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Household Template 19 -Form Fill
Demographic Details
Q01
Interviewer name
Q02
Interviewer code
Q03
Date of the interview
Q04
District Name
Q05
District Code
Q06
Block Name
Q07
Block Code
Q08
Type of Area
Urban
Rural
Q09
Ward Name
Q10
Gram Panchayat Name
Q11
Village Name
Q12A
UID (To be filled by investigator)
Q12B
Name of Respondent
Q12C
Relation of respondent to Head of Household
I am head of household
Wife/Husband
Son/Daughter
Daughter-in-law/Son-in law
Grandchild
Father /Mother
Brother/Sister
Father-in law/Mother-in law
Nephew/Niece
Brother-in-law/Sister-in law
Other relatives
Q12D
Postal Address
Q12E
List the landmark to identify the household
Q13
Please tell us the number of people who reside in your house.
Q14
What is the name of the head of the household?
Q15
What is the gender of the head of the household?
Male
Female
Transgender
Prefer not to say
Other (Specify)
Q16
What is the age of the head of the household (in completed years)?
Q17
What is the educational status of the head of the household?
No education
Primary (1st to 4th class)
Middle (5th to 8th class)
Secondary (8th to 12th)
Diploma
Graduate and above
Q18
What is the current marital status of the head of the household?
Unmarried
Married
Widowed
Separated / Divorced
Refuse to answer
Q19
Primary Activity Status of head of the household
Cultivation
Allied Agriculture (Livestock Rearing)
Agricultural Wage Labour
Non-agricultural wage labour/wage work
Artisan/Independent work
Petty shop/small business
Organized trade/business (if >5 employees)
Salaried employee
Retired/Pension
Household work
Student
Looking for work/unemployed
Too young to work
Unfit to work.
Others (Specify)
Q20
Average Annual Income Generated
No income
0 to 150000
150000 to 300000
300000 to 450000
450000 to 600000
600000 to 750000
750000 to 1000000
1000000 and more
Q21
Which of the following document is held by head of the household
Q21_1
Aadhar Card
Yes
no
Do not know
Refuse to answer
Q21_2
PAN Card
Yes
no
Do not know
Refuse to answer
Q21_3
Ration Card
Yes
no
Do not know
Refuse to answer
Q21_4
Birth Certificate
Yes
no
Do not know
Refuse to answer
Q21_5
Caste Certificate
Yes
no
Do not know
Refuse to answer
Q21_6
Bank Account/ Post Office Savings Account
Yes
no
Do not know
Refuse to answer
Q21_7
MGNREGA Card
Yes
no
Do not know
Refuse to answer
Q22
Name of the person
Q23
Gender of [Name]
Male
Female
Transgender
Prefer not to say
Other (Specify)
Q24
What is the age of [Name] (in completed years)?
Q25
[Name] is living with
Both parents
Mother
Father
Relatives
Away from family
Others(specify)
Q26
What is the status of enrolment [child name]?
Currently Enrolled
Completed
Dropped out
Never enrolled in school
Q27
How many years of education has [Name] completed?
Too young to go to school
Anganwadi/Pres-school
Primary (1st to 4th class)
Middle (5th to 8th class)
Secondary (9th to 12th)
Diploma
Graduate and above
Don’t Know
Refuse to answer
Others (Specify)
Q28
What is the current marital status of [Name]?
Unmarried
Married
Widowed
Separated / Divorced
Don’t know
Refuse to answer
Q29
Has [name] any physical disabilities that affect his/her daily life or mobility?
Yes
no
Do not know
Refuse to answer
Q30
Has [name] any children?
Yes
no
Do not know
Refuse to answer
Q31
Primary Activity Status of [Name]
Cultivation
Allied Agriculture (Livestock Rearing)
Agricultural Wage Labour
Non-agricultural wage labour/wage work
Artisan/Independent work
Petty shop/small business
Organized trade/business (if >5 employees)
Salaried employee
Retired/Pension
Household work
Student
Looking for work/unemployed
Too young to work
Unfit to work.
