Surveypoint

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

Q11A

Name of Respondent

Q11B

Relation of respondent to 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

Q12

Postal Address

Q13

List the landmark to identify the household

A01

Please tell us the name of head of the household?

A02

What is the gender of the head of the household?

Male

Female

Transgender

Prefer not to say.

Other

A03

What is the age of the head of the household (in completed years)?

A04

What is the educational status of the head of the household?

No education

Anganwadi/Preschool

Primary (1st to 4th class)

Middle (5th to 8th class)

Secondary (9th to 12th)

Diploma

Graduate and above

A05

What is the current marital status of the head of the household?

Unmarried

Married

Widowed

Separated / Divorced

Refuse to answer

A06

What is the occupational status of head of the household?

No work

Unfit to work.

Student

Daily wage earner

Salaried employee

Farmer

A06A

Please select appropriate options from the choices given below if chosen 4 in A06

Daily wage earner with irregular pattern, daily wage below Rs. 150

Daily wage earner with regular pattern, daily wage below Rs. 150

Daily wage with irregular employment, daily wage up to Rs. 150-500

Daily wage with regular employment, daily wage up to Rs. 150-500

Regular employment with daily wages more than Rs 500

A06B

Please select your monthly income from the choices given below: ask if chosen 5 in A06

No income

Up to 5000

5000-10000

10000 -25000

25000-50000

50000-60000

60000-75000

75000-100000

100000 and above

A06C

Please select your annual income from the choices given below:ask if chosen 6 in A06

No income

Up to 60,000

60000-120,000

120,000 – 300,000

300,000 – 600,00

600,000 – 720,000

720,000 – 900,00

900,00 – 1,200,000

1,200,000 and above

B01

Please tell us the number of people who usually reside in your house.

Eight or more

Seven

Six

Five

Four

Three

Two

One

B02

How many earning members are there in the household?

Eight or more

Seven

Six

Five

Four

Three

Two

One

B03

What is the annual income of the of the household?

No income

0 to 10000

10000 to 25000

25000 to 60000

60000 to 200000

200000 to 500000

500000 and more

B04

Could you please share with us the total amount that your family is able to save within a year?

No savings

0 to 5000

5000 to 10000

10000 to 50000

50000 to 100000

100000 and more

B05

What is your social category?

General

OBC

SC

ST

Other

Don’t know

Refused to answer

B06

What is your religion?

Hindu

Muslim

Sikh

Christian

Buddhist

Other

Don’t know

Refused to answer

C01

Please tell us number of children (below 18 years) in your household

C02

Name of the child

C03

Gender [child name]

Male

Female

Prefer not to say.

Others

C04

Age [child name]

C05

What is the status of enrolment [child name]?

Currently Enrolled

Completed

Dropped out

Never enrolled in school

C06

Education status of [child name]

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)

C07

Marital status of [child name]

Unmarried

Married

Widowed

Separated / Divorced

Don’t know

Refuse to answer

C08

Employment status of [child name]

Not Working

Working

Don’t know.

Refuse to answer

C09

Type of work performed by [child name]

Helping family business

Non-hazardous work

Hazardous work

Don’t know

Refuse to answer

C10

[child name] is living in/with

Both parents

Mother

Father

Away from family

Others(specify)

C11

Where is the [child name] living at present?

Family home

Ashram School

Kinship Care (relatives/extended family member/close family friend)

Adoption

Foster Care

Small Group Home

Living with in-laws/spouse

Living independently

Others, Please Specify

C12

What are the reasons for [child name] to leave the family (multiple selection possible)

Working someplace else/Employed someplace else.

Ran away.

Exposure to negative peer pressure or peer influence

Parental incapacity or disability that affects the child's well-being.

Parental involvement in criminal activities.

Children in conflict with law.

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.

Went to live with in-laws/Spouse.

Don’t Know.

Other (specify)

C13

Has the [child name] ever received support or assistance from residential care facilities or institutions

Yes

No

C14

Has the [child name] ever received case management services from professionals or organizations?

Yes

No

C15

Do you feel [child name] is consistently sad or unhappy, which makes it difficult for them to participate in daily activities (such as playing with friends and family)?

