Household Interview

1. INTERVIEWER _________________________________________ Date _____________

2. NAME OF THE VILLAGE ____________________________________________________

3. GRAM PANCHAYAT ___________________ PANCHAYAT SAMITI ______________

TEHSIL ___________________________ DISTRICT ______________________________
FIRST SETTLEMENT YEAR ______________________

Questions

(i) Name of the person (optional):

(ii) How many persons in the household: _____________ (male adults) ___________ (female adults)
______________ (male minor) __________ (female minor)

(iii) Educational Qualification of persons in the household: ______________________ (male adults)

__________________ (female adults) ______________ (male minor) ____________ (female minor)

(iv) Occupation of the persons in the household: ______________________________ (male adults)

______________ (female adults) _______________ (male minor) _______________( female minor)

(v) Whether LPG connection available in the house hold: _________ (Yes) _________ (No)

(vi) Whether toilet facilities available in the household :___________( Yes) _________ (No)

(vi)(a) If yes, whether these facilities are used___________ (Yes) _________ (No)

(vii) Whether toilet facilities are there in the common areas of village :_____( Yes) _____ (No)

(vii)(a) Whether these are used regularly___________(Yes)________(No)

(vii)(b) Who cleans these common area toilets? _________________________________________

(vii)(c) Whether there is running water facility in these common area toilet :_____( Yes) ____ (No)

(viii) Whether benefit of any govt scheme being taken in the household :._____( Yes) _____ (No)

(viii)(a) if yes, details of the scheme

_________________________________________________________________________________

_________________________________________________________________________________

(viii) (b) How do they obtain the benefit? Whether they receive it in form of Direct Benefit
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Transfer?
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(viii) (c) Whether they receive the full amount: _________ (Yes) ___________ (No)

(viii) (d) Whether they have to give back some amount to get this benefit?........(Yes)….....(No)

(viii) (e) Are they aware whether it is a state govt scheme or central govt scheme?

(ix) Are they aware of any other government scheme/s?

(x) Whether electricity available in the household: ___________ (Yes) ___________ (No)

(xi) Whether children of the household go to the school: _________ (Yes) _________ (No)

(xi)(a) Does the school have drinking water/tap water facility_______ (Yes) _______ (No)

(xii) Whether anyone of the household have visited the nearest health centre recently______ (Yes)
______ (No)

(xii)(a) If yes, whether services are satisfactory__________ (Yes) _______ (No)

(xii) (b) Whether there is drinking water/ tap water facility in health centre:_______(Yes)____(No)

(xiii) Whether household covered under immunization program :_________( Yes) ________ (No)

(xiv) Whether the household has potable water facility_______ (Yes) _________ (No)

(xv) Whether the household has mobile phone facility: __________ (Yes) ______ (No)

(xvi) Whether the household has livestock: ________ (Yes) _________ (No)

(xvii) Whether anyone from household is associated with any self-help group: ____ (Yes) ____ (No)

(xviii) Do you know your banking correspondent.__________ (Yes) ___________ (No)

(xix) Does anyone in the household has bank account __________ (Yes) _________ (No)

(xx) What are the means of mobility for the household?

(xxi) What are the means of entertainment for the household?

(xxiii) Are they aware of any developmental scheme or program in their village for any specific
section in the village which has been implemented after 01.01.2019? ________ (Yes) ________ (No)

(xxili)(a) If yes, details of the scheme and its impact_______________________________________

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RUDSETI/RSETI…………………………………… CLDC……………………………….
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