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Household Template 26 -Form Fill

Village Information
Q01

State  

Q01A

code

Q02

District

Q02A

code

Q03

Block

Q03A

code

Q04

Village

Q04A

code

Q05

Hamlet

Q06

Structure No.

Q07

HH No.

Q08

UID

Q09

Is any member of your household part of an SHG?

Q10

Is she available for a one-hour interview right now?

Respondent Information
A01

Name of the head of the household

A02

Address

A03

Important Landmark nearest to the HH

A04

Phone Number

A05

Name of the respondent

A06

Age of the respondent

A07

Name of the Child

A08

Date of Birth of the Child

A09

Age of the Child

A10

Gender of child

Survey Information
B01

First Visit

B01_1

Interviewer name

B01_2

Interviewer code

B01_3

Date of the interview

B01_4

Result of the interview

B02

Second Visit

B02_1

Interviewer name

B02_2

Interviewer code

B02_3

Date of the interview

B02_4

Result of the interview

B03

Third Visit

B03_1

Interviewer name

B03_2

Interviewer code

B03_3

Date of the interview

B03_4

Result of the interview

B03_5

RECORD TIME WHEN YOU START THE INTERVIEW.

HOUSEHOLD ROSTER
C01

Line Number

C02

Please tell me the names of all the persons who usually live in your household, starting with the head of the household.

C03

What is the relationship of [NAME] to the head of household?

C04

What is the sex of [NAME]?

C05

How old is [NAME]?

C06

What is [NAME’s] marital status?

C07

What was your age when you got married?

C08

What was your age when you gave birth to your first child?

C09

How old was your husband when you got married?

HOUSEHOLD CHARACTERISTICS (ALL CATEGORIES)
D01

Name of the respondent

D02

Line Number of respondent

D03

What is your religion?

D04

Which caste do you belong to?

D04A

Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?

D05

Does your household own this house or any other house?

D06

LOOK AT THE FLOOR AND CODE THE MAIN MATERIAL OF THE FLOOR

D07

LOOK AT THE ROOF AND CODE THE MAIN MATERIAL OF THE ROOF

D08

LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS

D09

TYPE OF WINDOWS

D09_1

ANY WINDOWS

D09_2

WINDOWS WITH GLASS

D09_3

WINDOWS WITH SCREENS

D09_4

WINDOWS WITH CURTAINS OR SHUTTERS

D10

How many rooms in this house are used for sleeping?

D11

Do you have a separate room which is used as a kitchen?

D12

What type of fuel does your household mainly use for cooking?

D13

What is the main source of lighting in this household?

D14

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

D14A

Is the main source of drinking water within the premises of the household?

D14B

How far is the main source of drinking water located?

D14C

How long does it take to go to the water source, get water, and come back during the rainy season?

D14D

How long does it take to go to the water source, get water, and come back during the dry season?

D15

Do you treat / do something special with the water that you fetch to make it safer to drink?

D16

What do you usually do to the water to make it safer to drink?

D16A

Does your household have a toilet?

D16B

What kind of toilet facilities does your household have?

D17

What kind of toilet facility do members of your household usually use?

D18

In the past week has anyone in your household including children defecated in the open for example in the field or in the river?

D19

The last time a child passed stools, what was done to dispose of the stools?

D19A

Does the household have soap and water immediately near the toilet facility?

D20

On what occasions did you wash your hands with soap since this time yesterday?

D21

Does your household have

D21_1

Electricity

D21_2

A mattress

D21_3

A pressure cooker

D21_4

A chair

D21_5

A cot or bed

D21_6

A table

D21_7

An electric fan

D21_8

A radio or transistor

D21_9

A black and white television

D21_10

A color television

D21_11

A sewing machine

D21_12

A mobile telephone

D21_13

Any other type of telephone

D21_14

A computer/laptop

D21_15

A refrigerator

D21_16

A watch or clock

D21_17

A bicycle

D21_18

A motorcycle or scooter

D21_19

An animal-drawn cart

D21_20

A car

D21_21

A water pump

D21_22

A thresher

D21_23

A tractor

D21_24

Internet

D21_25

Air Conditioner or Cooler

D21_26

Washing Machine

ACCESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
E01

Have you ever heard about _?

E01_1

Indira Awas Yojna (IAY)

E01_2

Swajaldhara

E01_3

Swachh Bharat Abhiyan

E01_4

Janani Shishu Suraksh Karykaram

E01_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)

E01_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)

E01_7

Atal Pension Yojana

E01_8

Pension for the disabled

E02

Is your household / anyone in your household eligible for this scheme?

