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Household Template 7 -Form Fill
Q1
Name of the household member
Q2
What is the relationship of (name) to the head of the household?
Head
Wife/Husband
Son/Daughter
Son-in-law/Daughter-in-law
Grandchild
Parent servant
Parent-in-law
Brother/Sister
Brother-in-law/Sister-in-law
Niece/Nephew
Other relative
Adopted/Foster/Step-child
Domestic
Other not related
Don’t know
Q3
Is (name) male or female
Male
Female
Q4
How old is (name)? (in completed years)
Q5
What is the current marital status of (name)?
Currently married
Married, but Gauna not performed
Widowed
Divorced
Separated
Deserted
Never married
Don’t know
Q6
Can (name) read or write?
Yes
No
Q7
Has (name) ever attended school?
Yes
No
Q8
What is the highest standard (name) has completed?
Q9
Employment Type
Q10
What is the main source of drinking water for members of your household?
Piped into dwelling
Piped into yard/plot
Public taps/Standpipe
Tube well or borehole
Protected well
Unprotected well
Protected spring
Unprotected spring
Rainwater
Tanker truck
Cart with small tank
Surface water (river/dam/lake/pond/stream/canal/irrigation channel)
Bottled water
Others (specify)
Q11
What is the main source of drinking water used by your household for other purposes such as cooking or hand washing?
Piped into dwelling
Piped into yard/plot
Public taps/Standpipe
Tube well or borehole
Protected well
Unprotected well
Protected spring
Unprotected spring
Rainwater
Tanker truck
Cart with small tank
Surface water (river/dam/lake/pond/stream/canal/irrigation channel)
Others (specify)
Q12
Where is the water source located?
In own dwelling
In own yard/plot
Elsewhere
Q13
How long does it take to go there, get water, and come back in one trip?
Q14
Who usually goes to the source to fetch the water for your household?
Adult woman
Adult man
Female child under age 15 years
Male child under age 15 years
Others (specify)
Q15
Do you treat your water in any way to make it safer to drink?
Yes
No
Don’t know
Q16
What do you usually do to the water to make it safer to drink?
oil
se alum
dd bleach/chlorine tablets
train through a cloth
se water filter (ceramic/sand/composite/etc.)
se electronic purifier
et it stand and settle
Don’t know
Others (specify)
Q17
What kind of toilet facility do members of your household usually use?
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Flush, don’t know where
Ventilated improved pit (VIP)/biogas latrine
Pit latrine with slab
Pit latrine with slab
Twin pit/composting toilet
Dry toilet
No facility/uses open space or field
Others (specify)
Q18
Do you share this toilet facility with other households?
Yes
No
Q19
How many households use this toilet facility?
Q20
When members of household get sick, where do they generally go for treatment?
Government/Municipal Hospital
Government Dispensary
CHC/Rural Hospital/PHC
Sub-centre
Anganwadi/ICDS Centre.
Government mobile clinic
Other public sector health facility
NGO or Trust Hospital/Clinic
Pvt. Hospital
Pvt. Doctor/clinic
Paramedic
Vaidya/Hakim/Homeopath
Traditional healer
Pharmacy/drugstore
Dai (TBA)
Other private sector health facility
Shop
Home treatment
Other (specify)
Q21
Why don’t members of your household generally go to a government facility when they are sick?
No nearby facility
Facility timing not convenient
Health personnel often absent
Waiting time too long
Poor quality of care
Others (specify)
Q22
What is the religion of the head of the household?
Hindu
Muslim
Christian
Sikh
Buddhist/neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No religion
Others (specify)
Q23
What is the caste or tribe of the head of the household?
Scheduled caste
Scheduled tribe
Other backward class
General
Don’t know
Q24
Specify the name of your caste or tribe?
