when you start the interview
CLF Information
B01
What is the name of this CLF
B02
What is the date of formation of this CLF?
B03
Is this CLF registered?
Yes
No
B04
What is the date of registration of this CLF?
B05
What is the registration number of this CLF?
B06
How many VOs are there in this CLF?
B07
In the last one year, has the accounts of this CLF been audited by an external agency (chartered accountant)
Yes
No
Vision/ Mission of the CLF
C01
Does the CLF have a vision statement,/ mission statement?
Yes
No
C02
Are the vision and mission used to set priorities of the CLF?
Yes
No
C03
Are these statements posted openly in the office or somewhere that members can see?
Displayed in the CLF office
Printed on CLF records
Not displayed anywhere
Others (specify)
C04
Does the CLF review the vision and mission statements?
Yes
No
C05
When was the last time CLF reviewed its vision/mission statement?
C06
Does the CLF has made an annual action plan?
Yes
No
C07
What are the key priorities of the annual action plan?
Leadership
D01
Name of the office bearer
D02
Age of this office bearer
D03
Religion of this office bearer
Hinduism
Islam
Christianity
Jainism
Sikhism
Buddhism
Other
D04
Social category of this office bearer
SC
ST
OBC
General
Others
D05
Position currently held by this office bearer
President
Vice president
Secretary
Treasurer
D06
How many times has the position rotated since the formation of CLF?
D07
In which year did the last rotation in position take place?
D08
Is the current position a paid position
Yes
No
D09
Education level of this office bearer
Primary
Middle
Secondary
Senior secondary
Certificate/ Diploma course
Graduate
Postgraduate
Others, specify
Never attended school
D10
Type of ration card the office bearer have?
PHH
AYY
Do not have ration card
D11
Is the office bearer disabled
Yes
No
D12
What are the trainings received by the office bearer?
CLF concept and Management
leadership training
CLF visioning
Business plan development
Training on CLF Books of Accounts
Financial Management of CLF
Development of Annual Action Plan
Cadre Selection and Management
Convergence
livelihood training
No training received
Others (specify)
Governing Body/ Executive Committee (EC)
E01
When was the present Executive Committee (EC) of the CLF constituted ?
E02
What is the norm for conducting EC meeting of this CLF?
Fortnightly
Monthly
Quarterly
E03
How many EC meetings were held in the last 12 months?
E03A
EC meetings held before CORONA (COVID-19) lockdown
E03B
EC meetings held during CORONA (COVID-19) lockdown
E03C
EC meetings held after CORONA (COVID-19) lockdown
E04
Can you please tell me if the last four meetings were conducted?
E04_1
Meeting 1
Yes
No
E04_2
Meeting 2
Yes
No
E04_3
Meeting 3
Yes
No
E04_4
Meeting 4
Yes
No
E04A
Why were the meetings not held?
Office bearers were not available
There was a function (marriage, festival etc.) in the village
Meetings were suspended due to CORONA (COVID-19)
Others (specify)
E05
How many EC members were absent in each of the last four consecutive meetings
E05_1
Meeting 1
E05_2
Meeting 2
E05_3
Meeting 3
E05_4
Meeting 4
E06
What was the penalty levied if any of the EC member did not attend the EC meeting
E06A
Was penalty levied even during the lockdown period?