E02_1

Indira Awas Yojna (IAY)

E02_2

Swajaldhara

E02_3

Swachh Bharat Abhiyan

E02_4

Janani Shishu Suraksh Karykaram

E02_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)

E02_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)

E02_7

Atal Pension Yojana

E02_8

Pension for the disabled

E03

Has anyone in your household ever availed this scheme?

E03_1

Indira Awas Yojna (IAY)

E03_2

Swajaldhara

E03_3

Swachh Bharat Abhiyan

E03_4

Janani Shishu Suraksh Karykaram

E03_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)

E03_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)

E03_7

Atal Pension Yojana

E03_8

Pension for the disabled

E04

When was the last time someone in your household used this scheme?

E04_1

Indira Awas Yojna (IAY)

E04_2

Swajaldhara

E04_3

Swachh Bharat Abhiyan

E04_4

Janani Shishu Suraksh Karykaram

E04_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)

E04_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)

E04_7

Atal Pension Yojana

E04_8

Pension for the disabled

E05

Have you ever heard about Mahatma Gandhi rural Employment Guarantee Act?

E06

Does anyone in your household have a MGNREGA job card? If yes, please show me.

E07

In the past year, how many days did members of your household work for MGNREGA?

E08

For this total number of days worked by household members, how many days were worked by men and how many days were worked by women?

E09

When was the last time someone in your household worked for MGNREGA in last 1 year?

E10

Have you ever heard of Public Distribution System?

E11

Have you ever heard of Antyodaya Anna Yojana?

E12

Does your household have a ration card?

E12A

Is your name included in the ration card?

E13

Which card do you have?

E14

In the past 30 days, did you buy anything from a ration shop?

E15

Which items did you buy from the ration shop in the last 30 days and in what quantity?

E16

Whether Purchased

E16_1

Rice

E16_2

Wheat

E16_3

Sugar

E16_4

Salt

E16_5

Kerosene

E16_6

Clothes

E16_7

Other

E17

Quantity Purchased

E17_1

Rice

E17_2

Wheat

E17_3

Sugar

E17_4

Salt

E17_5

Kerosene

E17_6

Clothes

E17_7

Other

E18

Have you ever heard of the ICDS scheme / Anganwadi centre?

E19

At present is there any ____ in your household?

E19_1

Pregnant Woman

E19_2

Lactating Woman

E19_3

Child aged 6-35 months

E19_4

Child aged 3-6 years

E20

Did the member receive supplementary nutrition / hot cooked food from the AWC in the last 12 months?

E21

How many times did the member receive food from the AWC in the last month?

E22

Have you ever heard about the Janani suraksha Yojana Scheme?

E23

Do you know how much money the beneficiary is supposed to get under the JSY scheme?

E24

Does the household avail the following?

E24_1

SAVINGS

E24_2

CREDIT

E24_3

INSURANCE

E24_4

REMITTANCE

E24_5

PENSION

E25

Where does the household save?

E26

From what sources does the household avail credit?

E27

What type of insurance does the household have?

E28

Does anyone in your household have a bank account opened under the Pradhan Mantri Jan Dhan Yojana?

E29

Has the account been operated in the last 3 months?

E30

What activity was performed on the account?

E31

Have you availed the overdraft facility from your account under the Jan Dhan Yojana in the last 1 year?

E32

If yes, what was the overdraft amount?

E33

Does any member of your household avail retirement pension?

E34

What are the pensions that the household members receive?

E35

Have you ever heard of the old Age Pension Scheme?

E36

How many members in your household were eligible for the Old Age Pension Scheme in the last 1 year?

E37

How many members availed the Old Age Pension Scheme in the last 1 year?

E38

Have you ever heard of the widow pension scheme?

E39

How many members in your household were eligible for the Widow Pension Scheme in the last 1 year?

E40

How many members have availed the Widow Pension Scheme in the last 1 year?

E41

Have you ever heard about Rashtriya Swasth Bima Yojana (RSBY)?

E42

Does your Household have a RSBY smart card?

E43

Was the smart card updated in the last one year?

E44

Did anyone in your household use the smart card in last one year?

LAND OWNERSHIP AND USE OF LAND FOR FARMING
F01

Does any your household own, lease in any agricultural land?

F02

Does your household engage in agricultural activities?

F03

How much agricultural land does your household presently have access to:

F03A

unit

F04

Out of this land how much is irrigated or rainfed?

F04A

unit

Risk taking Behaviour and adoption of new crop varieties
G01

What is the main crop that your produce?