C15A

“Child who is consistently sad or unhappy shows any of the following signs

C15A_1

Mood changes

Yes

No

C15A_2

Withdrawn from interaction with friends and family.

Yes

No

C15A_3

Loss of interest in daily activities

Yes

No

C15A_4

Performing badly in school

Yes

No

C15A_5

Change in sleeping pattern/time

Yes

No

C15A_6

Changes in appetite/eating habits

Yes

No

C15A_7

Crying frequently

Yes

No

C15A_8

Low on energy”

Yes

No

C16

Does [child name] have any physical or mental handicap?

C16_1

Blindness

Yes

No

C16_2

Low vision

Yes

No

C16_3

Leprosy cured persons

Yes

No

C16_4

Hearing impairment (deaf and hard of hearing)

Yes

No

C16_5

Locomotor disability (including cerebral palsy, dwarfism, and muscular dystrophy)

Yes

No

C16_6

Intellectual disability (including Down syndrome)

Yes

No

C16_7

Mental illness

Yes

No

C17

Does [child name] have access to Anganwadi/School in the neighbourhood?

Yes

No

C18

Does [child name] regularly (at least 3 days/week) attend the Anganwadi/School ?

Yes

No

C19

What is your current ability to meet your child/children’s educational needs?

We struggle to pay for education

We usually struggle to pay for education

We sometimes struggle to pay for education

We never struggle to pay for education

C20

Has the [child name] participated in any skill development programs or vocational training in the past year?

Yes

No

D01

Has your household experienced any significant financial emergencies or shocks, such as sudden loss of income, unexpected expenses, or economic hardships due to natural disasters or other unforeseen events, in the past?

We were not affected by any shocks.

No shocks have ever occurred.

More than 10 years ago

5-10 years ago

1-5 years ago (Not COVID19 related)

COVID19 related.

In the last year

Refused to answer

D02

Has the household recovered from those shocks?

Household never recovered.

Household is still recovering.

Household recovered over time.

Household recovered immediately.

Refused to answer

D03

How would household recover if some shock of similar kind 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

D04

Which of the following document is held by head of the household?

Aadhar Card

PAN Card

Ration Card

Bank Account/ Post Office Savings Account

None

E01

In the last month (30 days), did a household member have to go hungry because there was no food at home?

Yes

No

E02

Can you tell me how often this happened (in a month)?S

Rarely (1-2 times)

Sometimes (3-10 times)

Often (more than 10 times)

E03

What is your family’s current ability to meet your food needs?

We have trouble arranging food

We mostly struggle in arranging food

We sometimes struggle in arranging food

We never struggle in arranging food

F01

What type of house does the respondent live in?

Kutcha

Semi pucca

Pucca

F02

Can you indicate which of the toilet facilities listed below you currently possess or have access to?

No toilet facility/Open defecation

Private toilet or latrine

Public or shared toilet facility

F03

What is your main source of cooking energy?

Sources which emit smoke (Paraffin/Coal/Wood/Dung)

Sources which do not emit smoke (LPG /Electricity)

None

Other (Specify)

F04

What is the main source of drinking water for the 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

Other (specify)

F05

Does the household possess any of the following? (Multiple selections possible)

Refrigerator

Stove/Gas Burner

Pressure Cooker/Pressure Pan

Television

Electric Fan

Almirah/Dressing Table

Chair/Stool/Bench/Table

Motorcycle/Scooter/Motor Car/Jeep

Mobile/Smartphone/Telephone

None

F06

Do you own this house, or do you pay rent?

We have our own house.

We live in a rented house and sometimes struggle to pay rent.

We live in a rented house and usually struggle to pay rent.

We live in a rented house and do not struggle to pay rent.

We do not have any shelter.

We are living in a relative’s house

G01

Do the children and mothers in your household have access to supplementary nutrition? This is to understand the status of nutrition in the household (Supplementary nutrition means food that is added to the child or mother’s diet to make sure they get all the nutrients they need)

Yes

No

G01A

From where do you get most of your supplementary nutrition ?

Through the Anganwadi or Integrated Child Development Services (ICDS) program

Through a school meal program like the Mid-Day Meal Scheme

Through a community kitchen or food bank

Through a government-run nutrition program other than Anganwadi or ICDS

Through a non-governmental organization (NGO) or charitable organization

Through personal purchase or other means

Other (Specify)

G02

Do the children and adults in your household have access to immunisation?

