Survey

Q.1 House number (Assigned by PCD):

Q.2 Number of family members:

Q.3
Sr. No NAME GENDER AGE RELATION QUALIFICATION AADHAR CARD
WITH HEAD
1 Yes/no
2 Yes/no
3 Yes/no
4 Yes/no
5 Yes/no
6 Yes/no
7 Yes/no
8 Yes/no

Q.4 Contact number:

Q.5 What is source of income?:

Q.6 How many persons of the family are employed?:

Q.7 How long have you been living here?:

Q.8 Average income of the family?:
Q.9 Do you have the following documents?

 Ration card/Bank account/Pan card/Bahmasha card

EDUCATION

Q.10 How frequently do children go to school?

 O-20% / 20-40% / 40-60% / 60% and above

Q.11 If children don't go to school then why not?

 Work /Home /Marriage /Other

Q.12 If 14 years and greater plan after 10th?

Q.13 Are you satisfied with the school service? Yes/No

Q.14 If no what are the problems?:

Facilities

Q.15 Do you have the following facilities?

  Toilet/Smart phone/Gas cylinder/Electricity

Q.16 Dumping area of the house?

Q.17 How much do you spare monthly for electricity?

Health
Q.18 Where do you go to hospital?

 Birla sarvjanic/Government hospital/Any other/Bass clinic

Q.19 Any other health problem with the family?

 Diabetes/Blood pressure/Arthritis/Eye issue/Any other

Q.20 Do you get free medicine from hospital? Yes/No

Q.21 Are you satisfied with the service of hospital? Yes/No

Q.22 If no what are the issues?

Water
Q.23 Where do you get daily use water?

Q.24 Are you getting adequate amount of water for daily use?

Q.25 How many liters of water/ how many pots?

Q.26 What are the main sources of water?

 Tap /Can (change)/Purifier/Other

Q.27 Any issues with water?

Q.28 Do the women have following skill?

(a) stitching (b)basic mathematics (c)read eng (d)read hindi (e)write eng(f)write hindi (g)farming
(h)handicraft(i)other
Q.29 Do the women know about Unnati center? Yes/no
Q.30 Do the women contribute to the finances of the family? Yes/ no
Q.31 Do they use sanitary pads? (unnati volunteer) yes/no

Q.32 Note {Problems in the village, views on Bitsian, any kind of help from NIRMAAN}//family pic