Others (Specify)
Q32
Average Annual Income Generated
No income
0 to 150000
150000 to 300000
300000 to 450000
450000 to 600000
600000 to 750000
750000 to 1000000
1000000 and more
Q33
Which of the following document is held by [Name]
Q33_1
Aadhar Card
Yes
no
Do not know
Refuse to answer
Q33_2
PAN Card
Yes
no
Do not know
Refuse to answer
Q33_3
Ration Card
Yes
no
Do not know
Refuse to answer
Q33_4
Birth Certificate
Yes
no
Do not know
Refuse to answer
Q33_5
Caste Certificate
Yes
no
Do not know
Refuse to answer
Q33_6
Bank Account/ Post Office Savings Account
Yes
no
Do not know
Refuse to answer
Q33_7
MGNREGA Card
Yes
no
Do not know
Refuse to answer
Q34
What is your religion?
Hindu
Muslim
Christian
Sikh
Buddhist/neoBuddhist
Jain
Jewish
Parsi/Zoroastrian
No religion
Other (Specify)
Don’t know
Q35
Do you belong to a scheduled caste, scheduled tribe, other backward class, or general class?
Scheduled Caste
Scheduled Tribe
Other Backward Class
General
Other (Specify)
Don’t know
Q36
Amenities and resources the family is connected to
Q36A
Available
Q36A_1
Water
Yes
No
Q36A_2
Electricity
Yes
No
Q36A_3
Sanitation Facility
Yes
No
Q36A_4
Primary Healthcare Centre
Yes
No
Q36A_5
Anganwadi
Yes
No
Q36A_6
Primary School
Yes
No
Q36A_7
High School
Yes
No
Q36A_8
Panchayat Meetings/Ward Meeting
Yes
No
Q36A_9
VCPC/Ward CPC Meeting
Yes
No
Q36B
Access
Q36B_1
Water
Yes
No
Q36B_2
Electricity
Yes
No
Q36B_3
Sanitation Facility
Yes
No
Q36B_4
Primary Healthcare Centre
Yes
No
Q36B_5
Anganwadi
Yes
No
Q36B_6
Primary School
Yes
No
Q36B_7
High School
Yes
No
Q36B_8
Panchayat Meetings/Ward Meeting
Yes
No
Q36B_9
VCPC/Ward CPC Meeting
Yes
No
Q36C
Use
Q36C_1
Water
Yes
No
Q36C_2
Electricity
Yes
No
Q36C_3
Sanitation Facility
Yes
No
Q36C_4
Primary Healthcare Centre
Yes
No
Q36C_5
Anganwadi
Yes
No
Q36C_6
Primary School
Yes
No
Q36C_7
High School
Yes
No
Q36C_8
Panchayat Meetings/Ward Meeting
Yes
No
Q36C_9
VCPC/Ward CPC Meeting
Yes
No
Q37
Which of the following situations is applicable to the household?
Migration
Disaster affected
Drug Addiction among adults
Chronic illness in child’s parent(s)
Loss of child’s mother
Loss of child’s father
Loss of both parents
Loss of child’s parents/family members due to COVID19
Orphan/Living Alone
Child is Homeless
Child’s parents with terminal illness
Child’s both parents are imprisoned/ sentenced to death
History of involvement of child’s family members in criminal offences
Other (Specify): ___________
Q38
Do you/members of house have access to all parts of the neighbourhood?
Yes
No
Q39
What is the reason?
Q40
Are all communities (religious, caste-based, economic etc.) in the region treated equally?
Yes
No
Q41
What is the reason?
Q42
Have you ever been negatively impacted by differential treatment?
Yes
No
Q43
What is the reason?
Q44
Is your current household your usual place of residence?
Yes
No
Q45
Has the family been residing here for the past 60 days or less?
Yes
No
Q46
Have earning members of the family been residing elsewhere for 60 days or less?
Yes
No
Q47
Do members of the family migrate seasonally?
Yes
No
Q48
What was the reason for migration?
