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Household Template 21 -Form Fill

Village Information
Q01

State
Q02

Code

Q03

District
Q04

Code

Q05

Block
Q06

Code

Q07

Village
Q08

Code

Q09

Hamlet
Q10

Structure No.
Q11

HH No.
Q12

UID
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

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
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
D01

Name of the respondent
D02

Line Number of respondent
D03

What is your religion?
D04

Which caste do you belong to?
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 thehousehold 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
EDUCATION
E01

Name of child
E02

Age
E03

Sex
E04

Reading level
E05

Math level
E06

Was [Name] ever enrolled in any school?
E07

What was the age of [child name] when s/he was enrolled in the school for first time?
E08

From the time that [Name] was enrolled for the first time till what age did s/he go to school without dropping out?
E09

Is [Name] currently attending school/college?
E10

Which school does (s) he go to?
E11

Which standard is [Name] currently enrolled in?
E12

What are the entitlements that [Name] avail at school?
ACESS TO AND KNOWLEDGE OF GOVERNMENT SCHEMES
F01

Have you ever heard about _?

F01_1

Indira Awas Yojna (IAY)
F01_2

Swajaldhara
F01_3

Swachh Bharat Abhiyan (SBA)
F01_4

Janani Shishu Suraksh Karykaram (JSSK)
F01_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)
F01_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
F01_7

Atal Pension Yojana
F01_8

Pension for the disabled
F02

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

F02_1

Indira Awas Yojna (IAY)
F02_2

Swajaldhara
F02_3

Swachh Bharat Abhiyan (SBA)
F02_4

Janani Shishu Suraksh Karykaram (JSSK)
F02_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)
F02_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
F02_7

Atal Pension Yojana
F02_8

Pension for the disabled
F03

Has anyone in your household ever availed this scheme?

F03_1

Indira Awas Yojna (IAY)
F03_2

Swajaldhara
F03_3

Swachh Bharat Abhiyan (SBA)
F03_4

Janani Shishu Suraksh Karykaram (JSSK)
F03_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)
F03_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
F03_7

Atal Pension Yojana
F03_8

Pension for the disabled
F04

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

F04_1

Indira Awas Yojna (IAY)
F04_2

Swajaldhara
F04_3

Swachh Bharat Abhiyan (SBA)
F04_4

Janani Shishu Suraksh Karykaram (JSSK)
F04_5

Pradhanmantri Surakha Beema Yojana (accidental death insurance)
F04_6

Pradhan Mantri Jeevan Jyoti Beema Yojana (Life Insuarance)
F04_7

Atal Pension Yojana
F04_8

Pension for the disabled
F05

Have you ever heard about Mahatma Gandhi rural Employment Guarantee Act?
F06

Does anyone in your household have a MGNREGA job card? If yes, please show me.
F07

In the past year, how many days did members of your household work for MGNREGA?
F08

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?
F09

When was the last time someone in your household worked for MGNREGA in last 1 year?
F10

Have you ever heard of Public Distribution System?
F11

Have you ever heard of Antyodaya Anna Yojana?
F12

Does your household have a ration card?
F12A

Is your name included in the ration card?
F13

Which card do you have?
F14

In the past 30 days, did you buy anything from a ration shop?
F15

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

F16

Whether Purchased

F16_1

Rice
F16_2

Wheat
F16_3

Sugar
F16_4

Salt
F16_5

Kerosene
F16_6

Clothes
F17

Quantity Purchased

F17_1

Rice
F17_2

Wheat
F17_3

Sugar
F17_4

Salt
F17_5

Kerosene
F17_6

Clothes
F18

Have you ever heard of the ICDS scheme / Anganwadi centre?
F19

At present is there any ____ in your household?

F19_1

Pregnant Woman
F19_2

Lactating Woman
F19_3

Child aged 6-35 months
F19_4

Child aged 3-6 years
F20

Did the member receive supplementary nutrition / hot cookedfoodfrom the AWC in the last 12 months?

