APPENDIX - I

Community Service Project

Questionnaire for Socio-Economic Survey of the Village / Habitation

Name of the Village: Ward:

Name of the Mandal: Name of the District:

(Note: Please put a tick mark in the appropriate place.)

PERSONAL INFORMATION

1. Name & address of the Household

2. Age
3. Gender Male / Female
4. Caste SC / ST / BC / OC

5. Religion Hindu / Christian / Muslim / Other

6. Marital Status Married / Unmarried / Divorced

7. Type of family Single (Nucleus) / Joint family

Illiterate / Primary school / High school /

8. Education Qualification
Above high school

9. O ccupation in the Agriculture / Private Company / Hereditary Occupation

10.Total members of family Total No. ____ / Male: ___ / Female:

11.Type of House Thatched / Asbestos / Tiled / Terraced

11a. Ownership Own / Rent
12.Source of Drinking Water
Tap water connection in thehouse /
Tap water in the street / Purchase of water

13.What fuel is used in cooking LPG / Fire Wood / Both

14.Do you have the following Facilities? Drainage / Toilet

15.No. of earning members in the family One / Two / Three / More than three
 ECONOMIC CONDITIONS

Below 35,000 / 35.000 to 50.000 / 50,000 to 65000

16.What is your annual income?
Above 65.000

17. Major Source of Income

18.Do you or any other member of your

family pay income tax? Yes / No

Below 35,000 / 35.000 to 50.000 / 50,000 to 65000

19.What is your annual expenditure?
Above 65.000
Post Office / Banks / SHGs / Chit Fund
20.Do you have any savings?
Private Institutions / No savings
21. Do you have any debts? Yes /No

Commercial Banks / Cooperative Banks / SHGs

21a. If yes sources of debt
Private Money lenders / Friends & Relatives
22.How much property do you / your
family have Agricultural Land / Residential Plots/
Size of the plot:_________________ / RCC Building

23.Do you have the following live Stock? Cows / Buffalos / Goats/ Sheep / Pet Animals
24. do you have any Income from live
Yes /No
stock?
SOCIAL SECURITY BENEFITS

25.Do you have white ration card? Yes / No

26.Are you receiving old age pension Yes / No

LIC Policy / Health Insurance

27.What social security benefits do you
Bank Account under PradhanMantri Jan Dhan Yogana
have
/ Accident benefit / Non-of the above

28.Medical Facilities RMP / Primary Health Centre / Private Hospital

29.Any other information you wouldlike to

share