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    Household Survey Form

    Uploaded by

    Medalson Ronghang
    This document is a baseline household survey form that collects information about households in various villages. It collects details such as respondent profile, household information, family member details, migration status, government scheme benefits, landholding, agricultural inputs, produce, livestock, and sources of water, energy and power. The form has 11 sections to comprehensively understand the socio-economic status of village households.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Household Survey Form

    Uploaded by

    Medalson Ronghang
    193 views2 pages
    This document is a baseline household survey form that collects information about households in various villages. It collects details such as respondent profile, household information, family member details, migration status, government scheme benefits, landholding, agricultural inputs, produce, livestock, and sources of water, energy and power. The form has 11 sections to comprehensively understand the socio-economic status of village households.

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    © © All Rights Reserved

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    This document is a baseline household survey form that collects information about households in various villages. It collects details such as respondent profile, household information, family member details, migration status, government scheme benefits, landholding, agricultural inputs, produce, livestock, and sources of water, energy and power. The form has 11 sections to comprehensively understand the socio-economic status of village households.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    193 views2 pages

    Household Survey Form

    Uploaded by

    Medalson Ronghang
    This document is a baseline household survey form that collects information about households in various villages. It collects details such as respondent profile, household information, family member details, migration status, government scheme benefits, landholding, agricultural inputs, produce, livestock, and sources of water, energy and power. The form has 11 sections to comprehensively understand the socio-economic status of village households.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Baseline Household Survey Form

    Village: _________________________________ Gram Panchayat: ________________________________


    Ward No. ___________ ___________________ Block: _____________________________________
    District: ___________ ____________________ State: _____________________________________
    1. Respondent's Profile
    Name: Gender: Male / Female / Others Age (Yrs):

    Relationship with Head of Household: Contact Number:

    2. General Household Information (Tick appropriate option)


    Name of the Head (Household): Male / Female No. of family members:

    Category: Gen / SC / ST / OBC Poverty Status: APL / BPL


    Own House: Yes / No Type of House: Kutcha / Semi Toilet: Private / Community / Drainage linked to House:
    Pucca / Pucca/Homeless Open Defecation Covered / Open / None
    Waste Collection System - Compost Pit -
    Biogas Plant:
    Door Step / Common Point / No Collection System Individual / Group/ None Individual / Group / Community
    / None

    3. Family Member Information (Fil appropriate option)


    Sr. No. Name Age Sex Level of Going to Aadhaar Bank Computer Social Major MNREGA Self Help Occupa
    (Yrs.) M/ F / Educatio AWC/ Card A/C Literate Security Health Job Card Groups tions
    (First name) 0 n Code
    1
    School (Y/ N) (Y/N) Y/N Pension" Proble Y/N Tick Code6
    /College ms, against
    Code
    3
    if any member
    involved

    4. Migration Status in a family


    Does any member of the household migrate for Work? Yes / No
    If Yes How many members of the family migrated
    Family migrates for how many days/ months?
    Since how many years the migration is taking place? Yes / No

    Not Married — 1, Married — 2, Widowed — 3, Divorced/Separated — 4, Not Literate — 01, Literate — 02, Completed Class 5 — 03, Class 8' — 04, Class 10th- 05, Class 12"- 06,
    ITI Diploma-07, Graduate-08, Post Graduate/Professional — 09 (write the highest level applicable), Going to AWC — 01, School — 02, College — 03, Not Going — 04, Not Applicable- 05
    (write the highest level applicable) No Pension — 0, Old Age Pension —1, Widow Pension — 2, Disability Pension — 3, Other Pension — 4 (mention), 'Gen — 01, SC — 02, ST — 03, 08C— 04
    6 Farming on own Land-01, Sharecropping /Farming Leased Land-02, Animal Husbandry-03,Pisci-culture/Poultry-04,Fishing-05, Skilled Wage Worker-06,
    Unskilled Wage Worker-07, Salaried Employment in Government-08, Salaried Employment in Private Sector-09, Weaving-10, Other Artisan (mention)-11, Other Trade & Business-12�
    Baseline Household Survey Form
    5. Information of Government Schemes
    S. No. Name Beneficiary 6
    Individuals 7
    (In Number) 8
    1 PM Jan Dhan Yojana 9
    2 Sukanya Samridhi Yojana
    3 Mudra Yojana
    8. Landholding Information (in Acres)
    4 PM Jivan Jyoti Bima Yojana 1. Total 2. Cultivable
    5 PM Suraksha Bima Yojana Area
    6 Atal pension Yojana
    3. Irrigated Area 4. Un irrigated
    7 Kaushal Vikas Yojana
    Area
    8 Janani Suraksha Nana
    5. Barren/Waste 6. Uncultivable
    Beneficiary
    land area Area
    Household
    (Y/N) 9. Agricultural Inputs
    9 Fasal Bima Yojana
    Particulars Tick If Yes,
    10 Kisan Credit Card
    appropriately Fertilizer
    11 Krishi Sinchai Yojana
    Use(Kg/Acre)
    12 Swachh Bharat Mission Toilet
    Do you use Chemical Fertilisers Yes/No
    13 Soil Health Card
    Do you use Chemical Yes/No
    14 PM Ujjwala Yojana
    Insecticides
    15 PM Awas Yojana
    Do you use Chemical Weedicide Yes/No
    6. Source of Water (Distance from source in km) Do You use organic Manures Yes/No

    Source of Water Distance Irrigation: Canal / Tank / Borewell / River/Other / None


    Piped Water at Home Yes / Irrigation System: Drip / Sprinkler / Flooding/ None
    No
    10. Agricultural Produce in a normal year (Top 5)
    Community Water Yes /
    Tap No S. Area under the Producti
    Hand Pump (Public / Private) No. Crop in Prey. Year vity (in
    Cro p
    Y es / N o (Acre) quintals
    Open Well (Public / Private) per Acre)
    Y es / N o 1
    Mode of Water Storage 2
    (Community/Individual) 3
    4
    Any other source (mention) 5

    11. Livestock Numbers (in numbers)


    7. Source of Energy and Power (Tick appropriately) Goats/
    Cows: Buffalo:
    Sheep:
    Electricity Connection to Household: Yes / No Poultry/
    Calves: Bullocks:
    Ducks:
    Electricity Availability per day (hours):
    Others (mention):
    Lighting: Electricity / Kerosene / Solar Power
    Mention if Any Other: Shelter for Livestock: Pucca / Kutcha / Open

    Cooking: LPG / Biogas / Kerosene / Wood / Cow Dung / Average Daily Production of Milk(Litres):_

    Agro-Residues / Electricity Animal Waste/Cow Dung (in Kg.)

    Mention if Any Other:


    12. Major problems in village, if any (Top 3)
    If cooking in Chullah: Normal/ Smokeless
    SN Appliances Nos. Duration/day Problems Possible Suggestions by villagers
    (in hours)

    1.
    2.
    3.
    4.
    Schedule Filled By (Name & Sign):
    5. Date of Survey:

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