RURAL ENGAGEMENT PROGRAMME https://docs.google.com/forms/u/0/d/1tqQTr1Bt5CxmPokLvuYxchLz...

RURAL ENGAGEMENT PROGRAMME

District- Khargone

* Required

1. Name *

2. Age

3. Education

4. Occupation

5. Contracted Covid-19 (self)

Mark only one oval.

Yes

No

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6. Any family member contracted Covid-19?

Mark only one oval.

Yes

No

7. Completed Vaccination *

Mark only one oval.

Yes

No

8. Vaccine name *

9. Agency administering vaccine *

10. Money spent or received free? *

Mark only one oval.

Money

Free

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11. Do you greet people without physical contact (eg. hug in family function)? *

Mark only one oval.

Yes

No

12. Do you maintain physical distance of 6 feet (do gaj ki doori) when in crowd or
line? *

Mark only one oval.

Yes

No

13. Do you wear a cloth mask regularly when (going out/ with others in room/ having
cold cough)? (If no give reason) *

Check all that apply.

Yes
No
Other:

14. Do you regularly wash the mask after 8 hours of usage? ( If no give reason) *

Check all that apply.

Yes
No
Other:

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15. Are you avoiding touching of nose,eyes and mouth inadvertently? (If no give
reason) *

Check all that apply.

Yes
No
Other:

16. Do you regularly wash your face especially after cough or sneeze? (If no give
reason) *

Check all that apply.

Yes
No
Other:

17. Do you regularly wash hands with soap or use hand sanitizer? (If no give reason)
*

Check all that apply.

Yes
No
Other:

18. Do you regularly clean the places/objects frequently used? (If no give reason) *

Check all that apply.

Yes
No
Other:

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RURAL ENGAGEMENT PROGRAMME https://docs.google.com/forms/u/0/d/1tqQTr1Bt5CxmPokLvuYxchLz...

19. Do you have habit of spitting? (If yes did you stop/reduced it during covid-19) *

Check all that apply.

Yes
No
Other:

20. Are you avoiding unnecessary travel? (If no ask for reason why they cannot
avoid travel and precautions taken) *

Check all that apply.

Yes
No
Other:

21. Did you or your family member suffer from discrimination during covid-19? (If
yes explain) *

Check all that apply.

Yes
No
Other:

22. Do you keep away from crowd? (If no what precautions are taken) *

Check all that apply.

Yes
No
Other:

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RURAL ENGAGEMENT PROGRAMME https://docs.google.com/forms/u/0/d/1tqQTr1Bt5CxmPokLvuYxchLz...

23. Did you receive or send any unverified information on social media about
covid-19? (If yes(received/sent) ask for description) *

Check all that apply.

Yes
No
Other:

24. Which source do you use to seek information related to covid-19? *

25. Did you ever call national or Madhya Pradesh helpline for covid-19 related query?
(Did you get required support? how was your experience? if used the service) *

Check all that apply.

Yes
No
Other:

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