Surveypoint

Q01

District Name

Q02

District Code

Q03

Block Name

Q04

Block Code

Q05

Village Name

Q06

Village Code

Q07

Village Organization Name

Q08

Village Organization Code

Q09

Number of SHGs under the Village Organization

Q10

Type of Area

Q11

Name of Gram Panchayat

Q12

Code of Gram Panchayat

Q13

Date of visit

Q14

Interviewer name

Q15

Interviewed code

Q16

Result of the interview

VO does not exist

VO exists but does not have record of SHGs

VO members not available for interview

Interview complete

Others (Specify)

A01

Please provide the following details for all the SHGs under this VO.

A02

Code of VO

A03

Name of the SHG

A04

SHG code

A05

Number of SHG members

A06

When did this SHG join the VO?

A07

Is the SHG functional?

Yes

No

A08

Total amount of loan received by this SHG from the VO till date?

A09

Grading of the SHG

A10

Total number of SHGs under the VO reported by UPSRLM

A11

Total number of SHGs reported by VO records

B01

SHG Code

B02

Name of the current SHG member

B03

Member code

B04

Name of the member’s husband or Father-in-law

B05

Name of the hamlet within the village

B06

When did this member join the SHG?

C01

Name of the current SHG member

C02

Household identification code

C03

Code of the SHG

C04

Code of the VO

C05

Interviewer name

C06

Interviewed code

C07

Date of the interview

C08

Result of the interview

Interview complete

Visit rescheduled

Interview incomplete

Refused

Household not located

Respondent is out of station for extended period

Respondent is temporarily away

Other (specify)

C09

Record time when you start the interview

D01

What is the religion of the household?

Hindu

Muslim

Christian

Sikh

Buddhist/neo-Buddhist

Jain

Jewish

Parsi/Zoroastrian

No religion

Others (Specify)

Don’t know

D02

What is the caste of the household?

Scheduled Caste

Scheduled Tribe

Other Backward Class

General

Others (Specify)

Don’t know

D03

What type of ration card (color) does your household have?

Priority household card (PHH) (Orange)

Antodaya Ann Yojana card (AAY) (Yellow)

No ration card

D04

Can you read and write?

Cannot read and write

Can read only

Can sign only

Can read and write

D05

What is the highest standard or class you have completed?

D06

Can your husband read and write?

Yes

No

Husband is not alive

D07

What is the highest standard your husband has completed?

D08

Apart from housework, what kinds of work did/do you do for which you are paid in cash or kind in the last 12 months?

Self‐employed in agriculture/ fishery/ orchard/ animal husbandry

Self‐employed in non‐agriculture

Regular salaried/wage employee in government/private sector

Casual wage labor in public works (e.g., MGNREGA)

Casual labor in agriculture

Casual labor in non‐agriculture other than public works

Traditional service occupation (Cobbler, Dhobi, Barber)

Unpaid family workers in agriculture/fishery/orchard/animal husbandry

Unpaid family worker in non-agriculture

Unemployed

Others (Specify)

D09

How many members currently stay in this household? By this, we mean people who are usual residents and eat from the same kitchen.

D10

How many women/girls who are usual residents in this household are between the ages of 15 and 49 years?

D11

How many of the above women/girls have ever been married?

D12

Were there any ever-married woman/girl aged 15-49 years who were usual resident in this household but no longer live here due to out-migration or death after Feb 2018?

Yes

No

D13

Please tell me the total number of such women/girls who out-migrated or died?

D14

Name of the ever-married girl

D15

Type of the respondent

Self

Others

D16

Age in completed years

D17

Since when have you been in this village/town

D18

Are you currently pregnant?

Yes

No

D19

How many months are you pregnant?

D20

Did give birth after 28th Feb 2018?

Yes

No

E01

Record the woman’s name and S. No from 506

E02

Please tell me the total number of births that you had between after Feb 2018.

E03

What is the name of the child?

E04

What is the sex of the child?

Boy

Girl

Other

Don’t know

E05

Please tell me the date of birth of the child

E06

Is the child still alive?

Yes

No

E07

Was this a single or multiple birth?

Single

Multiple

E08

Is the child living with you?

Yes

No

F01

Is there any child born after Feb 2018, who lives in the household without his/her mother?

Yes

No

Refuse to answer

F02

Please tell me the total number of children born after Feb 2018, who have not been documented.?

F03

What is the name of the child?

F04

What is the name of the child’s mother?

F05

What is the sex of the child?

Boy

Girl

Other

Don’t know

F06

Please tell me the date of birth of the child

G01

Number of currently pregnant women in the household

G02

Number of focal children born after Feb 2018.

G03

Record time when you end the interview

G04

Record the number respondents for main survey

G04_1

Currently pregnant women

G04_2

Mothers of 0-5-month child

G04_3

Mothers of 6-11-month child

G04_4

Household Listing Template 2 -Form Fill

District Name

District Code

Block Name

Block Code

Village Name

Village Code

Village Organization Name

Village Organization Code

Number of SHGs under the Village Organization

Type of Area

Name of Gram Panchayat

Code of Gram Panchayat

Date of visit

Interviewer name

Interviewed code

Result of the interview

Please provide the following details for all the SHGs under this VO.

Code of VO

Name of the SHG

SHG code

Number of SHG members

When did this SHG join the VO?

Is the SHG functional?

Total amount of loan received by this SHG from the VO till date?

Grading of the SHG

Total number of SHGs under the VO reported by UPSRLM

Total number of SHGs reported by VO records

SHG Code

Name of the current SHG member

Member code

Name of the member’s husband or Father-in-law

Name of the hamlet within the village

When did this member join the SHG?

Name of the current SHG member

Household identification code

Code of the SHG

Code of the VO

Interviewer name

Interviewed code

Date of the interview

Result of the interview

Record time when you start the interview

What is the religion of the household?

What is the caste of the household?

What type of ration card (color) does your household have?

Can you read and write?

What is the highest standard or class you have completed?

Can your husband read and write?

What is the highest standard your husband has completed?

Apart from housework, what kinds of work did/do you do for which you are paid in cash or kind in the last 12 months?

How many members currently stay in this household? By this, we mean people who are usual residents and eat from the same kitchen.

How many women/girls who are usual residents in this household are between the ages of 15 and 49 years?

How many of the above women/girls have ever been married?

Were there any ever-married woman/girl aged 15-49 years who were usual resident in this household but no longer live here due to out-migration or death after Feb 2018?

Please tell me the total number of such women/girls who out-migrated or died?

Name of the ever-married girl

Type of the respondent

Age in completed years

Since when have you been in this village/town

Are you currently pregnant?

How many months are you pregnant?

Did give birth after 28th Feb 2018?

Record the woman’s name and S. No from 506

Please tell me the total number of births that you had between after Feb 2018.

What is the name of the child?

What is the sex of the child?

Please tell me the date of birth of the child

Is the child still alive?

Was this a single or multiple birth?

Is the child living with you?

Is there any child born after Feb 2018, who lives in the household without his/her mother?

Please tell me the total number of children born after Feb 2018, who have not been documented.?

What is the name of the child?

What is the name of the child’s mother?

What is the sex of the child?

Please tell me the date of birth of the child

Number of currently pregnant women in the household

Number of focal children born after Feb 2018.

Record time when you end the interview