F20_1

Pregnant Woman
F20_2

Lactating Woman
F20_3

Child aged 6-35 months
F20_4

Child aged 3-6 years
F21

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

F21_1

Pregnant Woman
F21_2

Lactating Woman
F21_3

Child aged 6-35 months
F21_4

Child aged 3-6 years
F22

Have you ever heard about the Janani suraksha Yojana Scheme?
F23

Do you know how much money the beneficiary is supposed to get under the JSY scheme?
F24

Does the household avail the following?

F24_1

SAVINGS
F24_2

CREDIT
F24_3

INSURANCE
F24_4

REMITTANCE
F24_5

PENSION
F25

Where does the household save?
F26

From what sources does the household avail credit?
F27

What type of insurance does the household have?
F28

Does anyone in your household have a bank account opened under the Pradhan Mantri Jan Dhan Yojana?
F29

Has the account been operated in the last 3 months?
F30

What activity was performed on the account?
F31

Have you availed the overdraft facility from your account under the Jan Dhan Yojana in the last 1 year?
F32

If yes, what was the overdraft amount?
F33

Does any member of your household avail retirement pension?
F34

What are the pensions that the household members receive?
F35

Have you ever heard of the old Age Pension Scheme?
F36

How many members in your household were eligible for the Old Age Pension Scheme in the last 1 year?
F37

How many members availed the Old Age Pension Scheme in the last 1 year?
F38

Have you ever heard of the widow pension scheme?
F39

How many members in your household were eligible for the Widow Pension Scheme in the last 1 year?
F40

How many members have availed the Widow Pension Scheme in the last 1 year?
F41

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

F42

Does your Household have a RSBY smart card?
F43

Was the smart card updated in the last one year?
F44

Did anyone in your household use the smart card in last one year?
LAND OWNERSHIP AND USE OF LAND FOR FARMING
G01

Does any your household own, lease in any agricultural land?
G02

Does your household engage in agricultural activities?
G03

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

G03A

OWNED LAND
G03A1

UNIT
G03B

LEASED LAND
G03B1

UNIT
G04

Out of this land how much is irrigated or rainfed?

G04A

IRRIGATED LAND
G04A1

UNIT
G04B

RAINFED LAND
G04B1

UNIT
Risk taking Behaviour and adoption of new crop varieties
H01

What is the main crop that your produce?
H02

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.
H03

What type of crops do you choose to grow?
H04

What type of animals do you rear
H05

What type of non-farm activities do you undertake?
PRODUCTION TECHNOLOGY (ASK THIS SECTION TO THE RESPONDENT ONLY)
I01

Main crop of household
I02

What type of seed was primarily used for production of ____?
I03

When was the last time you purchased new seeds for this crop?
I04

Do you treat the seeds in some way before planting?
I05

How long before transplantation/sowingdo you practice weeding?
I06

Do you use a germination test to check the seeds?
I07

Was any fertilizer used on the land during production of _______?
I08

Do you apply anything else to improve the quality of the soil?
I09

For this crop, are you mostly using line planting/transplanting or do you broadcast the crop in the main field or both?
I10

At what stage of the cropping practices do you usually apply urea?
I11

How many days after planting do you irrigate the crop?
I12

After planting, when do you practice earthing-up?
I13

Do you practice hoeing in fields where you grow _____?
I14

What inputs does your HH normally purchase for a cropping season

I14_1

SEEDS
I14_2

CHEMICAL FERTILIZERS
I14_3

ORGANIC FERTILIZERS
I14_4

CHEMICAL PESTICIDES
I14_5

ORGANIC PESTICIDES
I14_6

FARMING TOOLS (such as spades, sickles etc.)
I14_7

FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
I14A

Do you ever go to purchase _____ for the crop?

