———Inividual Questionnaire Name: Ae Gender Male:[—] Female:(] others:[] Adress: MactaiStatuc Singles] Maried-[] Separated-(] widowed-[] Religion Hindu:[—] Mustin: [—] chistians:[—) Budahise-[—] Jaire[—] otters: 1) If any particular eigion, mention their caste/vama: tanguage:Tami:[—] Matayam-(—] Tetugu:(] ina] others] ‘educational status: selow 20%:["] atric pass:[—] reduate:[] postaraduate:[] ‘occupation: Publc:[—] prvate:[—] _sett-employed:[—] Domestic work [—] sectorsof work Weaving-|_] Farming:[_] pesksebe-[_] other ‘Mode of Payment/income: Daily Basis:[_] Reguiar/Monthly:[~] others. House Hold Details — No. of famity members [Belowthe age of 18__ Between 18-35__ Between 35-60__or Above 60__] If married, Occupztion of spouse: Domestic work: [_] Self Employed: [~] Private: [—] Pubic: [_] Sector Weaving:[] famits[—] Deskjet] others] Total Household income pr Annum: ‘= 1,00,000: [“] 1,00,000-2,00,000: [—] _2,50,000:[—] 5,90,000- 190,000: [~] > 10,00,000: [] Whether any ancestral ocupations:Yes:["] Ne: [=] tyes Spey Tye cfresidence: Owmed:[—]_ Rented] \ehices owned by the fami None:[] Bides:[] 2 Wheelers(avtomobie):(—] 4whesters:[] others: 7] Type cffuel used orcooking 196/625] Firewood: [=] Kerosene:(—] otter: ‘whether happy with the public savices provided by thei author Yee:[—]_ wo: [—] ‘ate the folowing avices/amertis inthe ci: eot-[] average] Poor] ood: [] averages) Poor 7] eod-[—] average: [—) Poor [] vod-[] average: Poor] ‘Good: [] average: [] oor: [] rub ranepert public Tanepor: Sewage Managemen: Sold waste Management: lecticty Supply: brinkng water suply: ow ofen do youus pubieraepor oar ["]. wey one]. tarot] ‘means of publictransport you we: Bus [_—] Shared auto Rikshaw-[—] others. Distance walked to reach public transport from the house/ofce: < kilometer: [7] ‘Are the street Pedestrain friendly: ves:[_] wo: [_] \syourhouse/office connected tothe city based drainage networ-Yes: [—] ne: [—] ‘tyes, how often sit maintained: Weebly once: —] Monthlyonce:[—] Less frequent: [—] are the draine covered: ves:[] No: [—] ‘othe drains overflow during Rains: ves:[—] no-[—] ‘bo they easy collect water from the Roads during Rain: Yes:[—] no: [—] ‘How fare the garbage bin rom yourhouse:<300m:[] 90make[—] Nearest Dispensary, Poly-inic and Hospital: < hm: [—] akm~stm:(].>akm:(] (uaity/standard of ray tation (cy): Good: []Fai:(—] Bae: [] Distance to road for away sation (uaity/standaré of Bus stand (cn): Good:[]Fair:[—] sae: 7]Distance to road for Sus stand, Whatare commercial options for you: Local markets (Haat /sandayi): [] Supermarkets:[] ‘Controlled prices shops are there:Ves:[_] No: [_] \Whatare the dfferant recreation facilis, avalible? Parks] Cnema thestres:[—] Drama/play theatre (Open): others-[]. Whether involved in agrniture:Yee:(] wos] \Whatcrops do you grow Padéy-(] whest:[] cottons] otha] Agriculture is only source of income: Yes: (]_ No: [] Means of water for irrigation purposes: Canal:[_| Tube wells:[ | Lakes/Ponds:|_] Others:|_| ‘Any platform fr sling cu irecty to pub: Yes:[]_ No: [] ‘Are you involved animal husbandry: Yes:[_] No: [] Whatanimat:Cow:[] Goat: [7] Pigs] Pouty:[—] others:[}