G02

Now I would like to ask you whether you are completely dependent on your main crop or you also grow other crops or engage in livestock rearing or other non-farm activites.

G03

What type of crops do you choose to grow?

G04

What type of animals do you rear

G05

What type of non-farm activities do you undertake?

PRODUCTION TECHNOLOGY
H01

Main crop of household

H02

What type of seed was primarily used for production of ____?

H03

When was the last time you purchased new seeds for this crop?

H04

Do you treat the seeds in some way before planting?

H05

How long before transplantation/sowingdo you practice weeding?

H06

Do you use a germination test to check the seeds?

H07

Was any fertilizer used on the land during production of _______?

H08

Do you apply anything else to improve the quality of the soil?

H09

For this crop, are you mostly using line planting/transplanting or do you broadcast the crop in the main field or both?

H10

At what stage of the cropping practices do you usually apply urea?

H11

How many days after planting do you irrigate the crop?

H12

After planting, when do you practice earthing-up?

H13

Do you practice hoeing in fields where you grow _____?

H14

What inputs does your HH normally purchase for a cropping season

H14A

Do you ever go to purchase _____ for the crop?

H15

Who decides on the purchase of inputs required for farming?

H16

Where does your HH purchase   the inputs from?

H17

What according to you is the best place to buy the agricultural inputs from?

H18

Why do you think ____ is the best place to buy the agricultural inputs?

H19

Does your hh sell any of the agricultural produce in the market?

H19A

Do you ever go to sell _____?

H20

Who decides on the sale of the produce in the market?

H21

Where does your hh sell the produce?

H22

What according to you is the best place to sell the agricultural produce?

H23

Why do you think ____ is the best place to sell the agricultural produce?

Women’s space in agricultural decision making and gendered division of labor
I01

Did you participate in _____ in the past 12 months?

I01_1

Food crop farming: crops that are grown primarily for household food consumption

I01_2

Cash crop farming: crops that are grown primarily for sale in the market

I01_3

Livestock raising

I01_4

Poultry (e.g. chicken, duck, pigeon)

I01_5

piscicultue or fishpond culture

I02

How much input did you have in making decisions about_____?

I02_1

Food crop farming: crops that are grown primarily for household food consumption

I02_2

Cash crop farming: crops that are grown primarily for sale in the market

I02_3

Livestock raising

I02_4

Poultry (e.g. chicken, duck, pigeon)

I02_5

piscicultue or fishpond culture

I03

Are you engaged in any of the agricultural activities?

I04

Are you engaged in ________?

I04_1

Tilling/ Ground preparation

I04_2

Sowing/Transplanting

I04_3

Intercultural operations (weeding, hoeing)

I04_4

Fertiliser application

I04_5

Irrigation application

I04_6

Harvesting

I05

Why do you think you should be involved in this activity?

I05_1

Tilling/ Ground preparation

I05_2

Sowing/Transplanting

I05_3

Intercultural operations (weeding, hoeing)

I05_4

Fertiliser application

I05_5

Irrigation application

I05_6

Harvesting

INCOME
J01

Did anyone in the household earn income from any of the following sources in the last 12 months?

J02

Whether earned from this activity?

J02_1

In last 12 months has anyone in your household engaged in agriculture labour

J02_2

In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging

J02_3

In last 12 months has anyone in your household engaged in skilled labour

J02_4

In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)

J02_5

In last 12 months has anyone in your household engaged in NTFP selling (Mohwa seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)

J02_6

In last 12 months has anyone in your household earned from salaried job?

J02_7

In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock as we will talk about agriculture and livestock later

J03

Who in the household earned income over last 12 months?

J04

How much did the household earn from [activity] ______ over the past 12 months?

J04_1

In last 12 months has anyone in your household engaged in agriculture labour

J04_2

In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging

J04_3

In last 12 months has anyone in your household engaged in skilled labour

J04_4

In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)

J04_5

In last 12 months has anyone in your household engaged in NTFP selling (Mohwa seeds, amla, honey, fruits, nuts, vegetables, medical plants, resins, rattans and other plants and grasses.)

J04_6

In last 12 months has anyone in your household earned from salaried job?

J04_7

In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock as we will talk about agriculture and livestock later

J05

In the last 12 months, has any member of the household or other relatives have sent you any money from outside?

J06

How often has your household received remittances in the last 12 months?

J07

How much money did your household receive as remittances in the last 12 months?

J08

During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc.?

J09

How many _______ did you sell in the last 12 months?