I14A_1

SEEDS
I14A_2

CHEMICAL FERTILIZERS
I14A_3

ORGANIC FERTILIZERS
I14A_4

CHEMICAL PESTICIDES
I14A_5

ORGANIC PESTICIDES
I14A_6

FARMING TOOLS (such as spades, sickles etc.)
I14A_7

FARMING IMPLEMENTS (such as tillers, threshers, Pesticide sprayers etc.)
I15

Who decides on the purchase of inputs required for farming?
I16

Where does your HH purchase the inputs from?

I17

What according to you is the best place to buy the agricultural inputs from?
I18

Why do you think ____ is the best place to buy the agricultural inputs?
I19

Does yourhh sell any of the agricultural produce in the market?

I19_1

Cereal
I19_2

Pulses
I19_3

Vegetable
I19_4

Fruits
I19A

Do you ever go to sell _____?

I19A_1

Cereal
I19A_2

Pulses
I19A_3

Vegetable
I19A_4

Fruits
I20

Who decides on the sale of the produce in the market?
I21

Where does yourhh sell the produce?
I22

What according to you is the best place to sell the agricultural produce?
I23

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
J01

Did you participate in _____ in the past 12 months?

J01_1

Food crop farming: crops that are grown primarily for household food consumption
J01_2

Cash crop farming: crops that are grown primarily for sale in the market
J01_3

Livestock raising
J01_4

Poultry (e.g. chicken, duck, pigeon)
J01_5

piscicultueor fishpond culture
J02

How much input did you have in making decisions about _____?

J02_1

Food crop farming: crops that are grown primarily for household food consumption
J02_2

Cash crop farming: crops that are grown primarily for sale in the market
J02_3

Livestock raising
J02_4

Poultry (e.g. chicken, duck, pigeon)
J02_5

piscicultueor fishpond culture
J03

Are youengaged in any of the agricultural activities?
J04

Are you engaged in ________?

J04_1

Tilling/ Ground preparation
J04_2

Sowing/Transplanting
J04_3

Intercultural operations (weeding, hoeing)
J04_4

Fertiliser application
J04_5

Irrigation application
J04_6

Harvesting
J05

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

J05_1

Tilling/ Ground preparation
J05_2

Sowing/Transplanting
J05_3

Intercultural operations (weeding, hoeing)
J05_4

Fertiliser application
J05_5

Irrigation application
J05_6

Harvesting
INCOME
K01

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

K02

Whether earned from this activity?

K02_1

In last 12 months has anyone in your household engaged in agriculture labour
K02_2

In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging wells etc.
K02_3

In last 12 months has anyone in your household engaged in skilled labour
K02_4

In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
K02_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.)
K02_6

In last 12 months has anyone in your household earned from salaried job?
K02_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

K03

Who in the household earned income over last 12 months?
K04

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

K04_1

In last 12 months has anyone in your household engaged in agriculture labour
K04_2

In last 12 months has anyone in your household engaged in non-agricultural labour like construction of roads, carrying bricks, digging wells etc.
K04_3

In last 12 months has anyone in your household engaged in skilled labour
K04_4

In last 12 months has anyone in your household engaged in Small business activities (street vending, shop keeping, handicrafts, sells liquor)
K04_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.)
K04_6

In last 12 months has anyone in your household earned from salaried job?
K04_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

K05

In the last 12 months, has any member of the household or other relatives have sent you any money from outside?
K06

How often has your household received remittances in the last 12 months?
K07

How much money did your household receive as remittances in the last 12 months?
K08

During the last 12 months, did anyone in the household own any animals including livestock, poultry, fish, etc.?
K09

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

K09_1

Buffalo
K09_2

Oxen
K09_3

Cow

K09_4

Goat
K09_5

Sheep
K09_6

Duck
K09_7

Poultry
K09_8

Pig
K09_9

Fish
K10

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

K10_1

Buffalo
K10_2

Oxen
K10_3

Cow

K10_4

Goat
K10_5

Sheep
K10_6

Duck
K10_7

Poultry
K10_8

Pig
K10_9

Fish
K11

Now we would like some information on your household's production and selling of animal products. Please only consider the previous 12 months.

