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Household Template 4 -Form Fill
Village Information
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
hamlet name
Q10
structure no.
Q11
HH no.
Q12
UID
Q13
Block type
Project
Comparison
Respondent Information
A01
Name of the head of the household
A02
Address
A03
Important Landmark nearest to the HH
A04
Phone Number
A05
Respondent category
Women with children age 0-5 months
Women with children age 6-11 months
Women with children age 12-23 months
Women with children age 24-59 months
A06
Name of the respondent
A07
Age of the respondent
A08
Name of the Child
A09
Date of Birth of the Child
A10
Age of the Child
A11
Gender of child
MALE
FEMALE
TRANSGENDER
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
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
REFUSED
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY
OTHER (SPECIFY)
B02
Second Visit
B02_1
Interviewer name
B02_2
Interviewer code
B02_3
Date of the interview
B02_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
REFUSED
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY
OTHER (SPECIFY)
B03
Third Visit
B03_1
Interviewer name
B03_2
Interviewer code
B03_3
Date of the interview
B03_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
REFUSED
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY
OTHER (SPECIFY)
B03_5
RECORD TIME WHEN YOU START THE INTERVIEW.
HOUSEHOLD ROSTER
C01
Please tell me the names of all the persons who usually live in your household, starting with the head of the household.
C02
What is the relationship of [NAME] to the head of household?
HEAD OF THE HOUSEHOLD
SPOUSE
SON/DAUGHTER
SON/DAUGHTER IN LAW
GRANDCHILD
FATHER/MOTHER
FATHER/MOTHER IN LAW
BROTHER/SISTER
BROTHER/SISTER IN LAW
NIECE/NEPHEW
GRAND PARENT/GRAND PARENT-IN-LAW
OTHER RELATIVE
ADOPTED/FOSTER/STEPCHILD
DOMESTIC SERVANT
OTHER (SPECIFY)
NOT STATED
C03
What is the sex of [NAME]?
MALE
FEMALE
TRANSGENDER
C04
How old is [NAME]?
C05
What is [NAME’s] marital status?
CURRENTLY MARRIED
MARRIED, GAUNA NOT PERFORMED
WIDOWED
DIVORCED
SEPARATED
DESERTED
NEVER MARRIED
NOT MARRIED, BUT LIVE TOGETHER
C06
Are you currently a member of any SHG?
Yes
No
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?
HINDU
MUSLIM
CHRISTIAN
SIKH
BUDDHIST/NEO-BUDDHIST
JAIN
JEWISH
PARSI/ZOROASTRIAN
NO RELIGION
SARNA
OTHER (SPECIFY)
D04
Which caste do you belong to?
D05
Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?
SCHEDULED CASTE
SCHEDULED TRIBE
OTHER BACKWARD CASTE
GENERAL
OTHER (SPECIFY)
D06
Does your household have
Yes
No
D06_1
Electricity
Yes
No
D06_2
A mattress
Yes
No
D06_3
A pressure cooker
Yes
No
D06_4
A chair
Yes
No
D06_5
A cot or bed
Yes
No
D06_6
A table
Yes
No
D06_7
An electric fan
Yes
No
D06_8
A radio or transistor
Yes
No
D06_9
A black and white television
Yes
No
D06_10
A color television
Yes
No
D06_11
A sewing machine
Yes
No
D06_12
A mobile telephone
Yes
No
D06_13
Any other type of telephone
Yes
No
D06_14
A computer/laptop
Yes
No
D06_15
A refrigerator
Yes
No
D06_16
A watch or clock
Yes
No
D06_17
A bicycle
Yes
No
D06_18
A motorcycle or scooter
Yes
No
D06_19
An animal-drawn cart
Yes
No
D06_20
A car
Yes
No
D06_21
A water pump
Yes
No
D06_22
A thresher
Yes
No
D06_23
A tractor
Yes
No
D06_24
Internet
Yes
No
D06_25
Air Conditioner or Cooler
Yes
No
D06_26
Washing Machine
Yes
No
LAND OWNERSHIP AND USE OF LAND FOR FARMING
E01
Does any your household own, lease in any agricultural land?
Yes
No
E02
Does your household engage in agricultural activities?
Yes
No
E03
How much agricultural land does your household presently have access to:
E03A
OWNED LAND
E03A1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E03B
LEASED LAND
E03B1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04
Out of this land how much is irrigated or rainfed?
E04A
OWNED LAND
E04A1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
E04B
LEASED LAND
E04B1
UNIT
Decimal
Biswa
Katha
Bigha
Acre
Hectare
Other
INCOME
F01
Did anyone in the household earn income from any of the following sources in the last 12 months?