Yes
No
E07
What topics were discussed in the last 4 meetings of the executive committee
E07_1
Meeting 1
Issues related to savings & loans
Maintenance of records
disbursement of CIF
Schedule and loan repayment terms
issues related to VHSND
quality of services provided by ASHA/AWW/ANM
Health and nutrition related issues
Sanitation issues
Annual action plan of the CLF
Convergence with welfare schemes
Gender issues
Symptoms and preventive measures for CORONA (COVID-19)
Others (Specify)
E07_2
Meeting 2
Issues related to savings & loans
Maintenance of records
disbursement of CIF
Schedule and loan repayment terms
issues related to VHSND
quality of services provided by ASHA/AWW/ANM
Health and nutrition related issues
Sanitation issues
Annual action plan of the CLF
Convergence with welfare schemes
Gender issues
Symptoms and preventive measures for CORONA (COVID-19)
Others (Specify)
E07_3
Meeting 3
Issues related to savings & loans
Maintenance of records
disbursement of CIF
Schedule and loan repayment terms
issues related to VHSND
quality of services provided by ASHA/AWW/ANM
Health and nutrition related issues
Sanitation issues
Annual action plan of the CLF
Convergence with welfare schemes
Gender issues
Symptoms and preventive measures for CORONA (COVID-19)
Others (Specify)
E07_4
Meeting 4
Issues related to savings & loans
Maintenance of records
disbursement of CIF
Schedule and loan repayment terms
issues related to VHSND
quality of services provided by ASHA/AWW/ANM
Health and nutrition related issues
Sanitation issues
Annual action plan of the CLF
Convergence with welfare schemes
Gender issues
Symptoms and preventive measures for CORONA (COVID-19)
Others (Specify)
Sub-committees of the CLF
F01
Does the CLF has formed different sub-committees for managing various roles and responsibilities of the CLF?
Yes
No
F02
COMMITTEE TYPE
Social Action Committee
Bank linkage/CBRM committee
Livelihoods committee
Education committee
Monitoring committee
Others(specify)
F03
When was this committee formed?
F04
How many members are there in the committee currently?
F05
How many times did this committee meet in the last 12 months?
F06
Key roles and responsibilities of the committee
F07
How would you rate the effectiveness of this committee?
very effective
effective
not effective
no response
F08
Were the following issues discussed during the last four EC meetings ?
F08_1
Health and nutrition related issues – importance of balance diet, child and maternal health, health services in the village
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_2
Sanitation related issues- importance of cleanliness, sanitation practices, availability of clean drinking water, construction of toilets etc
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_3
Education in the village- school enrolment, availability of the teaching staff etc.
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_4
Involvement in Panchayati Raj Institutions – Participation in Gram Sabha (General)
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_5
Active Participation in Government Schemes- by facilitating members to access Govt. Welfare/ Development Schemes/Programs (e.g. MGNREGS, PDS, etc.
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_6
Discussion on Household Livelihoods
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_7
Self-employment schemes
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_8
Discussion around ways to prevent CORONA (COVID-19) infection, social distancing, handwashing, use of mask etc.
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F08_9
Others (Specify)
No
Yes but not recorded in minutes of meeting register
Yes and recorded in minutes of meeting register
F09
Health and nutrition related issues discussed in the last four EC meetings
F09A
Issue discussed
F09A_1
Meeting 1
F09A_2
Meeting 2
F09A_3
Meeting 3
F09A_4
Meeting 4
F09B
Amount of time spend on discussion
F09B_1
Meeting 1
F09B_2
Meeting 2
F09B_3
Meeting 3
F09B_4
Meeting 4
Role of CLF on Health and Nutrition issues
G01
Do you think it is the responsibility of the CLF to create awareness on Health and Nutrition issues?
Yes
No
G02
If no, why?
Creating awareness on Health and Nutrition is the responsibility of health department
It would interfere with the core business of CLF (lending, monitoring and reviewing activities of member SHGs etc.)
Others (specify)
G03
What are the roles and responsibilities of your CLF on the Health and Nutrition issues ?
Creating a cadre of CRP to train the SHGs on Health and Nutrition module
helping VOs in rolling out the Health and Nutrition module in the member SHGs
Monitoring the activities of VOs/ SHGs regarding Health and Nutrition issues
Helping VOs/ SHGs in taking action on the HN issues
Enagaging with ASHA/ANM/AWW for facilitating access to public health
Occassional visits to PHC to monitor the quality of health services provided
Approaching UPSRLM block level officials/ health providers to raise the supply side issues on Health and Nutrition
Not applicable
Others (specify)
G04
Do ASHA/ANM/AWW attend the EC meetings?
Yes
ASHA/ANM/AWW is EC member
No
G05
On which occasions do ASHA/ANM/AWW attend EC meetings?