K12

Did you produce any ___ during the last 12 months?

K12_1

Animal/Fish meat/offal
K12_2

Poultry meat/offal
K12_3

Milk (including that produced for milk
K12_4

Eggs
K13

Did your household sell any of the ___ produced?

K13_1

Animal/Fish meat/offal
K13_2

Poultry meat/offal
K13_3

Milk (including that produced for milk
K13_4

Eggs
K14

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

K14_1

Animal/Fish meat/offal
K14_2

Poultry meat/offal
K14_3

Milk (including that produced for milk
K14_4

Eggs
K15

Did your household engage in agricultural activities in the past 12 months?
K16

Crop Code
K17

What is the total quantity produced?
K18

How much of the harvested____was sold?
K19

What was the income from the sale of ___?
K20

Does your household receive any farm produce from the land that you lease out?
K21

Crop Code
K22

What is the total quantity received?
K23

How much of the received ____was sold?(Quantity in kg)
K24

What was the income from the sale of ___?
FOOD SECURITY
L01

How many meals did you eat yesterday during the day and night?
L02

How many meals did the adult members (18+) of your household eat yesterday during the day and night?
L03

How many meals did the children 6 to18 years in this household eat yesterday during the day and night?
L04

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

L05

YOU AND OTHER FEMALE MEMBERS OF THE HH

L05_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
L05_2

Beans and peas, pulses groundnuts and cashew nuts`
L05_3

Vegetables (including leaves)
L05_4

Fruits

L05_5

Egg, meat, fish etc.
L05_6

Milk/yogurt/other dairy product

L05_7

Sugar or sugar products, honey
L05_8

Oils/fats/butter
L06

CHILDREN AGE 6-18 YRS

L06_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
L06_2

Beans and peas, pulses groundnuts and cashew nuts`
L06_3

Vegetables (including leaves)
L06_4

Fruits

L06_5

Egg, meat, fish etc.
L06_6

Milk/yogurt/other dairy product

L06_7

Sugar or sugar products, honey
L06_8

Oils/fats/butter
L07

OTHER MALE MEMBERS

L07_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
L07_2

Beans and peas, pulses groundnuts and cashew nuts`
L07_3

Vegetables (including leaves)
L07_4

Fruits

L07_5

Egg, meat, fish etc.
L07_6

Milk/yogurt/other dairy product

L07_7

Sugar or sugar products, honey
L07_8

Oils/fats/butter
L08

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

L08_1

Rice, Wheat, Maize, maize porridge, Other cereal (sorghum, millet, etc), Roots and Tubers (cassava, potatoes, sweet potatoes)
L08_2

Beans and peas, pulses groundnuts and cashew nuts`
L08_3

Vegetables (including leaves)
L08_4

Fruits

L08_5

Egg, meat, fish etc.
L08_6

Milk/yogurt/other dairy product

L08_7

Sugar or sugar products, honey
L08_8

Oils/fats/butter
COPING STRATEGY
M01

Usually, does your household has sufficient food available for the whole year?
M02

If no, in a year how many months / days, the household has insufficient food?
M03

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

M03_1

Skip entire days without eating?
M03_2

Limit portion size at mealtimes?
M03_3

Reduce number of meals eaten per day?
M03_4

Borrow food or rely on help from friends or relatives?
M03_5

Rely on less expensive or less preferred foods?
M03_6

Purchase/borrow food on credit?
M03_7

Gather unusual types or amounts of wild food / hunt?
M03_8

Send household members to eat elsewhere?
M03_9

Send household members to beg?
M03_10

You or other female members eat less?
M04

Have you sold any household assets to buy food?
MALARIA
N01

Does your household have any mosquito nets that can be used while sleeping?
N02

How many mosquito nets does your household have?
N03

Has any of the mosquito nets been treated or sprayed with any kind of medicine in the last 12 months?
N04