Q25
Does your household have:-A. Electricity
Yes
No
Q26
Does your household have:-B. Mattress
Yes
No
Q27
Does your household have:-C. Pressure cooker
Yes
No
Q28
Does your household have:-D. Chair
Yes
No
Q29
Does your household have:-E. Cot/bed
Yes
No
Q30
Does your household have:-F. Table
Yes
No
Q31
Does your household have:-G. Electric fan
Yes
No
Q32
Does your household have:-H. Radio/transistor
Yes
No
Q33
Does your household have:-I. B&W television
Yes
No
Q34
Does your household have:-J. Colour television
Yes
No
Q35
Does your household have:-K. Sewing machine
Yes
No
Q36
Does your household have:-L. Mobile telephone
Yes
No
Q37
Does your household have:-M. Any other telephone
Yes
No
Q38
Does your household have:-N. Computer
Yes
No
Q39
Does your household have:-O. Refrigerator
Yes
No
Q40
Does your household have:-P. Watch/clock
Yes
No
Q41
Does your household have:-Q. Bicycle
Yes
No
Q42
Does your household have:-R. Motorcycle/scooter
Yes
No
Q43
Does your household have:-S. Animal-drawn cart
Yes
No
Q44
Does your household have:-T. Car
Yes
No
Q45
Does your household have:-U. Water pump
Yes
No
Q46
Does your household have:-V. Thresher
Yes
No
Q47
Does your household have:-W. Tractor
Yes
No
Q48
What type of fuel does your household mainly use for cooking?
Electricity
LPG/Natural gas
Biogas
Kerosene
Coal/lignite
Charcoal
Wood
Straw/shrubs/grass
Agricultural crop waste
Dung cakes
Other (specify)
Q49
Do you have a separate room which is used as a kitchen?
Yes
No
Q50
Main material of the floor
Mud/clay/earth
Sand
Dung
Raw wood planks
Palm/bamboo
Brick
Stone
Parquet or polished wood
Vinyl or asphalt
Ceramic tiles
Cement
Carpet
Polished stone/marble/granite
Other (specify)
Q51
Main material of the roof.
No roof
Thatch/palm leaf/reed/grass
Mud
Sod/mud and grass mixture
Plastic/polythene sheeting
Rustic mat
Palm/bamboo
Raw wood planks/timber
Un-burnt brick
Loosely packed stone
Metal/GI
Wood
Calamine/cement fibre
Asbestos sheets
RCC/RBC/cement/concrete
Roofing shingles
Tiles
Slate
Burnt brick
Other (specify)
Q52
Main material of the exterior walls.
No walls
Cane/palm/trunks/bamboo
Mud
Grass/reeds/thatch
Bamboo with mud
Stone with mud
Plywood
Cardboard
Un-burnt brick
Raw wood/reused wood
Cement/concrete
Stone with lime/cement
Burnt bricks
Burnt bricks
Wood planks/shingles
GI/metal/asbestos sheets
Other (specify)
Q53
Type of windows.-A. Any windows
Yes
No
Q54
Type of windows.-B. Windows with glass
Yes
No
Q55
Type of windows.-C. Windows with screens
Yes
No
Q56
Type of windows.-D. Windows with curtains and shutters
Yes
No
Q57
How many rooms in the household are used for sleeping?
Q58
Does the household own this house or any other house?
Yes
No
Q59
Does this household own any agricultural land?
Yes
No
Q60
How much agricultural land does this household own?
Q61
Out of this land, how much is irrigated?
Q62
Does your household own any of the following animals?-A. Cows/bulls/buffaloes
Yes
No
Q63
Does your household own any of the following animals?-B. Camels
Yes
No
Q64
Does your household own any of the following animals?-C. Horses/donkeys/mules
Yes
No
Q65
Does your household own any of the following animals?-D. Goats
Yes
No
Q66
Does your household own any of the following animals?-E. Sheep
Yes
No
Q67
Does your household own any of the following animals?-F. Chicken/ducks
Yes
No
Q68
Does any usual member of this household have a bank account or a post office account?
Yes, bank account
Yes, post office account
Yes, both
No
Don’t know
Q69
Is any household member covered by a health scheme or health insurance?
Yes
No
Don’t know
Q70
What type of health scheme or health insurance?
Q71
Does this household have a BPL card?
Yes
No
Don’t know
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