Yes

No

G02A

From where do you access immunisation?

Through government centres/programmes

Through private centres

Through a non-governmental organization (NGO) or charitable organization

Other (specify)

G03

Does your household have access to health check-up?

Yes

No

G03A

From where do you access health check-ups?

Through government centres/programmes

Through private centres

Through a non-governmental organization (NGO) or charitable organization

Other (specify)

G04

What is your current ability to meet your healthcare expenditure?

We struggle to pay for our healthcare expenses

We usually struggle to pay our healthcare expenses

We sometimes struggle to pay our healthcare expenses

We do not struggle to pay for our healthcare expenses

Rapid_Vulnerability_Mapping -Form Fill

Interviewer name

Interviewer code

Date of the interview

District Name

District Code

Block Name

Block Code

Type of Area

Ward Name

Gram Panchayat Name

Village Name

Name of Respondent

Relation of respondent to Head of Household

Postal Address

List the landmark to identify the household

Please tell us the name of head of the household?

What is the gender of the head of the household?

What is the age of the head of the household (in completed years)?

What is the educational status of the head of the household?

What is the current marital status of the head of the household?

What is the occupational status of head of the household?

Please select appropriate options from the choices given below if chosen 4 in A06

Please select your monthly income from the choices given below: ask if chosen 5 in A06

Please select your annual income from the choices given below:ask if chosen 6 in A06

Please tell us the number of people who usually reside in your house.

How many earning members are there in the household?

What is the annual income of the of the household?

Could you please share with us the total amount that your family is able to save within a year?

What is your social category?

What is your religion?

Please tell us number of children (below 18 years) in your household

Name of the child

Gender [child name]

Age [child name]

What is the status of enrolment [child name]?

Education status of [child name]

Marital status of [child name]

Employment status of [child name]

Type of work performed by [child name]

[child name] is living in/with

Where is the [child name] living at present?

What are the reasons for [child name] to leave the family (multiple selection possible)

Has the [child name] ever received support or assistance from residential care facilities or institutions

Has the [child name] ever received case management services from professionals or organizations?

Do you feel [child name] is consistently sad or unhappy, which makes it difficult for them to participate in daily activities (such as playing with friends and family)? var statement=document.write(localStorage.getItem('total'));

“Child who is consistently sad or unhappy shows any of the following signs var statement=document.write(localStorage.getItem('total'));

Mood changes

Withdrawn from interaction with friends and family.

Loss of interest in daily activities

Performing badly in school

Change in sleeping pattern/time

Changes in appetite/eating habits

Crying frequently

Low on energy”

Does [child name] have any physical or mental handicap? var statement=document.write(localStorage.getItem('total'));

Blindness

Low vision

Leprosy cured persons

Hearing impairment (deaf and hard of hearing)

Locomotor disability (including cerebral palsy, dwarfism, and muscular dystrophy)

Intellectual disability (including Down syndrome)

Mental illness

Does [child name] have access to Anganwadi/School in the neighbourhood?

Does [child name] regularly (at least 3 days/week) attend the Anganwadi/School ?

What is your current ability to meet your child/children’s educational needs?

Has the [child name] participated in any skill development programs or vocational training in the past year?

Has your household experienced any significant financial emergencies or shocks, such as sudden loss of income, unexpected expenses, or economic hardships due to natural disasters or other unforeseen events, in the past?

Has the household recovered from those shocks?

How would household recover if some shock of similar kind occurred today?

Which of the following document is held by head of the household?

In the last month (30 days), did a household member have to go hungry because there was no food at home?

Can you tell me how often this happened (in a month)?S

What is your family’s current ability to meet your food needs?

What type of house does the respondent live in?

Can you indicate which of the toilet facilities listed below you currently possess or have access to?

What is your main source of cooking energy?

What is the main source of drinking water for the household?

Does the household possess any of the following? (Multiple selections possible)

Do you own this house, or do you pay rent?

Do you feel [child name] is consistently sad or unhappy, which makes it difficult for them to participate in daily activities (such as playing with friends and family)?

“Child who is consistently sad or unhappy shows any of the following signs

Does [child name] have any physical or mental handicap?