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Women Empowerment Template -Form Fill
Interview Details
Q01
GPS Coordinates
Q02
State / Union Territory
Uttar Pradesh
Telangana
Q03
District Name
Q04
Mandal/Block Name
Q05
GP Name
Q06
Village name
Q07
Project code
Q08
Name of Implementing Agency
Q09
Interviewer code
Q10
Interviewer Name
Q11
Supervisor Name
Q12
Date of Interview
Q13
Interview Start Time
Q14
Interview End Time
Respondent profile
A01
Name of the respondent
A02
Respondent’s phone number
A03
What is your age? (in completed years)
A04
How many members are there in your household?
A05
What is the highest level of education that you have completed?
No formal education
Has attended primary school (up to grade 6)
Has attended up to grade 10
Matriculate (10th pass)
Passed school (10+2)
Graduate
Postgraduate
ITI/ Diploma/ similar vocational course
Others (Specify)
A06
Which ID is used to verify the identity of the respondent?
Aadhar Card
Ration Card
Others (Specify)
A07
Please specify which card you have.
Above Poverty Line (APL)
Below Poverty Line (BPL)
Antyodaya Anna Yojana (AAY)
Don’t know/can’t say
A08
What is your social category?
Scheduled caste (SC)
Scheduled tribe (ST)
Backward caste (BC)
Minority (Muslim, Christian, Jain etc.)
General caste
Others
A09
What is your household’s main source of income?
Farming (on own land)
Farming on leased or rented-in land
Wage or salaried work (agricultural)
Wage or salaried work (non-agricultural)
Agri-business
Non-agri-business
Others (Specify)
A10
What is your annual income range?
Less than 50,000
50,000-100,000
100,000 -200,000
200,000 – 350,000
350,000 – 500,000
More than 500, 000
Don’t want to share
A11
Which state/UT were you born in?
A12
Where did you live before you moved here?
A13
How long have you been living in your current Village/Town/City of residence?
0 for less than 1 year
0-4 years
5 years or more
Livelihood, Income and Asset Ownership
B01
Aside from your own housework, have you worked in the last 12 months?
Yes
No
B02
Have you been involved in any job or business in the last 12 months?
Yes
No
B03
What is your occupation? (Probe- what kind of work do you mainly do)
Agricultural labour
Manufacturing / Factory Labour
Domestic labour
Daily wage labour
Self Employed
B04
Do you do this work for a member of your family, for someone else, or are you self-employed?
Family
Self
Others
B05
Do you work throughout the year, or do you work seasonally, or only on temporary basis?
Throughout the year
Seasonally
Temporarily
B06
Are you paid in cash or kind for this work, or are you not paid at all?
Cash
Kind
Not paid
B07
What is your monthly Income?
Less than Rs 2000
Rs. 2000 – Rs. 3000
Rs. 3000 – Rs. 4000
Rs. 4000 – Rs. 5000
More than Rs. 5000
B08
Do you own the house you live in or any other house either alone or jointly with someone else?
Yes
No
B09
Do you own any agricultural or non-agricultural land either alone or jointly with someone else?
Yes
No
B10
Do you own any livestock?
Yes
No
B11
What type of livestock do you own?
Cattle
Goats
Pigs
Other (specify)
B12
Do you access credit?
Yes
No
B13
Have you taken any loan in the past 12 months?
Yes
No
B14
If yes, what is the source of that loan?
Microfinance Institutions
Self Help Groups
Cooperative Banks
Friends/families
Others (Specify)
B15
What was kept as collateral for that loan?
Land
Jewellery
Vehicles
Collateral free loan
Others (Specify)
B16
What was the purpose of the loan?
Agricultural Investments
Setting up entrepreneurial venture
Education
Healthcare
Asset Acquisition
Wedding
Emergency needs
Others (Specify)
B17
Are you a member of any Self-Help group (SHG)?
Yes
No
B18
Do you have an account in a bank or other financial institution that you yourself use?
Yes
No
B19
Did you yourself put money in or take money out of this account in the last 12 months?
Yes
No
Access to Basic Amenities
C01
Do you have access to a toilet?
Yes
No
C02
What kind of toilet do you have access to?
Private, within the vicinity of your home
Semi-private/ Shared Toilet
Community Toilet
C03
Does your house have electricity connection?
Yes
No
C04
What is the average duration of electricity supply?
0-8 Hours
8-16 Hours
16- 24 Hours
24 Hours
C05
What is the main source of drinking water for members of your household?
Tap
Well
Hand Pump
Bottled / Tanker
Tubewell / Borewell
Surface water
Others (Specify)
C06
How far is the nearest source of safe drinking water from your household?
Within 100 meters
100-500 meters
More than 500 meters
Don’t know
C07
What type of health facility did you visit most recently for yourself
Govt/municipal hospital
Govt. Dispensary
UHC/UHP/UFWC
CHC/rural hospital/block PHC
PHC/additional PHC /FHC
Ayush
Anganwadi/ICDS Centre
Asha
Govt. Mobile clinic
Ngo or trust hospital/clinic
Private Hospital
Private Doctor/clinic
Private Paramedic
Traditional healer
Pharmacy/drugstore
Dai (trained birth attendant)
Home Treatment
Others (Specify)
C08
Why do you visit the doctor, usually?
