Surveypoint

Q01

Name of the state

Q02

Name of the district

Q03

Name of the respondent

Q04

Sex

Male

Female

Q05

Total number of household members

Q06

How many of them are in age group >60 years

Q07

Age of the respondent

Q08

Occupation of the Chief wage earner (CWE)

Farmer with at least 2 hectares of land

Farmer with less than 2 hectares of land

Tenant farmer

Permanent salaried employee (manager/officer grade)

Permanent salaried employee (non-managerial/non-officer grade)

Salaried employee in a part-time/non-permanent private job

Self-employed professional running any vocational trade (e.g. carpenter, plumber, self-employed driver, electrician, etc.)

Self-employed professional providing consulting services (e.g. doctor, lawyer, chartered accountant, real estate agent, etc. running their own consulting business)

Business/shop owner with paid employees

Business/shop owner without paid employees

Daily wage labourer

Domestic help

Home-based artisan/piecemeal job worker

Currently unemployed but seeking employment

Any other specify

Q09

Completed level of education of the CWE

Illiterate

Some schooling but below primary

Completed primary but not middle school

Completed middle school but not high school

Completed high school but not higher secondary

Completed higher secondary but not graduation

Completed graduation or above

Completed technical education after passing schooling

Q10

Usually, for smaller ailments which cannot be treated at home, where all do you go for seeking treatment?

Health Sub-centre

Health and Wellness center

PHC

CHC Block Hospital – CHC

District Government Hospital

Private Hospital

Private Clinic/Nursing home

Private Doctor

Traditional healer/quack

Indian form of medicine

Any Other

Q11

To what extent do you depend on home-based medicine or treatment/medicine provided by village traditional healer?

Completely

In most of the cases

In some of the cases

Rarely

Q12

Why do you prefer going in for such kind treatment?

It is convenient because the healer and medicine available within village

It is cheaper form of treatment

It is tried and tested form treatment using over generations

Have full faith on the healer

There are no government facility nearby

We get the treatment and pay later

Can pay in kind and providing services

Medicine prescribed by doctors not always available

No pharmacy available nearby for medicine prescribed by doctor

Any Other

Q13

For serious ailments which may or may not require hospitalisation, what is your 1st point of consultation

PHC

Health and Wellness Centre

CHC

District Government Hospital/Civil hospital

Private Hospital/clinic/Nursing home

Private Doctor/practitioner

Traditional healer/quack

Alternative medicine practitioner

Any Other

Q14

For surgeries, what is your 1st point of consultation?

PHC

CHC

District Government Hospital/Civil hospital

Medical college (Bada haspatal)

Private Hospital/clinic/Nursing home

Private Doctor/practitioner

Traditional healer/quack

Alternative medicine practitioner

Any Other (________________)

Q15

Last time when you or any of your household members suffered from serious ailment or emergency where did you go first for consultation?

PHC

CHC

District Government Hospital/Civil hospital

Medical college

Private Hospital/clinic

Private Doctor/practitioner

Traditional healer/quack

Alternative medicine practitioner

Any Other

Not applicable

Q16

Did you get complete treatment in the facility or did you have to visit another facility?

Yes, got complete treatment

No, I was referred to another facility

No, I went to another facility as I wanted a second opinion

Q17

For some serious ailments or surgeries. do people from your locality also go outside of the district for treatment?

Yes

No

Q18

How far do they go?

Outside district but within state

Outside of state

Q19

In last five years did you or any other member of your household go outside of your district for treatment?

Yes, outside the district but within the state

Yes, outside the state

No

Q20

How much did you spent on such treatment outside of your district?

Q21

why did you not go for treatment within your state?

Referred by the facility where I went for treatment

People I trust told to do so

Better treatment in this case is only available in the destination state as far as I know

Any Other

Q22

Are the facilities of Telemedicine services/Doctor consultation on phone call available in your nearby government health facilities or locality?

Yes

No

Q23

Is the service of telemedicine/doctor consultation on call available in the health facilities you usually go to and can you also avail this sitting at home?