Economic opportunities
Accessibility to amenities
Infrastructure
Family/community
Other____
Social Protection
A01
Social protection schemes the family is connected to
A01A
Urban
A01A_1
PDS
Yes
No
A01A_2
Jan Dhan Yojna
Yes
No
A01A_3
Atal Pension Yojna
Yes
No
A01A_4
Ujjwala Yojna
Yes
No
A01A_5
E-shram yojna
Yes
No
A01A_6
Ayushman Bharat Yojna
Yes
No
A01A_7
Mahatma Jyotibai Phule jan Aarogya Yojna
Yes
No
A01A_8
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Yes
No
A01A_9
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Yes
No
A01A_10
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Yes
No
A01A_11
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Yes
No
A01A_12
National Social Assistance Programme (NSAP) -Old age Protection
Yes
No
A01A_13
Pradhan Mantri Kisan Mandhan Yojana
Yes
No
A01A_14
Balsangopan Scheme
Yes
No
A01A_15
Sukanya Samridhi Yojana
Yes
No
A01A_16
Rajiv Gandhi Niradhar Yojana
Yes
No
A01B
Rural
A01B_1
MNREGA
Yes
No
A01B_2
PDS
Yes
No
A01B_3
Jan Dhan Yojna
Yes
No
A01B_4
Atal Pension Yojna
Yes
No
A01B_5
Ujjwala Yojna
Yes
No
A01B_6
E-shram yojna
Yes
No
A01B_7
Ayushman Bharat Yojna
Yes
No
A01B_8
Mahatma Jyotibai Phule jan Aarogya Yojna
Yes
No
A01B_9
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Yes
No
A01B_10
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Yes
No
A01B_11
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Yes
No
A01B_12
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Yes
No
A01B_13
National Social Assistance Programme (NSAP) -Old age Protection
Yes
No
A01B_14
Pradhan Mantri Kisan Mandhan Yojana
Yes
No
A01B_15
Balsangopan Scheme
Yes
No
A01B_16
Sukanya Samridhi Yojana
Yes
No
A01B_17
Rajiv Gandhi Niradhar Yojana
Yes
No
A02
Registered/ Eligible but Unregistered/ Not Eligible
A02A
Urban
A02A_1
PDS
Registered
Eligible but Unregistered
Not Eligible
A02A_2
Jan Dhan Yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_3
Atal Pension Yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_4
Ujjwala Yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_5
E-shram yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_6
Ayushman Bharat Yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_7
Mahatma Jyotibai Phule jan Aarogya Yojna
Registered
Eligible but Unregistered
Not Eligible
A02A_8
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Registered
Eligible but Unregistered
Not Eligible
A02A_9
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Registered
Eligible but Unregistered
Not Eligible
A02A_10
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Registered
Eligible but Unregistered
Not Eligible
A02A_11
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Registered
Eligible but Unregistered
Not Eligible
A02A_12
National Social Assistance Programme (NSAP) -Old age Protection
Registered
Eligible but Unregistered
Not Eligible
A02A_13
Pradhan Mantri Kisan Mandhan Yojana
Registered
Eligible but Unregistered
Not Eligible
A02A_14
Balsangopan Scheme
Registered
Eligible but Unregistered
Not Eligible
A02A_15
Sukanya Samridhi Yojana
Registered
Eligible but Unregistered
Not Eligible
A02A_16
Rajiv Gandhi Niradhar Yojana
Registered
Eligible but Unregistered
Not Eligible
A02B
Rural
A02B_1
MNREGA
Registered
Eligible but Unregistered
Not Eligible
A02B_2
PDS
Registered
Eligible but Unregistered
Not Eligible
A02B_3
Jan Dhan Yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_4
Atal Pension Yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_5
Ujjwala Yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_6
E-shram yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_7
Ayushman Bharat Yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_8
Mahatma Jyotibai Phule jan Aarogya Yojna
Registered
Eligible but Unregistered
Not Eligible
A02B_9
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Registered
Eligible but Unregistered
Not Eligible
A02B_10
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Registered
Eligible but Unregistered
Not Eligible
A02B_11
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Registered
Eligible but Unregistered
Not Eligible
A02B_12
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Registered
Eligible but Unregistered
Not Eligible
A02B_13
National Social Assistance Programme (NSAP) -Old age Protection
Registered
Eligible but Unregistered
Not Eligible
A02B_14
Pradhan Mantri Kisan Mandhan Yojana
Registered
Eligible but Unregistered
Not Eligible
A02B_15
Balsangopan Scheme
Registered
Eligible but Unregistered
Not Eligible
A02B_16
Sukanya Samridhi Yojana
Registered
Eligible but Unregistered
Not Eligible
A02B_17
Rajiv Gandhi Niradhar Yojana
Registered
Eligible but Unregistered
Not Eligible
A03
Frequency of utilisation in the last 6 months
A03A
Urban
A03A_1
PDS
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_2
Jan Dhan Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_3
Atal Pension Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_4
Ujjwala Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_5
E-shram yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_6
Ayushman Bharat Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_7
Mahatma Jyotibai Phule jan Aarogya Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_8
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_9
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_10
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_11
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_12
National Social Assistance Programme (NSAP) -Old age Protection
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_13
Pradhan Mantri Kisan Mandhan Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_14
Balsangopan Scheme
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_15
Sukanya Samridhi Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03A_16
Rajiv Gandhi Niradhar Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B
Rural
A03B_1
MNREGA
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_2
PDS
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_3
Jan Dhan Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_4