Regular check-ups
Illness
Vaccinations
Others
C09
How much is your monthly household healthcare expenditure?
Rs. 0 - 1000
Rs. 1000 – 3000
Rs. 3000 – 5000
More than Rs. 5000
C10
Do you face any challenges in accessing healthcare services?
Yes
No
C11
Are you covered by any health scheme or any health insurance?
Yes
No
C12
If, what kind of insurance cover do you have?
PMJJBY
PMSBY
LIC
Others (Specify)
C13
How many times did you comes fruits and vegetables in the past week?
Everyday
At least once in two days
At least once in 3 days
Did not consume
C14
If you are a non- vegetarian (inclusive of eggs), how many times did you consume meat or eggs in the past week?
Everyday
At least once in two days
At least once in 3 days
Did not consume
C15
What is the highest level of education that any of your children have completed?
No formal education
Has attended primary school (up to grade 6)
Has attended up to grade 10
Matriculate (10th pass)
Passed school (10+2)
Graduate
Postgraduate
ITI/ Diploma/ similar vocational course
Others (Specify)
Programme Benefits (only to beneficiaries)
D01
Are you supported by ITC’s Targeted Hardcore poor Programme?
Yes
No
D02
How long have you been affiliated with this programme?
Less than 6 Months
6 Month – 1 Year
1 Year – 1.5 Years
1.5 - 2 Years
More than 2 Years
D03
How long was the initial training period?
Less than 6 months
6 - 12 Months
1 – 1.5 Years
1.5 - 2 years
More than 2 years
D04
How frequently do you receive training?
Only once
Monthly
Quarterly
Never
D05
How would you rate the efficiency of the training?
Highly effective
Moderately effective
Average
Less effective
Not effective
D06
Did you any receive any material assets for your business?
Yes
No
D07
If yes, what are those assets?
Sewing machine
Makeup products
Agricultural tools
Other (specify)
D08
Do you receive any stipend?
Yes
No
D09
If yes, how much stipend do you receive on a weekly basis?
Less than Rs. 200
Rs. 200 – 500
Rs. 500 - 800
Rs. 800 - 1100
More than Rs. 1100
D10
Do you have access to regular mentorship?
Yes
No
D11
If yes, how often do you receive mentorship?
At least once a week
At least once in 15 days
At least once a month
Less frequently than that
D12
How would you rate the effectivity and availability of the mentorship?
Highly effective
Effective
Average
Less effective
Not effective
D13
How would you rate your level of financial literacy?
Intermediate
Beginner
Wish to learn
D14
Did you have a bank account prior to being affiliated with the THP programme?
Yes
No
D15
If yes, who makes key financial decision related to this account (deposits, withdrawal, access credit)
Self
Jointly along with my husband
Jointly along with my MIL
Others (Specify)
D16
What kind of entrepreneurial venture have you set up?
Retail store
Food cart / stall
Tailoring
Others (Specify)
D17
How much profit are you able to generate from this venture on a monthly basis? (In INR)
Less than Rs. 5,000
Rs. 5,000 - 10,000
Rs. 10,000 - 15,000
Rs. 15,000 – 20,000
Rs. 20,000 – 25,000
More than Rs. 25,000
D18
What is your income post affiliation with this programme?
Less than Rs. 5,000
Rs. 5,000 - 10,000
Rs. 10,000 - 15,000
Rs. 15,000 – 20,000
Rs. 20,000 – 25,000
More than Rs. 25,000
D19
As part of the programme, did you attend any sessions pertaining to socially relevant issues?
Regularly
Sometimes
At least once
Never
Entrepreneurial venture by women
E01
Do you run an entrepreneurial venture?
Yes
No
E02
If yes, what type of entrepreneurial venture do you run?
Tailoring and sewing
Makeup / Cosmetic Store
Food stall / cart
Retail store
Others (Specify)
E03
How much are your monthly profits?
Less than Rs. 5,000
Rs. 5,000 - 10,000
Rs. 10,000 - 15,000
Rs. 15,000 – 20,000
Rs. 20,000 – 25,000
More than Rs. 25,000
E04
What kind of training/ support do you require to expand your business?
Business Management Skills
Technical Skills
Market and vendor linkages
Financial Literacy
Capital / Assets
Others (Specify)
E05
Who supports you in running this venture?
Husband
Mother-in-Law
Children
Natal Family
Hired help
Others (Specify)
E06
Where do you run this venture?
Vicinity of your house
Rented space for production
Community centre / common areas
Rented Shop (Specify)
Others (Specify)
E07
What government schemes are you availing?
Mudra Yojana
Atal Pension Yojana
Pradhanmantri Suraksha Bima Yojana
Pradhan Mantri Jeevan Jyoti Bima Yojana
Pradhan Mantri Awas Yojana
Pradhan Mantri Garib Kalyan Yojana
National social assistance program
National food security act
Swachh Bharat
Pradhan mantri ujwala yojana
Others (Specify)
E08
To what extent were these schemes beneficial?
To a large extent
To some extent
To little extent
Did not help
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