Every EC meeting
Whenever needed
When EC meeting has health and nutrition agenda
Others (Specify)
G06
What do the ASHA/ANM/AWW discuss during meetings?
Issues related to VHSND
Government welfare programs on health and nutrition and entitlements
Discussing initiatives of social action committee on health and nutrition
Others (specify)
G06A
Did ASHA/ANM/AWW reachout to CLF during CORONA lockdown?
Yes
No
G07
What kind of support does CLF provide to ASHA/ANM/AWW?
CLF representatives work with AWW/ANM to mobilize women to participate in VHSND
CLF representatives monitor the service delivery of ASHA/ANM/AWW and provide regular feedback
Others (specify)
does not provide any support
Role of CLF in combating CORONA (COVID-19)
H01
Has your CLF received any information/directives on CORONA (COVID-19)
Yes
No
H02
Who has provided the information/directives ?
UPSRLM officials
ASHA/ANM
AWW
Gram Pradhan/sarpanch
Other(specify)
H03
What are the directives/infromation your CLF has received?
Suspend all the CLF, VO and SHG meetings until the next notice
Information on symptoms of CORONA (COVID-19)
Information on preventive measures for CORONA (COVID-19)
Instructions on how to carry out the CLF financial activities during the lockdown
Others (specify)
H04
What are the initiatives that your CLF took to fight against CORONA (COVID-19) in your cluster?
Provide information on symptoms and prevention from CORONA (COVID-19) to the VO and SHG members through mobile messaging
CLF members helped ASHA/ ANM/ AWW in distribution of face masks and sanitizers
Others (specify)
No initiative taken
H05
What are the preventive measures CLF members are adopting while helping with the CORONA situation at community level?
Wash hands frequently
Wash hands frequently with soap
Clean hands with sanitizer
Cover nose and mouth with handkerchief/ tissue/elbow while coughing or sneezing
Don't touch eyes, nose, or mouth
Don't be in close physical contact with anyone
Avoid crowded places
Be at least 1 meter away from everyone
Don't spit in public
Wear a mask if sick
Avoid physical contact with infected individuals
Avoid touching common surfaces, items or sharing plates/utensils
Avoid touching what sick persons have touched such as surfaces, items, plates/utensils
Keep cleaning common surfaces
Don't shake hands with others
Others (specify)
Don't Know
H06
Has your CLF received any support from government during the CORONA (COVID-19) crisis?
Yes
No
H07
What type of support has your CLF received?
Money/cash transfers
Insurance for all the CLF members
Others (specify)
Organizational Structure
I01
How many VOs are member of this CLF?
I02
What is the membership fee paid by member VOs?
I03
What is the yearly membership renewal fee paid by member VOs?
I04
What is the name of the VO?
I05
VO code
I06
When did this VO join the CLF?
I07
In which gram panchayat is the VO located?
I08
Based on available record what is the amount of CIF repaid by this VO to the CLF
I08_1
Before CORONA lockdown
I08_2
During CORONA lockdown
I08_3
After CORONA lockdown
I09
In the past 12 months, has the VO repaid the agreed CIF installments on time?
I09_1
Before CORONA lockdown
Yes, every time
Yes mostly, except few installments
Not paid most of the installments on time
Not Applicable
I09_2
During CORONA lockdown
Yes, every time
Yes mostly, except few installments
Not paid most of the installments on time
Not Applicable
I09_3
After CORONA lockdown
Yes, every time
Yes mostly, except few installments
Not paid most of the installments on time
Not Applicable
Cadre Management
J01
Community cadre engaged with the CLF
ICRP
ICRP-FNHW
Samuh Sakhi
Bookkeeper
Bank Sakhi
VO accountant / assistant
Pashu Sakhi
Krishi Sakhi
Banking Correspondent
Others (specify)
J02
Name of this community cadre ?
J03
Gender of this community cadre?
Male
Female
J04
Age in years completed
J05
Social category of this community cadre?
General
SC
ST
OBC
Minority
Others
J06
Religion of the community cadre?