How many mosquito nets have been treated or sprayed with medicine in the last one month?
N05

In the past 12 months were the interior walls of your dwelling sprayed against mosquitoes?
N06

Has any member of your household been detected with malaria in the past 3 months?
N07

How many members of your household been ill with malaria in the past 3 months?
N08

Line No.
N09

Slept under mosquito net last night
N10

Slept under ITN last night
N11

Been ill with fever in the last 2 weeks
N12

If yes, was (s)he tested for malaria
N13

If yes, did (s)he test positive
N14

Was (s)he given any drugs for treatment
MATERNAL HEALTH
O01

During your pregnancy with [CHILD NAME], did you register the pregnancy?
O02

In which month of pregnancy was your pregnancy registered?
O03

During your pregnancy with [CHILD NAME], did you go to see anyone for antenatal checkup?
O04

During your pregnancy with [CHILD NAME], did anyone come to you for antenatal checkup?
O05

Who all did your antenatal checkups during your pregnancy with [CHILD NAME]?
O06

When you were pregnant with [CHILD NAME], how many times did you receive antenatal checkup?
O07

During your pregnancy, as part of your antenatal check-ups were you weighed?
O08

During your pregnancy, as part of your antenatal check-ups was your blood pressure measured?

O09

During your pregnancy, as part of your antenatal check-ups did you give a urine sample?

O10

During your pregnancy, as part of your antenatal check-ups was your blood checked for hemoglobin level?
O11

During your pregnancy, as part of your antenatal check-ups was your abdomen checked?

O12

During your pregnancy, as part of your antenatal check-ups was your ultrasound done?

O13

During your pregnancy with [CHILD NAME], were you given a TT injection?
O14

During your pregnancy with [CHILD NAME], how many times did you receive a tetanus injection?
O15

During your pregnancy with [CHILD NAME], did you receive any Iron Folic Acid (IFA) tabletsor bottles?
O16

How many tablets or bottles did you receive in total during your whole pregnancy with [CHILD NAME]?
O17

During the whole pregnancy with [CHILD NAME], how many tablets or bottles did you consume?

O18

During the whole pregnancy, for how many days did you take the tablets or syrup?
O19

Did the ASHA come to meet you at your home during your pregnancy with [CHILD NAME]?
O20

How many times did the ASHA come to meet you at your home during your pregnancy with [CHILD NAME]?
O21

Was the delivery caesarean?
O22

Where did you deliver [CHILD NAME]?
O23

What type of a government health facility was it?
O24

Did you receive a benefit for delivery care from the Government (Janani Suraksha Yojana)?
O25

How much was the payment received?
O26

How long after the delivery did you receive the financial payment/assistance?
O27

Did the ASHA come to your home to check on you or [CHILD NAME] within 24 hours after your delivery?
CHILD HEALTH &NUTRITION (RC1/2/3)
P01

Did you ever breastfeed [CHILD NAME]?
P02

How long after birth did you first put [CHILD NAME] to the breast?
P03

Did you feed [CHILD NAME] your first yellow thick milk (local term)?
P04

Are you still breastfeeding [CHILD NAME]?
P05

For how many months did you breastfeed [CHILD NAME]?
P06

How long did you exclusively breastfeed [CHILD NAME]?
P07

Have you breastfed [CHILD NAME] in the past 24 hours – either day time or night time?
P08

How many times did you breastfeed [CHILD NAME] in the past 24 hours – either day time or night time?
P09

Next I would like to ask you about some liquids that your child may have had yesterday during the day or at night.

