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Village Template Template 2 -Form Fill
Village Identifier
Q01
state name
Q02
state code
Q03
district name
Q04
district code
Q05
block name
Q06
block code
Q07
village name
Q08
village code
Q09
total population
Q10
number of household
Respondent Information
A01A
Name of the respondent-1
A02A
Designation / Position
SARPANCH
AWW
ASHA
ANM
SCHOOL TEACHER/HEADMASTER
A01B
Name of the respondent-2
A02B
Designation / Position
SARPANCH
AWW
ASHA
ANM
SCHOOL TEACHER/HEADMASTER
A01C
Name of the respondent-3
A02C
Designation / Position
SARPANCH
AWW
ASHA
ANM
SCHOOL TEACHER/HEADMASTER
Village Demographics
B01
Number of HHs with MGNREGA job card
B02
Does the PSU have electricity?
YES
NO
IN SOME AREAS
B03
What is the electricity supply status?
AVAILABLE FOR LESS THAN 6 HOURS PER
AVAILABLE FOR 6-12 HOURS PER DAY
AVAILABLE FOR MORE THAN 12 HOURS PER DAY
IRREGULAR, NO SET PATTERN
B04
Is there a community toilet in the village?
YES
NO
B05
How many such toilets are there?
B06
Does the PSU have a sewerage facility?
YES
NO
IN SOME AREAS
B07
What are primary sources of drinking water
B08
Total number of households with hand pumps in the PSU (approx.)
B09
Total number of government hand pumps in the PSU (approx.)
B10
What is the main kind of road access?
KUCHCHA ROAD
PUKKA ROAD
B11
Distance to the nearest bus station
B12
Distance to nearest primary school
B13
Highest level of schooling available within village
B14
Distance to health facilities
B14A
PRIMARY HEALTH CENTRE (PHC)
B14B
GOVERNMENT DISPENSARY
B14C
NEAREST PRIVATE HOSPITAL/ NURSING HOME / PRIVATE CLINIC
B15
Are the following present in the village? If yes, how many?
YES
NO
B15A
ASHA
YES
NO
B15B
AWC
YES
NO
B15C
Mini-AWC
YES
NO
B15D
AWW
YES
NO
B15E
Sub-Center
YES
NO
B15F
Rural Medical Practitioners
YES
NO
B15G
Traditional Birth Attendant (Dai)
YES
NO
B15H
Trained Doctor
YES
NO
B15I
Pharmacy / Medical shop
YES
NO
B15J
PDS Shops
YES
NO
B15K
Bank Braches / Customer Service Center?
YES
NO
B15L
Credit Co-operatives
YES
NO
B15M
Weekly Market (haat)
YES
NO
B15N
Agricultural cooperative society
YES
NO
B15O
Milk cooperative society
YES
NO
B15P
Mahila Mandal / SHG
YES
NO
B15Q
Small business shops
YES
NO
LOCAL SELF-GOVERNMENT AND POLITICAL AFFILIATION
C01
Does the Sarpanch reside in this PSU?
YES
NO
C02
Gender of the current Sarpanch
MALE
FEMALE
TRANSGENDER
Anganwadi Facility Survey
D01
Where is the Anganwaadi Housed?
OWN BUILDING
RENTED BUILDING
ANGANWADI WORKER’S HOME
ANGANWADI HELPER’S HOME
PANCHAYAT BHAWAN
VILLAGE SCHOOL
OTHERS (SPECIFY)
D02
What is the area of the Anganwaadi?
D03
How many rooms does the Anganwaadi have?
D04
What is condition of the Anganwaadi?
YES
NO
D04A
Anganwaadi building needs repair
YES
NO
D04B
Anganwaadi is well ventilated
YES
NO
D04C
Anganwaadi is well lit
YES
NO
D05
Are the following facilities available at the Anganwaadi?
YES
NO
D05A
Electricity Connection
YES
NO
D05B
Electricity Fan in the Rooms
YES
NO
D05C
Clean drinking water
YES
NO
D05D
Functional Toilet
YES
NO
D05E
Indoor Activity Space
YES
NO
D05F
Examination Area for growth monitoring of children
YES
NO
D05G
Separate Kitchen/Cooking space
YES
NO
D05H
torage Facility
YES
NO
D06
Does the Anganwaadi have the following items?
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06A
Medicine Kit/First Aid Box
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06B
Baby Weighing scale
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06C
Wall Charts & Paintings
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06D
Vessels for cooking
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06E
Teaching Learning Material
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06F
Indoor Play Items
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
D06G
Vessel for storing water
YES, IN GOOD CONDITION
YES, BUT NOT IN GOOD CONDITION
NOT AVAILABLE
COULD NOT OBSERVE
School Survey
E01
Type of school
Primary School (class 1-5)
Upper primary / middle school (class 1 to 8)
Secondary School (Class 1 to 10)
Others
E02
Type of school
BOYS
GIRLS
CO-ED
E03
School Building
OWNED
RENTED
PARTLY RENTED AND PARTLY OWNED
E04
How many rooms does the school have?
E05
No. of rooms used for teaching
E06
Does the school have separate toilets for girls?
YES
NO
E07
Is the toilet functional?
YES
NO
E08
Does the school have a boundary wall?
YES
NO
E09
Is drinking water available within the premises?
YES
NO
E10
If yes, what is the source of drinking water?
TAP
HANDPUMP / SUBMERSIBLE PUMP
WELL
OTHER
E11
Does the school have an electricity connection?
YES
NO
E12
Does the school have functional fans in classrooms
YES
NO
E13
Does the school have MDM scheme
YES
NO
E14
Details of teachers
E14A
Full time teacher
E14B
Para / Contractual
E14C
Part time
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