Hinduism
Islam
Christianity
Jainism
Sikhism
Buddhism
Others
J07
Education level of this community cadre?
Primary
Middle
Secondary
Senior secondary
Certificate/ Diploma course
Graduate
Postgraduate
Never attended school
Others (specify)
J08
Since when the community cadre is working ?
J09
What are the trainings received by the cadre?
CLF concept and Management
training on CLF Books of Record
training on Banking Procedures (including opening of a bank account, deposit, withdrawal)
training on group formation
training on Health and Nutrition Modules
Others (specify)
J10
How was the cadre engaged in helping the community during CORONA crisis?
Review and Monitoring
K01
Does CLF have its own plan and annual target ?
Yes
No
K02
What is the annual target of this CLF?
K03
How often does the CLF review its plan and target achievement?
Monthly
Once in two months
No predetermined frequency
Never reviewed
Not Applicable
Others (specify)
K04
How often does the CLF review the activities of the member VOs?
Weekly
Fortnightly
Monthly
Once in two months
No predetermined frequency
Never reviewed
Not Applicable
Others (specify)
K05
What VO activities are reviewed by the CLF?
Books of records
Micro credit plan
Utilization of the CIF
Annual action plan
Implementation of Health and Nutrition module in SHG
Action taken on the key issues emerged during Health and Nutrition meetings
Others (specify)
K06
What kind of support does this CLF provide to the member VOs?
Capacity building trainings
Helping establish credit linkages with banks, MFIs etc.
Providing handholding support in maintenance of records
Providing support for rolling out Health and Nutrition module in the SHG
Providing information on flagship government schemes
Helping in establishing group-level livelihood activity
Facilitating market linkages
Others (specify)
k07
What kind of support does this CLF provide to the VOs for rolling out Health and Nutrition module?
Providing training on Health and Nutrition module to cadre working with VO
Providing training and support for developing VO’s annual plan
Others (specify)
Maintenance of Records
L01
Whether the record is introduced in the VO?
L01_1
Membership & Share Holder Register
Yes
No
L01_2
Attendance Register
Yes
No
L01_3
Minutes Book
Yes
No
L01_4
Savings Register
Yes
No
L01_5
General Ledger
Yes
No
L01_6
Daily Expenses Register
Yes
No
L01_7
Cash Book
Yes
No
L01_8
Loan Register
Yes
No
L01_9
Receipt Book
Yes
No
L01_10
Voucher Book
Yes
No
L01_11
Stock register
Yes
No
L01_12
Financial statements
Yes
No
L01_13
CLF Passbook
Yes
No
L01_14
Cheque Issue Register
Yes
No
L01_15
CLF DCB Register
Yes
No
L01_16
Others (specify)
Yes
No
L02
Please record date last updated
L02_1
Membership & Share Holder Register
L02_2
Attendance Register
L02_3
Minutes Book
L02_4
Savings Register
L02_5
General Ledger
L02_6
Daily Expenses Register
L02_7
Cash Book
L02_8
Loan Register
L02_9
Receipt Book
L02_10
Voucher Book
L02_11
Stock register
L02_12
Financial statements
L02_13
CLF Passbook
L02_14
Cheque Issue Register
L02_15
CLF DCB Register
L02_16
Others (specify)
Financial Management
M01
Did this CLF receive Community Investment Fund (CIF)?
Yes
No
M02
When did this CLF receive CIF ?
M03
Total amount of CIF received by this CLF till now
M04
Total amount of CIF disbursed to the member VOs
M05
Total amount of CIF repaid by member VOs to the CLF till date
M06
What action was taken by the CLF against loan defaulter VOs ?
Financial penalty
Taking over VO savings
Refusal of provision of new loans until the old one is repaid
Others (Specify)
M07
Did this CLF receive any bank loan?
Yes
No
M08
When was the first time this CLF received a bank loan?
M09
How many times has this CLF received a bank loan ?