Atal Pension Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_5
Ujjwala Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_6
E-shram yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_7
Ayushman Bharat Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_8
Mahatma Jyotibai Phule jan Aarogya Yojna
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_9
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_10
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_11
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_12
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_13
National Social Assistance Programme (NSAP) -Old age Protection
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_14
Pradhan Mantri Kisan Mandhan Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_15
Balsangopan Scheme
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_16
Sukanya Samridhi Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A03B_17
Rajiv Gandhi Niradhar Yojana
One time
Two time
Every month
Yet to receive benefits
Other (specify)
A04
Barriers in availing service
A04A
PDS
A04A_1
Jan Dhan Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_2
Atal Pension Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_3
Ujjwala Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_4
E-shram yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_5
Ayushman Bharat Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_6
Mahatma Jyotibai Phule jan Aarogya Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_7
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_8
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_9
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_10
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_11
National Social Assistance Programme (NSAP) -Old age Protection
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_12
Pradhan Mantri Kisan Mandhan Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_13
Balsangopan Scheme
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_14
Sukanya Samridhi Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04A_15
Rajiv Gandhi Niradhar Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B
Rural
A04B_1
MNREGA
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_2
PDS
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_3
Jan Dhan Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_4
Atal Pension Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_5
Ujjwala Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_6
E-shram yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_7
Ayushman Bharat Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_8
Mahatma Jyotibai Phule jan Aarogya Yojna
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_9
Pradhan Mantri Jeevan Jyoti Yojana (PMJJBY)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_10
Pradhan Mantri Shram Yogi Maan-Dhan Yojana (PM-SYM)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_11
Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_12
Pradhan Mantri Awaas Yojana – Gramin (PMAY-G)
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_13
National Social Assistance Programme (NSAP) -Old age Protection
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_14
Pradhan Mantri Kisan Mandhan Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_15
Balsangopan Scheme
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_16
Sukanya Samridhi Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
A04B_17
Rajiv Gandhi Niradhar Yojana
Distance from point of service
Denial of Service at POS
POS not operational / closed
Household Economic Status and Vulnerability
B01
What is the main source of income of the household?
Cultivation
Allied Agriculture (Livestock Rearing)
Agricultural Wage Labour
Non-agricultural wage labour/wage work
Artisan/Independent work
Petty shop/small business
Organized trade/business (if >5 employees)
Salaried employee
Retired/Pension
Household work
No income
Others (Specify)
B02
Could you please share with us the total amount that your family is able to save within a year?
B03
Household possess which of the following items?
stove/gas burner
pressure cooker/pressure pan
Television
electric fan
almirah/dressing table
chair, stool, bench, or table
motorcycle, scooter, motor car, or jeep
mobile/laptop/computer
None
B04
When was the last time the household experienced a shock or emergency?
No shocks have ever occurred
More than 10 years ago
5-10 years ago
1-5 years ago (Not COVID19 related)
COVID-19 related
In the last year
Refused to answer
B05
How did household recover from past shock?
Household never recovered
Household is still recovering
Household recovered over time
Household recovered immediately
Refused to answer
B06
How would household recover if same shock occurred today?
Household would never recover
Household would slowly recover
Household would quickly recover
Household would not be affected or would recover immediately
Refused to answer
Water, Sanitation and Shelter
C01
What is the main source of drinking water for members of your household?
Piped water supply system
Hand pump/tube well/bore well
Protected well/spring/surface water
Unprotected well/spring/surface water
Tanker truck/ Cart with Small Tank
Community RO plant
Others (specify)
C02
What is the frequency of drinking water supply for the household?
24/7 water
daily for fixed hours
twice a week
once a week
twice a month
once a month
not applicable
C03
Usually people wash/ clean hand with different materials. With which material your household members usually wash their hands?
Soap or Detergent (Bar, Liquid, Powder, Paste)
Ash, Mud, Sand
Only Water
Others (Specify)
C04
On what occasions do you or your household members wash hands with soap?
Before cooking
Before eating/feeding the child
After cleaning the house
After defecation
After cleaning child faeces
Others (Specify)
C05
How long should one wash one’s hands for with soap?
Less than 20 seconds
20 seconds or more
Don’t know
C06
What do you think are some of the benefits of using soap while washing hands?