J09_1

Buffalo

J09_2

Oxen

J09_3

Cow

J09_4

Goat

J09_5

Sheep

J09_6

Duck

J09_7

Poultry

J09_8

Pig

J09_9

Fish

J10

How much did your household receive for the sale of these _________ in the last 12 months?

J10_1

Buffalo

J10_2

Oxen

J10_3

Cow

J10_4

Goat

J10_5

Sheep

J10_6

Duck

J10_7

Poultry

J10_8

Pig

J10_9

Fish

J11

Did you produce any ___ during the last 12 months?

J11_1

Animal/Fish meat/offal

J11_2

Poultry meat/offal

J11_3

Milk (including that produced for milk products)

J11_4

Eggs

J12

Did your household sell any of the ___ produced?

J12_1

Animal/Fish meat/offal

J12_2

Poultry meat/offal

J12_3

Milk (including that produced for milk products)

J12_4

Eggs

J13

How much in total did your household receive for the sale of ________?

J13_1

Animal/Fish meat/offal

J13_2

Poultry meat/offal

J13_3

Milk (including that produced for milk products)

J13_4

Eggs

J14

Did your household engage in agricultural activities in the past 12 months?

J15

Crop Code

J16

What is the total quantity produced?

J17

How much of the harvested____was sold?

J18

What was the income from the sale of ___?

J19

Does your household receive any farm produce from the land that you lease out?

J20

Crop Code

J21

What is the total quantity received?

J22

How much of the received ____was sold?

J23

What was the income from the sale of ___?

J24

Are you or any other member from your household     part of a producer group (PG) or FPO?

J25

Why did you (or your family member) join the PG/FPO?

J26

What all activities have you participated in as a member of this PG/FPO?

J27

Have these benefits of being part of a PG/FPO led to higher income?

J28

What is the interval at which this PG/FPO meets?

FOOD SECURITY
K01

How many meals did you eat yesterday during the day and night?

K02

How many meals did the adult members (18+) of your household eat yesterday during the day and night?

K03

How many meals did the children 6 to18 years in this household eat yesterday during the day and night?

K04

Over the last 7 days, how many days were the following food groups consumed by

K05

YOU AND OTHER FEMALE MEMBERS OF THE HH

K05_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)

K05_2

Beans and peas, pulses groundnuts and cashew nuts`

K05_3

Vegetables (including leaves)

K05_4

Fruits

K05_5

Egg, meat, fish etc.

K05_6

Milk/yogurt/other dairy product

K05_7

Sugar or sugar products, honey

K05_8

Oils/fats/butter

K06

CHILDREN AGE 6-18 YRS.

K06_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)

K06_2

Beans and peas, pulses groundnuts and cashew nuts`

K06_3

Vegetables (including leaves)

K06_4

Fruits

K06_5

Egg, meat, fish etc.

K06_6

Milk/yogurt/other dairy product

K06_7

Sugar or sugar products, honey

K06_8

Oils/fats/butter

K07

OTHER MALE MEMBERS

K07_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)

K07_2

Beans and peas, pulses groundnuts and cashew nuts`

K07_3

Vegetables (including leaves)

K07_4

Fruits

K07_5

Egg, meat, fish etc.

K07_6

Milk/yogurt/other dairy product

K07_7

Sugar or sugar products, honey

K07_8

Oils/fats/butter

K08

What was the main source(s) of the food?

K08_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)

K08_2

Beans and peas, pulses groundnuts and cashew nuts`

K08_3

Vegetables (including leaves)

K08_4

Fruits

K08_5

Egg, meat, fish etc.

K08_6

Milk/yogurt/other dairy product

K08_7

Sugar or sugar products, honey

K08_8

Oils/fats/butter

COPING STRATEGY
L01

Usually, does your household has sufficient food available for the whole year?

L02

If no, in a year how many months / days, the household has insufficient food?

L03

In a year, how frequently do you have to do ________ because of insufficient food in the household

L03_1

Skip entire days without eating?

L03_2

Limit portion size at mealtimes?

L03_3

Reduce number of meals eaten per day?

L03_4

Borrow food or rely on help from friends or relatives?

L03_5

Rely on less expensive or less preferred foods?

L03_6

Purchase/borrow food on credit?

L03_7

Gather unusual types or amounts of wild food / hunt?

L03_8

Send household members to eat elsewhere?

L03_9

Send household members to beg?

L03_10

You or other female members eat less?

L04

Have you sold any household assets to buy food?

SELF-HELP GROUPS AND LEADERSHIP
M01

Are you a member of any Self-help  group (SHG)?

