Respondent Number: ☐☐

HOUSEHOLD -
Respondent Name:

Address:

1. Sex: ☐Male ☐ Female

2. Age: ☐☐

(In completed years)

3. Religion: ☐Hindu ☐Muslim

☐Christian ☐Others
4. Were you born in this locality?

☐Yes ☐No
5. How many people are living in the household?

☐1-2
☐3-4
☐4 and Above

6. Education level:

☐SSLC ☐Diploma
 ☐PUC ☐Others
☐Degree
7. Types of house:

☐Hut ☐Apartment
☐Pucca ☐Independent house
☐ Semi Pucca ☐Others
8. Occupation of the respondent:

☐Farmer ☐Service - Government ☐Unemployed

☐Wage labourer ☐Service Private ☐Others
☐Skilled worker ☐Homemaker
☐Petty Trader ☐Student
☐Self-employed ☐Retired
9. What is your total household income?

☐Below ₹10,000 ☐₹60,000 - ₹80,000

☐₹10,000 - ₹30,000 ☐₹80,000 - ₹100,000
☐₹30,000 - ₹60,000 ☐₹100,000 and above

10. How much is your Expenditure on Groceries in a month?

☐ Below ₹5000 ☐₹12,000 - ₹17,000

☐₹5000 - ₹7000 ☐₹17,000 - ₹22,000
☐₹7000 – ₹12,000 ☐above ₹22,000
11. How much you spend upon FMCG (daily products) in a month?
 ☐Below ₹3000 ☐₹8000 - ₹12,000
☐₹3000 - ₹ 5000 ☐₹12,000 - ₹15000
☐₹5000 - ₹8000 ☐above ₹15,000
12. How much is your outlay upon Clothing in a month?

☐Below ₹3000 ☐₹12,000 - ₹15,000

☐₹3000 - ₹6000 ☐₹15,000 - ₹20,000
☐₹6000 - ₹12,000 ☐above ₹20,000
13. How much your family spends upon Petrol/Diesel in a month?

☐Below ₹3000 ☐₹8000 - ₹10,000

☐₹3000 - ₹5000 ☐₹10,000 - ₹15,000
☐₹5000 - ₹8000 ☐above ₹15,000
14. How much is your Expenditure on Medical Treatments in a month?

☐Below ₹3000 ☐₹10,000 – ₹15,000

☐₹3000 - ₹6000 ☐₹15,000 – 20,000
☐₹6000 - ₹10,000 ☐above ₹20,000
15. How much is your outlay upon Entertainment in a month?

☐Below ₹2000 ☐₹6000 - ₹8000

☐₹2000 - ₹4000 ☐₹8000 - ₹10,000
☐₹4000 - ₹6000 ☐above ₹10,000
16. How much you spend upon Digital Platform in a month?

☐Below ₹1000 ☐₹5000 - ₹7000

☐₹1000 - ₹3000 ☐₹7000 - ₹10,000
☐₹3000 - ₹5000 ☐above ₹10,000
17. How much you spend upon Education in a month?

☐Below ₹18,000 ☐₹30,000 - ₹40,000

☐₹18,000 - ₹25,000 ☐₹40,000 - ₹50,000
☐₹25,000 - ₹30,000 ☐above ₹50,000
18. How much is your Expenditure on Other Goods in a month?

☐Below ₹3000 ☐₹8000 - ₹10,000

☐₹3000 - ₹5000 ☐₹10,000 - ₹15,000
☐₹5000 - ₹8000 ☐above ₹15,000