No benefits
Kills germs and disease
Keeps family safe
Keeps safe from COVID-19
Good smell
Others (Specify)
C07
What is the type of a latrine/toilet facility used by members of your HH?
No toilet facility/Open defecation
Private toilet connected to piped sewer system
Private toilet connected to septic tank
Private toilet connected to other system
Private Pit toilet or latrine
Public or shared toilet facility
C08
Is there any member in the household who goes for open defecation?
Yes
No
C09
What type of house does the respondent live in?
Kutcha
Semi Pucca
Pucca
C10
What is your current ability to meet your shelter needs?
We have our own house
We live in rented house and usually able to pay rent, but sometimes struggle
We live in rented house and sometimes are able to pay rent, but usually struggle
We do not have any permanent shelter
Food and Nutrition
D01
I would like to ask you about food that you may have had yesterday during day or night (or the day before if yesterday was unusual)
D01_1
Maize, maize porridge, dal and other cereal (rice, sorghum, millet, wheat, etc.), Roots and Tubers (cassava, potatoes, sweet potatoes)
Yes
No
D01_2
Beans and peas, groundnuts, and cashew nuts
Yes
No
D01_3
Vegetables (including relish and leaves)
Yes
No
D01_4
Fruits
Yes
No
D01_5
Goat or other red meat and pork, Poultry and eggs, Fish
Yes
No
D01_6
Sugar or sugar products, honey
Yes
No
D01_7
Oils/fats/butter
Yes
No
D02
Over the past 12 months, what has been the main source of food consumed by your household?
Donated
Given in return for work only
Bought from the market
Home grown
D03
How many meals does the household have in a day?
Some days no meal
One meal
2 meals per day
3 or more meals per day
Health
E01
How far is the nearest health facility?
More than 2 km
Within the range of 2 km
Less than 1 km
Do not know
E02
Does the community face any problems in access to care in these facilities?
Yes
No
Do not know
Refuse to answer
E03
If yes, what kind of problems?
E04
Where do people from the community generally go at the time of any health problems?
Public health facility
Private health facility
E05
Is there any presence of long-term illnesses in the HH?
Yes
No
Do not know
Refuse to answer
E06
If yes, what illnesses?
E07
Have there been deaths due to illness in the Household?
Yes
No
E08
How long ago?
Less than 6 months ago
Over a year ago
Last 2-3 years
Last 5 years
E09
Are there any outreach camps like Immunization camps being organised in your area?
Yes
No
E10
What is the frequency?
Monthly
Once in 3 months
Once in 6 months
E11
Do women and children from your community go to avail services from these outreach camps (immunization)?
Yes
No
E12
What are the reasons?
E13
How is the health of the [child name]?
In the past month, the child has been ill most of the time (chronically ill)
In the past month, the child was often (more than 3 days) too ill for school, work, or play.
In the past month, the child was ill and less active for a few days (1-3 days) but he/she participated in some activities.
In the past month, the child has been healthy and active, with no fever, diarrhoea, or other illnesses.
E14
What was the last time the [child name] was sick?
One month ago
More than 3 months ago
More than 6 months ago
More than a year ago
E15
What happens when a [child name] falls sick?
Child rarely or never receives the necessary health care services
Child only sometimes or inconsistently receives needed health care services (treatment or preventive)
Child received medical treatment when ill, but some health care services (e.g., immunizations) are not received.
Child has received all or almost all necessary health care treatment and preventive services
E16
Does [child name] visit the healthcare facility?
Yes
No
E17
Did [child name] miss school, work or play because of illness?
Yes
No
E18
How long?
2-3 days
One week
More than one week
E19
Has the [child name] been immunized to prevent illness?
Yes
No
E20
During the pregnancy, did you/mother of child receive any Ante-natal care services?
Yes
No
E21
Who provided you/mother of child with (ANC) services?
Doctor
ASHA
ANM
AWW
Others (Specify)
Don’t know
E22
Did you/mother of child receive IFA tablets during your last pregnancy?
Yes
No
E23
How many tablets did you/mother of child consume?
180 tablets or more
Less than 180 tablets
Don’t Remember/Can’t Say
E24
Where did you/mother of child deliver the baby?
Home
Government Hospital
Private Hospital
Community Health Centre
Primary Health centre
Village clinic by ANM
NGO/Trust Hosp
Others (Specify)
Don’t know
E25
Why did you/mother of the child do not deliver at a health facility?