M10
Total amount of bank loan received by the CLF till date
M11
Total amount of bank loan repaid by the CLF
M11A
Amount of bank loan repaid by the CLF during CORONA lockdown
M11B
Amount of bank loan repaid by the CLF after CORONA lockdown
M12
What is expenditure incurred by the CLF under the following heads:
M12_1
Payment of staff (cadre)
M12_1A
What was the payment status for cadre during lockdown?
Cadre were paid as per agreed terms
No payment made during the lockdown period
Others (specify)
M12_2
Training expenses
M12_3
Purchase of fixed assets (ag. Purchase/ Construction of CLF office, furnitures, almirah etc.)
M12_4
Miscellaneous expenses (eg. Printing of brochures, purchase of stationary etc.)
M12_5
Other expenses (specify)
M13
What is the amount received by the CLF under the following heads
M13_1
Membership fees (subscription fee) deposited by VOs
M13_2
Interest received on loans
M13_3
Earnings from other sources (specify)
M14
Total profit/surplus accumulated by the CLF
M15
Opening balance
M16
Closing balance
Social Action and Convergence
N01
Area of concern
N01_1
SHG/VO related issues
Non-repayment of loans to CLF
Conflict within SHG/VO members
Identification and mobilization of left-out poor
Issues related to bank linkage, bank loan and CIF repayment
Other (specify)
N01_2
Health facilities related issues
Poor service by health providers (AWW /ASHA/ ANM)
Lack of services/ supplies at PHC/HSC
Irregularity in VHSND
Lack of services/supplies at VHSND
Government response to covid crisis, partnering with frontline workers, providing health & sanitation messages, ensuring social distancing etc.
Others (specify)
N01_3
Social Issues
Domestic Violence
Alcoholism
Dowry Issues
Child labor
Child marriage
Discrimination against girl child
Discrimination against disadvantaged
Others (specify)
N01_4
Issues In availing benefits of welfare schemes
MGNREGS cards
Ration cards/ PDS shop
Pensions
Housing subsidy
Swachh Bharat Mission
Illegal liquor business/shop
Janani Suraksha Yojana
Pradhan Mantri Matru Vandana Yojana
Other (specify)
N02
Did the cluster face any problem regarding ISSUE?
Yes
No
N03
Did this CLF take any action against ISSUE?
Yes
No
N04
Action/ Collective Action taken up
Counselled the Perpetrator
Initiated police action against the perpetrator
Arranged for temporary stay for the victim
Counselled family members
Arranged for Rehabilitation
Provided financial assistance for rehabilitation
Mobilizing women to take collective actions
Other(specify)
N05
Did this CLF collaborate with or seek help from other institutions for this activity?
Yes
No
N06
If yes, which institutions did this CLF collaborate or seek help from?
Gram Panchayat
Police
Banks
Block office of NRLM
NGOs
Member VOs
Others (specify)
N07
Result
Problem was completely resolved
Problem was partially resolved
Problem was not resolved
Collective Business Activity
O01
Has the CLF undertaken any collective business activity where at least some members of this CLF jointly invest some money or time, and share surplus/ profits ?
Yes
No
CLF has started a business but it did not sustain
O02
What type of activity has the CLF taken up?
Collective Farming (including crops, vegetables, fruits, flowers)
Collective Animal Husbandry (including cattle, goatery, poultry, piggery)
Collective Non-Farm Activities (like textiles, handicrafts, petty business, fishing, etc
Service Provided to Village facilities (such as PDS outlet, angandwadi, School, etc.)
Service provided to mission (such as Exposure Visits,
Community Lunches, CRP drives, training, etc)
Others (specify)
O03
Is the CLF involved in this activity currently?
Yes
No
O04
What was the date of start of this activity?
O05
How many member VOs are part of the activity?
O06
What was the amount invested?
O07
What is the total expenditure incurred in past 3 years?
O08
What is the total revenue form the enterprise in past 3 years?
O09
What is the profit from the enterprise in past 3 years?
O10
How did you distribute the surplus?
Equally among member VOs
Among member VOs as per time- spent on activity
Others (specify)
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