HOUSEHOLD SURVEY

WARD NO:

OWNER NAME:
MEMBER DETAILS:

NO. MALE FEMALE CHILD/INFANT(GENDER) AGE EDUCATION WORKING

1
2
3
4
5
6
7
8

HOUSE TYPOLOGY

OWN
RENTED
1BHK 2BHK 3BHK OTHER
BUNGALOW
ROW HOUSE
TENAMENT
APPRTMENT
CHAWL
POL HOUSE

NO. OF VEHICLES

CYCLE
2 WHEELER
3 WHEELER
4 WHEELER

DISTANCE OF WORKPLACE FROM HOME

DISTANCE OF RECREATIONAL SPACE
DISTANCE OF MARKET PLACE
DISTANCE OF INSTITUTION PLACE

REGULAR MODE OF TRANSPORT

USE OF PUBLIC TRANSPORT

YES NO IF YES THEN FREQUENCY