Delivering at home seemed like it would be more comfortable
It was too inconvenient to go to the facility when the time arrived
Family convinced me not to go to the facility
I could not afford the costs of delivering at a facility, such as transport costs
There was no transportation facility available till the facility
The baby came before we could get to the facility
Facilities did not open due to lockdown
Facility refused service due to lockdown
Others (Specify)
Don’t know
Child Risk Profile
F01
What is the status of AWC/school enrolment? [Name]
Currently Enrolled
Completed
Dropped out
Never enrolled in school
F02
Why did [Name] drop out of school/college?
Failed
School/college far/inaccessible
Poor quality/lack of facilities
Financial problems
Health problems
Not interested in school
Household work/childcare
Work for pay
Gender/puberty
Lack of separate school/college for girls
Marriage
Parents/husband did not allow studying further
Getting teased/bullied at school
Migration
Others (Specify)
F03
Level of Education [Name]
Anganwadi/Pres-school
Primary (1st to 4th class)
Middle (5th to 8th class)
Secondary (9th to 12th)
Diploma
Don’t Know
Refuse to answer
Others (Specify)
F04
What gains do you observe for [Name] from going to school?
Academic support
Mid-day meal
Supervision and safety
Peer interaction
Other
F05
What are issues faced by [Name] in school?
Failure in the class last studied
Lack of interest in the school activities
Indifferent attitude of the teachers
No teachers in the classroom
Low classroom capacity
Poor infrastructure
Lack of separate toilets for girls and boys
Bullying in school
Long commute to school
Abuse or ill-treatment in school
Corporal punishment
Medium of instruction
Others
F06
In a given week, how regularly is [Name] attending the school?
Daily
3-4 days per week
1-2 days per week
1-2 days in two weeks
1-2 days in a month
Others (specify)
F07
Have you or your family received any support for your [child name]’s education?
Yes
No
F08
From whom did you receive support?
Government
NGO
Community
Relatives
Others (Specify)
F09
Have [child name] received training/support on the following?
Vocational Skills Training
Technical Skills Training
Life Skills Training
Digital Literacy Training
Financial Literacy Training
Sexual and Reproductive
Health Training
Career counselling
Placement/employment Support
None
F10
Has [child name] received benefit of/access to any of the following skill development schemes?
Pradhan Mantri Kaushal Vikas Yojana (PMKVY)
National Skill Development Mission (NSDM)
Skill India Mission
Deen Dayal Upadhyaya Grameen Kaushalya Yojana (DDU-GKY)
National Apprenticeship Promotion Scheme (NAPS)
None
Other (Specify)
F11
What is/was the key reason for you to participate in any of the training mentioned?
Was interested in a particular course/skill set
Training would be beneficial to get employment
Training would help to increase income
Was unemployed and wanted to utilize my time
Participated because my friends/family were also participating
Participated as suggested by friends/family
Participated as suggested by teachers
Participated in anticipation of stipend for undergoing the training
Wanted to start my own business/work
Others (Specify)
F12
Have you ever enrolled in an apprenticeship?
Never Enrolled
Ongoing
Completed
Dropped out
F13
What was the key reason for never enrolling/ dropping out of the apprenticeship?
Failed
School/college far/inaccessible
Poor quality of education
Poor infrastructure and facilities
Financial problems
Health problems
Not interested in school
Household work or taking care of siblings and family members
Work for pay
Puberty
Lack of separate school/college for girls
Marriage
Parents/husband did not allow studying further
Getting teased/bullied at school
Others (Specify)
F14
Is [child name] currently employed or working?
Yes
No
F15
Where does [child name] carry out his/her main work?
At own family dwelling
Client`s place
Formal office
Factory / Atelier
Plantations / farm / garden
Construction sites
Mines / quarry
Shop / kiosk / coffee house / restaurant / hotel
Different places (mobile)
Fixed, street or market stall
Pond/lake/river
Others (Specify)
F16
Why [child name] is not employed/working?
Could not find any employment
Could not find a job in their preferred job role
Could not find a job with minimum salary expectation
Interested in further education
Looking to start own business
Family not allowing to work
Not interested to work
Health issues
Family commitments
Unwilling to migrate to other location for job
Currently studying
Preparing for preferred job/ government job
Others (Specify)
Child Vulnerability
G01
Are there any instances of drug addiction within your village, ward, or local community?