At health facility only

Only from my home

From both at health facility as well as from home

Q24

Have anyone in your household ever utilised telemedicine/doctor consultation on call facility?

Yes

No

Q25

Is there a system of direct delivery of diagnostics services (including someone coming to your house to collect blood or urea sample) at your doorstep available to the people of your village?

Yes, by private agency only

Yes, by government health facilities

Yes, by both

No

Don't know

Q26

Have you ever availed this facility at home

Yes

No

Q27

Where do usually go for diagnostic services and purchasing/procuring of medicine

Q27A

For Diagnostic services

HSC

PHC

CHC

District Hospital

Pvt Hospital

Pvt Clinic/Nursing home

Pvt Diagnostic centres

Pvt Diagnostic centres which collects sample from home

Q27B

Medicine purchasing/procuring

HSC

PHC

CHC

District Hospital

Pvt Hospital

Pvt Clinic/Nursing home

Pvt Diagnostic centres

Pvt Diagnostic centres which collects sample from home

Q28

Which of these services do you or people like you need to be made available?

Doctor consultation on call/telemedicine

Diagnostic services provided at home

None of them

Don't know

Q29

Do you have a ABHA card (probe for card received from ANM or health department etc)?

Yes

No

Q30

Have you ever received any benefit from this card

Yes

No

Q31

What type of benefits have you received through your ABHA card?

Could share medical history with doctor

With ABHA card one can avail cashless transaction

Easy to find medical centres and consultant doctors

Cover of expenses of diagnostic services at Govt. Hospitals and dispensaries

Get discounts on medicines purchased from Govt. hospital and dispensaries

Up to Rs 5 lakhs coverage for the poor

Ensures that each member of the family gets access to quality healthcare services at empanelled hospitals

Any Other

Don’t know

Q32

Is there a system in place where frontline health workers maintain a registry for all those who are chronically ill in the village (including elderly) so that their health can be tracked by doctors?

Yes for everyone (including the elders)

Yes, for elders only

No

Q33

Is any one from your household suffering from any chronic illness?

Yes

No

Q34

What is/are their ages?

Q34_1

Patient 1

Q34_2

Patient 2

Q34_3

Patient 3

Q35

How much do you spend monthly on medicine for these patient/s?

Q36

Do you get any free medicine for their treatment?

Yes

No

Q37

If yes, how much worth of medicine you receive free for the total monthly expenses

Q38

Is/Are there anybody in the household who is/are mostly bed ridden and need constant care?

Yes

No

Q39

Is there a system or facility available through nearby health facilities or even private firms wherein trained ayas/nurses come home to take care of those who are chronically bed-ridden and take measures to reduce their suffering?

Yes

No

Q40

If it were made available, would you like to avail this service?

Yes

No

Q41

Would you be willing to pay for such a service?

Yes

No

Q42

Has someone in your household suffered from severe heat stroke or dehydration after working in extreme heat during the last one year?

Yes

No

Q43

Where did you take the patient for treatment?

Home treatment

Traditional healer

HSC

Health Welness Centre

PHC

CHC

District Hospital

Medical College

Pvt Hospital

Pvt Clinic/Nursing home

Q44

Does this happen often or rarely?

Happened often

Happened a few times

Happened very rarely

Q45

In the primary health facility you usually visit (local PHC/HWC) is there provisions for treatment of women subjected to physical and/or mental abuse?

Yes

No

Q46

If not, is there any alternate arrangement where victims of physical and/or mental abuse can go and get professional help?

Yes

No

Q47

Should such a facility be provided at the primary healthcare facility?

Yes

No

Q48

Does the local PHC/HWC offers counselling services for Mental Health patients

Yes

No

Q49

If not, if the need arises do you know where to go to get such services?

Yes

No

Q50

Should such a facility be provided at the primary healthcare facility?

