Rohan Biswa - 108574

Questionnaire set for Research

Respondent

Male ( ) Female ( ) Others ( )

1. Sociodemographic Profile (SDP)

 Household head: male or female? (Tick one)

 Age of head of household

o 20-30 31-40 41-50 51-60 >60

 Education level (Household Head). Tick one

 None

 Non-formal education

 Primary School

 High School

 Certificate/Vocational

 Diploma and above

 Household size: _ _

 Household members under 15 and over 65 years of age (Dependency Ratio)

 Under 15: __ OVER 65: __

 Do any members of your household require daily care because of age, physical or mental

condition, illness or disability?

 Yes, how many? No

2. Livelihood Strategies (LS)

 Do you or anyone in your household work in an activity related to growing crops,

rearing animals or collecting something from the forest, swamp or rivers? If yes, how

many?

 Does this account for main source of income? Yes or No

 Do you or anyone in your household work in an activity not related to growing crops,

rearing animals or collecting something from the forest, swamp or rivers?

 Does this account for main source of income? Yes or No

 Number of household members involved in agricultural activities _ _

 Number of household members involved in non-agricultural activities _ _

 Does your household receive remittances or funds: Yes or No?

3. Social Networks

 Did you borrow any money from relatives or friends in the past month? Yes or No, If

yes how many times?

 Did you lend any money to relatives or friends in the past month? Yes or No, If yes

how many times?

 In the past 12 months, have you or another in your household gone to your local

government office/ official for help? Yes or No, If yes how many times?

4. Health

 What is the time taken by to get to the nearest health facility on foot?

 Do you have family member suffering from chronic disease? Yes or No. If yes, how

many?
  Do you have family member suffering from chronic disease? Yes or No. If yes, how

many? = _ _

 Have any family member attended recent health awareness programs (past 12

months). Yes or No.

5. Food

 Does your household solely depend on the family farm for food? Yes or No

 Did your household face a food shortage in the past 12 months? Yes or No, if yes, for

how many months?

 What are the types of crops grown by the household?

 Does your household save or store crops? Yes or No?

 Does your household save seeds for next year?

6. Water

 Does your household have conflicts over water in the community? Yes or No

 Does your household experience water shortage problems?

 Does your household utilize water through a natural source (spring, river/stream)? If yes,

is it the primary water source?

 What is the time taken to reach the primary water source?

 Does your household receive consistent water supply?

 Are you observing drying up of water sources?

7. Natural disasters and climate variability

 Do you receive any warnings before natural disasters? Yes or No.

 Has your area been affected by flooding, landslide, etc., in the past? Yes or No. If yes,

how many times?

 Was anyone in your household injured or died as a result? Yes or No. If yes, how many?

 Did you suffer severe damage to the physical assets due to flooding/ storm events?? Yes

or No. If yes, what physical assets have you lost or been severely damaged?

 Are you observing increase in the occurrence of erratic rainfall? Yes or No