Yes
No
G01A
Please tell us more about it.
G02
Has any member of your family or any children in your household been affected by drug addiction?
Yes
No
G02A
Please tell us more about it.
G03
Are there any instances of alcohol addiction within your village, ward, or local community?
Yes
No
G03A
Please tell us more about it.
G04
Has any member of your family or any children in your household been affected by alcohol addiction?
Yes
No
G04A
Please tell us more about it.
G05
Are there any instances of discrimination within your village, ward, or local community?
Yes
No
G05A
Please tell us more about it.
G06
Has any member of your family or any children in your household been affected by discrimination()?
Yes
No
G06A
Please tell us more about it.
G07
Are there any instances of harassment() within your village, ward, or local community?
Yes
No
G07A
Please tell us more about it.
G08
Has any member of your family or any children in your household been affected by harassment?
Yes
No
G08A
Please tell us more about it.
G09
Are there any instances of domestic violence within your village, ward, or local community?
Yes
No
G09A
Please tell us more about it.
G10
Has any member of your family or any children in your household been affected by domestic violence?
Yes
No
G10A
Please tell us more about it.
G11
Do you know any children in your locality or family who has experienced inadequate care or support from a parents/caregiver?
Yes
No
G11A
Please tell us more about it.
G12
Has children in your family or someone you know encountered instances of emotional mistreatment or persistent psychological harassment?
Yes
No
G12A
Please tell us more about it.
G13
Has any children of your family faced physical punishment or discipline within the school environment?
Yes
No
G13A
Please tell us more about it.
G14
Has someone in your locality or any children from your family been subjected to physical harm or abuse?
Yes
No
G14A
Please tell us more about it.
G15
Has someone in your locality experienced any form of sexual abuse, which involves non-consensual or exploitative actions in past?
Yes
No
G15A
Please tell us more about it.
G16
Has someone in your locality have been exploited through commercial sexual activities or involved in human trafficking?
Yes
No
G16A
Please tell us more about it.
G17
If you want to discipline your child, which of the following approaches seem most suitable?
Talking to the child
Scolding the child
Corporal Punishment
Asking community members to intervene
Others (specify)
G18
In the past three months, have you or another caregiver used the following method of discipline with any child in your house?
Punched, kicked, or hit a child with any object
Withheld a meal to punish a child
Used abusive words/language toward the Child
None of the Above
Other
Child Protection System
H01
Have there been any workshops/sessions in your region where you were told about how to keep your child safe?
Yes
No
H02
Do you know of any committees in your region that address matters of harm/maltreatment faced by children?
Yes
No
H03
Are you aware of bodies called CPCs, CWCs, and CCIs?
Yes
No
H04
How did you learn about them?
Awareness workshops/sessions in the region by NGO/social workers
Word of mouth
Through Panchayat or ULB members
Through CPC members
Others (Specify)
H05
What do you think they do?
H06
Is there a CPC in your village/Gram Panchayat?
Yes
No
H07
If you see a child being abused/neglected/treated poorly, would you seek assistance/help for redressal?
Yes
No
H08
Whom would you reach out to in such a case?
Parent/Guardian
Panchayat/ULB Members
Local Police
CPC
Child Helpline
Others
Don’t know
H09
Have you ever filed a complaint in such a situation previously?
Yes
No
H10
If yes, where?
H11
Was the case addressed?
Yes
No
H12
If someone in the region is experiencing abuse/neglect/maltreatment, what are factors you think that might discourage them/their family from reporting the case to the concerned authorities?
Social stigma and shame
Lack of awareness about authorities that can be approached
Lack of faith in authorities
Fear of exclusion/violence from community
Lack of awareness about what constitutes as abuse/maltreatment
Others (Specify)
H13
Would you be open to fostering a child in distress?
Yes
No
H14
What are the motivation to foster a child?
H15
What is the cause of hesitance to foster a child?
Limited financial resources
Limited space in the house
Additional responsibility
Possible conflict within household
Fear of compatibility
Others (Specify)
H16
What kind of support would be required to foster a child?
Training
Sensitisation and counselling
Financial Support
H17
If your child require support, in what form will you seek it?
Counselling by Social Worker
Counselling by Psychologist
School staff/teacher
Community-based support group
Others (specify)
H18
Do feel comfortable discussing issues concerning your child with members outside your family?
Yes
No
H19
Whom do you seek out in the community for support?