Yes
No
F01_1
In last 12 months has anyone in your household engaged in agriculture
Yes
No
F01_2
In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks,
Yes
No
F01_3
In last 12 months has anyone in your household engaged in skilled labour
Yes
No
F01_4
In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
Yes
No
F01_5
In last 12 months has anyone in your household engaged in NTFP selling
Yes
No
F01_6
In last 12 months has anyone in your household earned from salaried job?
Yes
No
F01_7
In last 12 months has anyone in your household engaged in Other activity(specify)- – excluding Agriculture and livestock
Yes
No
F02
Whether earned from this activity?
Yes
No
F03
Who in the household earned income over last 12 months?
MEN
WOMEN
BOTH MEN & WOMEN
CHILDREN
ALL HH MEMBERS
F04
How much did the household earn from [activity] ______ over the past 12 months?
F05
In the last 12 months, has any member of the household or other relatives have sent you any money from outside?
Yes
No
F06
How often has your household received remittances in the last 12 months?
EACH MONTH
MANY TIMES / YEAR
TWICE A YEAR
ONCE A YEAR
LESS THAN ONCE A YEAR
DO NOT KNOW
F07
How much money did your household receive as remittances in the last 12 months?
F08
During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc.?
Yes
No
F09
Animal / poultry name
Buffalo
Oxen
Cow
Goat
Sheep
Duck
Poultry
Pig
Fish
Others (Specify)
F10
How many _______ did you sell in the last 12 months?
F11
How much did your household receive for the sale of these _________ in the last 12 months?
F12
Now we would like some information on your household's production and selling of animal products. Please only consider the previous 12 months.
F13
Did you produce any ___ during the last 12 months?
Yes
No
F13_1
Animal/Fish meat/offal
Yes
No
F13_2
Poultry meat/offal
Yes
No
F13_3
Milk (including that produced for milk
Yes
No
F13_4
Eggs
Yes
No
F14
Did your household sell any of the ___ produced?
Yes
No
F14_1
Animal/Fish meat/offal
Yes
No
F14_2
Poultry meat/offal
Yes
No
F14_3
Milk (including that produced for milk
Yes
No
F14_4
Eggs
Yes
No
F15
How much in total did your household receive for the sale of ________?
F16
Did your household engage in agricultural activities in the past 12 months?
Yes
No
F17
Crop Code
RICE
WHEAT
MAIZE
SORGHUM
MILLETS
BUCKWHEAT
BARLEY
GROUNDNUT
SOYBEANS
LENT
PEAS
CHICKPEAS
BEANS
SUGARCANE
COTTON
SUNFLOWER
TOBACCO
TEA
OIL SEEDS
SWEET POTATOES
POTATOES
CARROTS
CUCUMBER
CHILI
EGGPLANT
GREEN LEAFY VEGETABLES
OKRA / LADY FINGER
ONION
CAPSICUM
CABBAGE
CAULIFLOWER
BOTTLE GOURD
SPONGE GOURD
BITTER GOURD
GREEN BEANS
GARLIC
GINGER
PUMPKIN / ZUCHIMI
TOMATO
AVOCADO
GUAVA
MANGO
LEMON / LIME
ORANGE / TANGERINE
PAPAYA
MELON
LYCHEE
APPLE
BERRIES
BANANAS
SARSON
URAT DAL
MUSSOR DAL
ARHAR DAL
CHANA
OTHER (SPECIFY)
F18
What is the total quantity produced?
F19
How much of the harvested____ was sold?
F20
What was the income from the sale of ___?
F21
Does your household receive any farm produce from the land that you lease out?
Yes
No
F22
Crop Code
RICE
WHEAT
MAIZE
SORGHUM
MILLETS
BUCKWHEAT
BARLEY
GROUNDNUT
SOYBEANS
LENT
PEAS
CHICKPEAS
BEANS
SUGARCANE
COTTON
SUNFLOWER
TOBACCO
TEA
OIL SEEDS
SWEET POTATOES
POTATOES
CARROTS
CUCUMBER
CHILI
EGGPLANT
GREEN LEAFY VEGETABLES
OKRA / LADY FINGER
ONION
CAPSICUM
CABBAGE
CAULIFLOWER
BOTTLE GOURD
SPONGE GOURD
BITTER GOURD
GREEN BEANS
GARLIC
GINGER
PUMPKIN / ZUCHIMI
TOMATO
AVOCADO
GUAVA
MANGO
LEMON / LIME
ORANGE / TANGERINE
PAPAYA
MELON
LYCHEE
APPLE
BERRIES
BANANAS
SARSON
URAT DAL
MUSSOR DAL
ARHAR DAL
CHANA
OTHER (SPECIFY)
F23
What is the total quantity received?
F24
How much of the received ____ was sold?
F25
What was the income from the sale of ___?
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