P09_1

PLAIN WATER
P09_2

HONEY
P09_3

SUGAR WATER
P09_4

GHUTTI
P09_5

OIL TO CLEAN TONGUE
P09_6

TINNED / POWDERED MILK
P09_7

ANIMAL MILK
P09_8

RICE WATER
P09_9

DAL WATER
P09_10

ROTI MIXED IN MILK
P09_11

SATTU IN WATER/MILK
P09_12

THIN SUJI HALWA
P09_13

THIN KHICHDI
P09_14

JUICE
P09_15

OTHER LIQUIDS
P09_16

OTHER FOOD
P10

Do you have a mother and child protection card (immunization card)?
P11

COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. CODE ‘77’ IF CARD IS BLANK AND THEN SKIP TO N12. WRITE ‘44’ IN ‘DAY’ COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. CODE 0 IF DATE IS NOT MENTIONED & THE CARD DOES NOT SHOW THAT A VACCINE WAS GIVEN OR NOT. IF ONLY PART OF DATE IS SHOWN ON CARD, RECORD ‘99’ OR ‘9999’ FOR ‘DO NOT KNOW’ IN THE COLUMN FOR WHICH INFORMATION IS NOT GIVEN.

P11_1

BCG
P11_2

POLIO 0 (POLIO GIVEN AT BIRTH)
P11_3

HEPATITIS B 0 (HEPATITIS B GIVEN AT BIRTH)
P11_4

POLIO 1
P11_5

DPT 1
P11_6

HEPATITIS B 1
P11_7

PENTAVALENT 1
P11_8

POLIO 2
P11_9

DPT 2
P11_10

HEPATITIS B 2
P11_11

PENTAVALENT 2
P11_12

POLIO3
P11_13

DPT 3
P11_14

HEPATITIS B 3
P11_15

PENTAVALENT 3
P11_16

MEASLES
P11_17

DPT (16-24 MONTHS)
P11_18

POLIO (16-24 MONTHS)
P11_19

VITAMIN A (FIRST DOSE)
P11_20

VITAMIN A (SECOND DOSE)
P11_21

VITAMIN A (THIRD DOSE)
P12

Please tell me if [CHILD NAME] received any of the following vaccinations:

P12_1

A BCG vaccination against tuberculosis that is, an injection in the arm or shoulder that usually causes a scar?
P12_2

A Polio vaccine that is drop given in the mouth?
P12_3

How many times?
P12_4

Was the first polio vaccine received in the first two weeks after birth?
P12_5

Drops in the mouth as part of the Pulse Polio campaign?
P12_6

A DPT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?
P12_7

How many times?
P12_8

A Hepatitis B vaccination, that is, an injection given sometimes at the same time as DPT?
P12_9

How many times?
P12_10

A pentavalent vaccine given in place of DPT, HEP B and Hib in child’s thigh to protect from 5 diseases.
P12_11

How many times?
P12_12

An injection against measles at right arm/shoulder?
P12_13

Vitamin A that is given by a spoon?
P12_14

How many times?
P13

Do you give [CHILD NAME] any solid, semi-solid, mashed or soft foods to eat?
P14

Now I would like to ask you about the food [CHILD NAME] ate during the last 24 hours, either separately or combined with other foods.

P14_1

Porridge or gruel (Rice/Khichdi)
P14_2

Biscuit
P14_3

Commercially fortified baby food such as Cerelac or Farex
P14_4

Bread, roti, chapatti

P14_5

Daal (Foods made with lentils or beans)
P14_6

Pumpkin, carrots, or sweet potatoes that are yellow or orange inside
P14_7

Green leafy vegetables
P14_8

Ripe mangoes or ripe papayas
P14_9

Other fruits or vegetables (potatoes)
P14_10

Meat/chicken/fish
P14_11

Egg
P14_12

Nuts
P14_13

Salty purchased snacks foods (chips, kurkure, namkeen,)
P14_14

Sweet purchased snacks ( chocolate, candies)
P15

From what age did you start feeding [CHILD NAME] solid, semi-solid, mashed or soft foods?
P16

Excluding oil for cooking, did you add oil/ghee/butter to the food you gave [CHILD NAME] in the last 24 hours?
P17

How many times did [CHILD NAME] eat solid, semi-solid, mashed or soft foods other than liquids yesterday during the last 24 hours?
SELF-HELP GROUPS AND LEADERSHIP
R01