Neighbour
Friends
Relatives
Community elders
None of the above
Others (specify)
H20
What kind of support you have sought previously?
H21
What would you do if any of your children experienced or became a victim of child abuse or violence?
Nothing/negotiate with offender
Talk to neighbor
Talk to relatives
Reach out to community for help
Report to /Police/Probation, court, Child Protection Committee, CDO, Human rights office, CSO, para social worker and VHT
H22
Maya, a 13-year-old girl, resides in a rural village and comes from a marginalized community and lives with her single mother, who works long hours to support the family. Maya's father passed away when she was very young, leaving her vulnerable to various risks. Maya's mother works as a daily wage labourer where contractor is asking maya to drop out from school and join her mother as daily wage labourer to pay off her father’s debt. What should maya do?
Comply with the demand and work as wage labourer
Ask support form family/relatives
Report to CPC/local police/school authority
Don’t know
H23
Is any children of of your family currently participating in a peer-support group?
Yes, I am currently participating
No, but I have participated in the past
No, I am aware of peer support group but have never participated
I am not aware about any peer support group in our locality
H24
How frequently do they attend peer-support group meetings?
Once a week or more
Once a month or more
Less than once a month
Never
H25
Do you think peer-support groups have been helpful for your children??
Yes, very helpful
Somewhat helpful
Not very helpful
Not at all helpful
I have not participated in a peer-support group
Psychosocial Support
I01
Do you feel [child name] is withdrawn or consistently sad, unhappy or depressed, not able to participate in daily activities including playing with friends and family?
Yes
No
I02
Do you worry about the [child name]’s sadness?
Yes
No
I03
If yes, what do you do to support the [child name]?
I04
Do you worry the [child name] might hurt himself/herself?
Yes
No
I05
Do you worry the [child name] might hurt others?
Yes
No
I06
Do you think [child name] is obedient?
Yes
No
I07
Does this child need to be punished often?
Yes
No
I08
Does the [child name] play with other children or have close friends?
Yes
No
I09
Does [child name] enjoy being with other children?
Child has behavioural problems frequently does not interact well with peers, guardians, or others at home or school
Child has minor problems getting along with others and argues or gets into fights sometimes
Child sometimes likes to play with peers and participates in group or family activities
Child always like to play with peers and participates in group or family activities.
I10
Does [child name] fight with other children?
Never
Rarely
Sometimes
Most of the times
Always
Don’t Know
Refuse to answer
I11
Have you/any children/any member of your family ever attended a counselling session?
Yes
No
I12
How often do you/children/ your family members attend counselling sessions?
Once a week
Once every two weeks
Once a month
Less than once a month
I13
How satisfied are you or your family members with the counselling sessions?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
I14
Have you heard of the term "positive parenting" before?
Yes
No
I15
On a scale of 1-5, how much do you agree with the statement "Positive parenting involves nurturing and encouraging children's positive behavior and emotional development"?
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I16
Which of the following strategies do you think are important for positive parenting?
Active listening
Praise and rewards
Time-outs
Logical consequences
Physical punishment
I17
How important do you think it is for parents to set appropriate boundaries for their children?
Not important at all
Slightly important
Moderately important
Very important
Extremely important
I18
In your opinion, what are some of the benefits of positive parenting?
Improved behaviour in children
Better communication between parent and child
Enhanced emotional development in children
Stronger parent-child relationship
Reduced stress and conflict in the household
None
I19
Have you attended any session on positive parenting?
Yes
No
Case History of Institutionalization or Alternative Family Care
J01
Why is the [child name] not living in the household?
Child went to work
Child went for a job
Child went for education
Child ran away
Child was chased away
Child did not like staying in this house
Child is living with relative because family cannot support him
Do not know
Refuse to answer
J02
Where is the [child name] living at present?
Family home
Ashram School
Kinship Care
Adoption
Foster Care
Small Group Home
In different institution
Others (Specify)
Refuse to answer
J03
What are the reasons for [child name] to leave the family (multiple selection possible)
Experience of physical, emotional, or sexual abuse by parent(s), guardian(s), or stepparent(s)
Engagement in child labor or being forced to work
Exposure to negative peer pressure or peer influence
Parental incapacity or disability that affects the child's well-being
Parental involvement in criminal activities
Experience of parental separation or divorce
Loss of a parent or caregiver due to death
Financial hardships or poverty that affect the child's well-being
Other (specify)
J04
Has the [child name] received institutional care or case management services in the past?
Yes
No
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