M01A

In which year did you become an SHG member?

M01B

Is your SHG supported by PRADAN?

M02

Are you a panchayat member?

M03

What position do you hold as a panchayat member?

M04

Are you a member of any committee associated with Gram Panchayat?

M05

Which committees are you associated with?

M06A

Are you a member of the Village Organization?

M06B

Do you hold any position in the VO?

M06C

Which position do you hold in the VO?

M06D

Are you a member of the CLF, Executive Committee or Board of Directors?

M06E

Do you hold any position in the CLF?

M06F

Which position do you hold in the  CLF?

M06G

Are you a member of any sub committees in the CLF?

M07

What crop have you taken up as an FPO member?

GENDER
N01

Did you engage in any income generating activities in last 12 months?

N02

Was it usually at home or away from home?

N03

Was it usually throughout the year, seasonal or once in a while?

N04

Were you usually paid in cash or kind for this work?

N05

According to you, what share of household income do you contribute to?

N06

Who decided how to use the money you earn?

N07

Do you save any of the income that you earn?

N08

Where do you save?

N09

Do you have any money of your own that you can decide how to spend?

N10

Does your household have any bank account?

N11

Who does the account belong to?

N12

Is there an account in your name?

N13

If yes, have you operated it in the last 3 months?

N14

What is your role in buying or selling of land or other similar assets?

N15

What is your role in buying, selling OR mortgaging of gold or other jewelry?

N16

What is your role in buying or selling of livestock?

N17

What is your role in buying or selling of farm produce?

N18

How easy it is for you to go to the following places?

N18_1

To go out and work

N18_2

Ration Shop

N18_3

Paternal Home

N18_4

Weekly Market

N18_5

Government Offices

N18_6

Banks

N18_7

Gram Sabha

N18_8

Jati Panchayat

N18_9

Police Station

N18_10

Meeting/training in the village

N18_11

Meeting / training outside village

N19

Do you usually go to the local market place?

N20

Was any Gram Sabha meeting held during the last one year?

N21

How many Gram Sabha meetings were held in the last one year?

N22

Did you attend any of the Gram Sabha meetings that were held in the last one year?

N23

How many meetings did you attend in the last one year?

N24

Did you raise any issue in the meetings that you attended?

N25

Was any Jati Panchayat meeting held during the last one year?

N26

How many Jati Panchayat meetings were held in the last one year?

N27

Did you attend any of the Jati Panchayat meetings that were held in the last one year?

N28

How many meetings did you attend in the last one year?

N29

Did you vote in any of the elections in last 5 years?

N30

Who decides who will you cast your vote to?

N31

Have you ever wathched TV in the last one year?

N32

How often do you watch TV?

N33

Have you ever listened to the radio in the last one year?

N34

How often do you listen to the radio?

N35

Do you think that girls should be given equal opportunities for employment outside the house or may be to work in another village as boys?

N36

What do you think should be ideal age for girls to get married?

COVID-19 PANDEMIC: MANAGEMENT AND RESILIENCE
O01

Was anyone in your family affected by COVID-19?

O02

Did the affected persons receive proper and timely treatment?

O03

Were you able to purchase all necessary medicines for home treatment?

O04

Were you able to keep them isolated in a corner of your house to minimize spread of infection?

O05

Did the VO help you in access to necessary medicines?

O06

Did you receive any form of food relief and support from the VO?

O07

Did your family avail of services from the community kitchen during lockdown?

O08

Did your family receive enough masks for daily usage during the height of the pandemic?

O09

Did you receive awareness messages from the VO on safety measures like social distancing and hand washing?

O10

Did your family receive enough hygiene products like hand soap and sanitizer from the VO ?

O11

Did the SHG you are a part of take up mask making as a livelihood activity?

O12

How much income was   earned from such an activity?

O13

Did you make use of quarantine or isolation facilities in your Panchayat?

O14

Did these facilities have adequate food and water provisioning?

O15

What is the status of food availability in your village?

O16

Did frontline health workers (ASHA/ANM/AWC) come to your house to regularly check your temperature and monitor other symptoms of coronavirus infection?

O17

What are the initiatives that your VO  took to fight against COVID-19 in your cluster?

O18

What are the preventive measures VO members are adopting while helping with the CORONA   situation at the community level?

O19

Were there problems in being able to have regular SHG/VO meetings due to the lockdown?

O20

How many times did your SHG meet in the last year?

O21

When was the last meeting conducted?

O22

When did you attend the last SHG meeting?

O23

Were regular FPO/PG meetings disrupted due to the pandemic?