Are you a member of any Self-help group (SHG)?
R02

Are you a panchayat member?
R03

What position do you hold as a panchayat member?
R04

Are you a member of any committee associated with Gram Panchayat?
R05

Which committees are you associated with?
GENDER
S01

Did you engage in any income generating activities in last 12 months?
S02

Was it usually at home or away from home?
S03

Was it usually throughout the year, seasonal or once in a while?
S04

Were you usually paid in cash or kind for this work?
S05

According to you, what share of household income do you contribute to?
S06

Who decided how to use the money you earn?
S07

Do you have any money of your own that you can decide how to spend?
S08

Do you save any of the income that you earn?
S09

Where do you save?
S10

Does your household have any bank account?
S11

Who does the account belong to?
S12

Is there an account in your name?
S13

If yes, have you operated it in the last 3 months?
S14

What is your role in buying or selling of land or other similar assets?
S15

What is your role in buying, selling OR mortgaging of gold or other jewelry?
S16

What is your role in buying or selling of livestock?
S17

What is your role in buying or selling of farm produce?
S18

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

S18_1

To go out and work
S18_2

Ration Shop
S18_3

Paternal Home
S18_4

Weekly Market
S18_5

Government Offices
S18_6

Banks
S18_7

Gram Sabha
S18_8

Jati Panchayat
S18_9

Police Station
S18_10

Meeting/training in the village
S18_11

Meeting / training outside village
S19

Do you usually go to the local market place?
S20

Was any Gram Sabha meeting held during the last one year?
S21

How many Gram Sabha meetings were held in the last one year?
S22

Did you attend any of the Gram Sabha meetings that were held in the last one year?
S23

How many meetings did you attend in the last one year?
S24

Did you raise any issue in the meetings that you attended?
S25

Was any Jati Panchayat meeting held during the last one year?
S26

How many Jati Panchayat meetings were held in the last one year?
S27

Did you attend any of the Jati Panchayat meetings that were held in the last one year?
S28

How many meetings did you attend in the last one year?
S29

Did you vote in any of the elections in last 5 years?
S30

Who decides who will you cast your vote to?
S31

Have you ever wathched TV in the last one year?
S32

How often do you watch TV?
S33

Have you ever listened to theradio in the last one year?
S34

How often do you listen to the radio?
S35

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?
S36

What do you think should be ideal age for girls to get married?
ANTHROPOMETRY
T01

Name of index child
T02

Sex
T03

RECORD DATE OF BIRTH
T04

RECORD AGE OF [CHILD NAME]
T05

Name of mother
T06

Age of mother
T07

RECORD WHETHER WEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
T08

RECORD WEIGHT (G) OF THE MOTHER AND CHILD

T08A

FIRST MEASUREMENT
T08B

SECOND MEASUREMENT
T09

RECORD WEIGHT (G) OF THE MOTHER

T09A

FIRST MEASUREMENT
T09B

SECOND MEASUREMENT
T10

RECORD WHETHER CHILD’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
T11

RECORD HEIGHT (cm)

T11A

FIRST MEASUREMENT
T11B

SECOND MEASUREMENT
T12

RECORD WHETHER MOTHER’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
T13

RECORD HEIGHT (cm)

T13A

FIRST MEASUREMENT
T13B

SECOND MEASUREMENT
T14

Is there a girl of age 10-19 years in this household?
T15

What is the name of the adolescent girl?
T16

What is the age of the adolescent girl?
T17

RECORD WHETHER ADOLESCENT GIRL’SWEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
T18

RECORD WEIGHT (KG)

T18A

FIRST MEASUREMENT
T18B

SECOND MEASUREMENT
T19

RECORD WHETHER ADOLESCENT GIRL’S HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
T20

RECORD HEIGHT (cm)

T20A

FIRST MEASUREMENT
T20B

SECOND MEASUREMENT