General Information

Email address -

Name -

Age-

Occupation -

Address –

No. of years living –

Level Of Education -

Monthly Income-

Size of Family –

Availability of Assets or Personal Amenities (AAPA)

Personal Vehicle

TV

Access to water

Electricity

Paved road to home

Pucca House

Computer

Internet Connection

Cell Phone

Bank Account

Insurance Policy

Beneficiary of Government Programs

Ration Card

School Going

Personal Home

Personal Land

Is Farmer

Pension Scheme

Govt. Servant

Distance of closest school

Distance of closest health facility

Opinions and Observations

Three most important problems of your area

Who suffers most from these?

Three needs

Three changes

Three corrections

Most powerful person

Most powerful group

Who does most for community-Individual & Groups

Things of proud

Next five years scenario

What you dream

What is needed to make dream come true