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Household Template 6 -Form Fill
Q1
Activities performed by men or women members of the household.- Fetching water
Male
Female
Jointly
Children
None
Q2
Activities performed by men or women members of the household. - Grazing animals
Male
Female
Jointly
Children
None
Q3
Activities performed by men or women members of the household. - Milking animals
Male
Female
Jointly
Children
None
Q4
Activities performed by men or women members of the household.- Market purchase
Male
Female
Jointly
Children
None
Q5
Activities performed by men or women members of the household.- Paying electricity bills
Male
Female
Jointly
Children
None
Q6
Activities performed by men or women members of the household.- Attending community meeting
Male
Female
Jointly
Children
None
Q7
Activities performed by men or women members of the household.-Taking ill family member to the hospital
Male
Female
Jointly
Children
None
Q8
Who in the family decides/ has responsibility for the following : (Encircle the option)- Girl Children are send to school
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q9
Who in the family decides/ has responsibility for the following : (Encircle the option)- Male children are send to school
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q10
Who in the family decides/ has responsibility for the following : (Encircle the option)- Marriage of the girl children
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q11
Who in the family decides/ has responsibility for the following : (Encircle the option)- Marriage of the male children
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q12
Who in the family decides/ has responsibility for the following : (Encircle the option)- Expenditure on health
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q13
Who in the family decides/ has responsibility for the following : (Encircle the option)- Expenditure on health
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q14
Who in the family decides/ has responsibility for the following : (Encircle the option)- Decision to take loan for household consumption & production needs
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q15
Who in the family decides/ has responsibility for the following : (Encircle the option)- Who actually approaches moneylender or bank or any other source for the loan?
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q16
Who in the family decides/ has responsibility for the following : (Encircle the option)- Who is responsible for repayment of the loan?
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q17
Who in the family decides/ has responsibility for the following : (Encircle the option)- Adoption of HYV
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q18
Who in the family decides/ has responsibility for the following : (Encircle the option)- Use of fertilizer
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q19
Who in the family decides/ has responsibility for the following : (Encircle the option)- Use of Plant protection Measures
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q20
Who in the family decides/ has responsibility for the following : (Encircle the option)- Purchase of farm machinery
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q21
Who in the family decides/ has responsibility for the following : (Encircle the option)- Purchase and sale of animals
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q22
Who in the family decides/ has responsibility for the following : (Encircle the option)- Changing of crops
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q23
Who in the family decides/ has responsibility for the following : (Encircle the option)- Marketing of produce
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q24
Who in the family decides/ has responsibility for the following : (Encircle the option)- Investment of added profit
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q25
Who in the family decides/ has responsibility for the following : (Encircle the option)- Whether to use any of the contraceptive methods
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q26
Who in the family decides/ has responsibility for the following : (Encircle the option)- Number of children you should have
NA
Elders of the family
Husband
Woman herself
Woman and husband together
Family decides collectively
Other (Specify)
Q27
Does your household own this house or any other house?
Yes
No
Q28
Type of House
Houseless
Pucca
Semi Pucca
Kuccha
Q29
What is the main source of drinking water for members of your household?
Piped water in residence/yard/plot
Hand pump in residence/yard/plot
Well water in residence/yard/plot
Public hand pump
Public tap
Public well
Bore well
Canal
Other source (specify)
Q30
What kind of toilet facility does your household have?
Open Defaction
Group latrine with irregular water supply
Group latrine with regular water supply
Clean Group latrine with regular water supply and regular sweeper
Own flush toilet
Own pit toilet
Q31
What is the main source of lighting for your household
Electricity
Kerosene lamp
Gas lamp
Candle
Solar energy
Other (specify)
Q32
What type of fuel does your household commonly use for cooking?
Wood
Crop residues
Dung cakes
Coal/ charcoal
Kerosene
Electricity
Liquid petroleum gas
Bio-gas
Other (specify)
Q33
Does your household own any of the following items: (Items are to be in working condition)-Electric connection
Yes
No
Q34
Does your household own any of the following items: (Items are to be in working condition-Pressure cooker
Yes
No
Q35
Does your household own any of the following items: (Items are to be in working condition)-Mixer/grinder
Yes
No
Q36
Does your household own any of the following items: (Items are to be in working condition)-Motorcycle/scooter
Yes
No
Q37
Does your household own any of the following items: (Items are to be in working condition)-Car/Jeep
Yes
No
Q38
Does your household own any of the following items: (Items are to be in working condition)-Tractor
Yes
No
Q39
Does your household own any of the following items: (Items are to be in working condition)-Bicycle
Yes
No
Q40
Does your household own any of the following items: (Items are to be in working condition)-Animal-drawn cart
Yes
No
Q41
Does your household own any of the following items: (Items are to be in working condition)-Chair
Yes
No
Q42
Does your household own any of the following items: (Items are to be in working condition)-Table
Yes
No
Q43
Does your household own any of the following items: (Items are to be in working condition)-Cot/ Bed
Yes
No
Q44
Does your household own any of the following items: (Items are to be in working condition)-Mattress
Yes
No
Q45
Does your household own any of the following items: (Items are to be in working condition)-Clock or watch
Yes
No
Q46
Does your household own any of the following items: (Items are to be in working condition)?-Electric fan
Yes
No
Q47
Does your household own any of the following items: (Items are to be in working condition)-Water pump
Yes
No
Q48
Does your household own any of the following items: (Items are to be in working condition)-Thresher
Yes
No
Q49
Does your household own any of the following items: (Items are to be in working condition)-Radio/Transistor
Yes
No
Q50
Does your household own any of the following items: (Items are to be in working condition)-Sewing machine
Yes
No
Q51
Does your household own any of the following items: (Items are to be in working condition)-Refrigerator
Yes
No
Q52
Does your household own any of the following items: (Items are to be in working condition)-B & W television
Yes
No
Q53
Does your household own any of the following items: (Items are to be in working condition)-Colour television
Yes
No
Q54
Does your household own any of the following items: (Items are to be in working condition)-CD player
Yes
No
Q55
Does your household own any of the following items: (Items are to be in working condition)-Telephone
Yes
No
Q56
Does your household own any of the following items: (Items are to be in working condition)-Computer
Yes
No
Q57
Does your household own any of the following items: (Items are to be in working condition)-Cell Phone
Yes
No
Q58
Does your household own any of the following items: (Items are to be in working condition)-Power Tiller
Yes
No
Q59
Does your household own livestock?
Yes
No
Q60
What all does livestock include-Bullocks
Yes
No
Q61
What all does livestock include:-Cow
Yes
No
Q62
What all does livestock include:-Buffalo
Yes
No
Q63
What all does livestock include:-Goats/Lambs
Yes
No
Q64
What all does livestock include:-Poultry
Yes
No
Q65
What all does livestock include-Other (Specify)
Yes
No
Q66
Do you have a ration card?
Yes
No
Q67
What is the colour of your card (observe the color and mark on the options provided)?
White
Red
Yellow
Q68
Have you got a NREGA card?
Yes
No
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