Yes

No

Q51

Where do people get treatment for accident/trauma related cases in your locality

HSC

Health Wellness Centre

PHC

Pvt. Hospital

Pvt clinic

CHC

District Hospital

No facility available for treatment of accident/trauma cases in this locality

Q52

If Coded '8' does it usually get referred upwards to the district hospital?

Yes

No

Q53

Apart from your own savings how do you meet health expenses?

Loan from friends/relatives

SHG loans

Loan from local money lender

Loan from bank

Health insurance

Any Other

Q54

If coded '5' under which your/family members' health is insured?

Ayushman Bharat

State Govt scheme

Insurance companies

Insured by the employer

Health Template -Form Fill

Name of the state

Name of the district

Name of the respondent

Sex

Total number of household members

How many of them are in age group >60 years

Age of the respondent

Occupation of the Chief wage earner (CWE)

Completed level of education of the CWE

Usually, for smaller ailments which cannot be treated at home, where all do you go for seeking treatment?

To what extent do you depend on home-based medicine or treatment/medicine provided by village traditional healer?

Why do you prefer going in for such kind treatment?

For serious ailments which may or may not require hospitalisation, what is your 1st point of consultation

For surgeries, what is your 1st point of consultation?

Last time when you or any of your household members suffered from serious ailment or emergency where did you go first for consultation?

Did you get complete treatment in the facility or did you have to visit another facility?

For some serious ailments or surgeries. do people from your locality also go outside of the district for treatment?

How far do they go?

In last five years did you or any other member of your household go outside of your district for treatment?

How much did you spent on such treatment outside of your district?

why did you not go for treatment within your state?

Are the facilities of Telemedicine services/Doctor consultation on phone call available in your nearby government health facilities or locality?

Is the service of telemedicine/doctor consultation on call available in the health facilities you usually go to and can you also avail this sitting at home?

Have anyone in your household ever utilised telemedicine/doctor consultation on call facility?

Is there a system of direct delivery of diagnostics services (including someone coming to your house to collect blood or urea sample) at your doorstep available to the people of your village?

Have you ever availed this facility at home

Where do usually go for diagnostic services and purchasing/procuring of medicine var statement=document.write(localStorage.getItem('total'));

For Diagnostic services

Medicine purchasing/procuring

Which of these services do you or people like you need to be made available?

Do you have a ABHA card (probe for card received from ANM or health department etc)?

Have you ever received any benefit from this card

What type of benefits have you received through your ABHA card?

Is there a system in place where frontline health workers maintain a registry for all those who are chronically ill in the village (including elderly) so that their health can be tracked by doctors?

Is any one from your household suffering from any chronic illness?

What is/are their ages? var statement=document.write(localStorage.getItem('total'));

Patient 1

Patient 2

Patient 3

How much do you spend monthly on medicine for these patient/s?

Do you get any free medicine for their treatment?

If yes, how much worth of medicine you receive free for the total monthly expenses

Is/Are there anybody in the household who is/are mostly bed ridden and need constant care?

Is there a system or facility available through nearby health facilities or even private firms wherein trained ayas/nurses come home to take care of those who are chronically bed-ridden and take measures to reduce their suffering?

If it were made available, would you like to avail this service?

Would you be willing to pay for such a service?

Has someone in your household suffered from severe heat stroke or dehydration after working in extreme heat during the last one year?

Where did you take the patient for treatment?

Does this happen often or rarely?

In the primary health facility you usually visit (local PHC/HWC) is there provisions for treatment of women subjected to physical and/or mental abuse?

If not, is there any alternate arrangement where victims of physical and/or mental abuse can go and get professional help?

Should such a facility be provided at the primary healthcare facility?

Does the local PHC/HWC offers counselling services for Mental Health patients

If not, if the need arises do you know where to go to get such services?

Should such a facility be provided at the primary healthcare facility?

Where do people get treatment for accident/trauma related cases in your locality

If Coded '8' does it usually get referred upwards to the district hospital?

Apart from your own savings how do you meet health expenses?

If coded '5' under which your/family members' health is insured?

Where do usually go for diagnostic services and purchasing/procuring of medicine

What is/are their ages?