ULTRA POOR SURVEY

ADULT MODULE

INTERVIEWER: COMPLETE BEFORE BEGINNING THE MODULE

1. Household ID number:

2. Respondent code from board:

3. Date of visit: Day Month Year

4. Interviewer codes:

6. Hamlet: __________________________

7. Village: __________________________

8. GP: __________________________

9. Block: __________________________

INTERVIEWER: COMPLETE AFTER ENDING THE MODULE

12. End Time: Hour: Min:

Consent

We are working with IIM and are doing a survey about household enterprises and
livelihood. Earlier, we did a PRA in your village in which you may have participated. We
have selected people in your village from which we would like to collect more
information. You are one of these selected people.

We would like to ask you some questions about yourself and family. This form will take
about 1.5 hours. You can choose not to answer a question at any time. The information
you share with us will be kept fully confidential. Will you answer our questions?

Yes.....................1
No......................2
SECTION A: BASIC RESPONDENT INFORMATION
A0.1 STARTING TIME OF
MODULE HOUR: [ ][ ]

MINUTE: [ ][ ]
A1.0 Name of respondent

A1.1 Respondent ID number

Record ID after Family [ ][ ]
Board is completed
A1.2 INTERVIEWER MALE…………………………………….1
CHECKPOINT: Is the FEMALE………………………………….2
respondent male or female?

A1.3 How many children have [ ][ ]

you ever had?
A1.4 What is the age and gender Child 1 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
of all of your children? Child 2 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
Child 3 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
INVESTIGATOR Child 4 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
CHECKPOINT: Record Child 5 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
answers on opposite side, Child 6 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
using the following codes: Child 7 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
Gender: Child 8 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
MALE………….1 Child 9 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
FEMALE……….2 Child 10 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
ALIVE: Child 11 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
YES…..1 Child 12 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
NO….. 2 Child 13 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
Record current age in Child 14 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
years. Child 15 GENDER: [1] [2] ALIVE: [1] [2] AGE:[ ][ ]YRS
SECTION B: CHILD OUTCOMES – ASPIRATIONS
B1.0 INTERVIEWER CHECKPOINT: Are there any YES……………………….1
unmarried children less than 19 years old in the NO………………………..2 →C1
household?

REPEAT QUESTIONS B1.1-B1.6 FOR ALL

CHILDREN (0-18 years old) OF RESPONDENT.
RECORD ANSWERS ON THE GRID ON THE
OPPOSITE PAGE.

READOUT: Now I would like to ask some questions regarding the educational, occupational and marital
aspirations for your children.
B1.1 Name of child

B1.2 Child ID number [ ][ ]

B1.3 What is the highest CLASS 1….…………………..……….…….1

education level that you CLASS 2……………….……..……….…….2
would like this child to CLASS 3….…………………..……….…….3
complete? CLASS 4….…………………..……….…….4
CLASS 5….…………………..……….…….5
CLASS 6….……….…………..…………….6
CLASS 7….…………..……….…………….7
CLASS 8….……….…………..…………….8
CLASS 9….….………………..…………….9
CLASS 10…..………………...…………….10
CLASS 11…………………….…………….11
CLASS 12….…………….…………………12
GRADUATE AND ABOVE.........................13
OTHER DIPLOMA/CERTIFICATE............14
SSK…………………………..…………….15
MSK………………………….…………….16
NO EDUCATION………………………….17
DON’T KNOW…………………………..-999
B 1.4 How will this level of Getting Job………………………………….. 1
education help him /her? Make him/her wiser…………………………. 2
Will not help ………………………………... 3
DON’T KNOW…………………………..-999
B1.54 At what age would you like [ ][ ] AGE IN YEARS
to see this child marry?
(specify age in years)
B1.65 What occupation would HOUSEWIFE…………………………………..1
you like this child to be WHATEVER IN-LAWS WANT………………2
doing when she/he is 25 OTHER (RECORD WORD FOR WORD) …996
 years old? ___________________________________
B1.76 Would you like to see this YES…………………………………………..1
B1. CHILD
childOUTCOMES
as the Gram –Pradhan
ASPIRATIONS
NO……………………………...……………2
of the village?
(1) (2) (3) DON’T
(4) KNOW…………………………..-999
(5) (6) (7) (8) (9) (10)
B1.1

B1.2 [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ]

B1.3 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8
9 9 9 9 9 9 9 9 9 9
10 10 10 10 10 10 10 10 10 10
11 11 11 11 11 11 11 11 11 11
12 12 12 12 12 12 12 12 12 12
13 13 13 13 13 13 13 13 13 13
14 14 14 14 14 14 14 14 14 14
15 15 15 15 15 15 15 15 15 15
16 16 16 16 16 16 16 16 16 16
17 17 17 17 17 17 17 17 17 17
-999 -999 -999 -999 -999 -999 -999 -999 -999 -999
B1.4 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 -999
-999 -999 -999 -999 -999 -999 -999 -999[ -999[
][ ] ][ ]

B1.5 [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ] [ ][ ]

B1.65 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2

B1.76 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2
-999 -999 -999 -999 -999 -999 -999 -999 -999 -999
SECTION C1: USE OF TIME
READOUT: Now we would like to ask about some of your activities in the last 24 hours.

C1.0 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
collecting water for this NO…………...2 you spend? MINUTES………..1
household? HOURS…………..2
C1.1 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
cooking / helping to cook NO…………...2 you spend? MINUTES………..1
for your household? HOURS…………..2
C1.2 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
cleaning your home? NO…………...2 you spend? MINUTES………..1
HOURS…………..2
C1.3 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
cleaning or caring for your NO…………...2 you spend? MINUTES………..1
household’s clothes? HOURS…………..2
C1.4 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
caring for younger NO…………...2 you spend? MINUTES………..1
children, elderly, or HOURS…………..2
disabled persons in your
household?
C1.5 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
gathering fuel for cooking NO…………...2 you spend? MINUTES………..1
or lighting for your HOURS…………..2
household?
C1.6 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
shopping for your NO…………...2 you spend? MINUTES………..1
household? HOURS…………..2
C1.7 Did you spend any time on YES……….….1 If YES, how much time did [ ][ ]
political activities / NO…………...2 you spend? MINUTES………..1
attending village meetings? HOURS…………..2
C1.8 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
watching TV / listening to NO…………...2 you spend? MINUTES………..1
the radio? HOURS…………..2
C1.9 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
working on a field you own NO…………...2 you spend? MINUTES………..1
or sharecrop? HOURS…………..2
C1.10 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
tending any animals you NO…………...2 you spend? MINUTES………..1
own or lease in? HOURS…………..2
C1.11 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
working at your own NO…………...2 you spend? MINUTES………..1
business (other than HOURS…………..2
farm/animals)?
C1.12 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
 fishing? NO…………...2 you spend? MINUTES………..1
HOURS…………..2
C1.13 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
working as an agricultural NO…………...2 you spend? MINUTES………..1
laborer (outside HOURS…………..2
household)?
C1.14 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
doing housework in NO…………...2 you spend? MINUTES………..1
someone else’s home? HOURS…………..2
C1.15 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
working as a non- NO…………...2 you spend? MINUTES………..1
agricultural laborer (other HOURS…………..2
than housework)?
C1.16 Did you spend any time YES……….….1 If YES, how much time did [ ][ ]
doing any other work for NO…………...2 you spend? MINUTES………..1
pay (money or in kind: HOURS…………..2
food, etc.)?
C1.17 Did you earn any money or YES……….….1
food from your activities NO…………...2 →C2.0
yesterday?
C1.18 Which activities? [ ][ ][ ][ ]
WRITE QUESTION [ ][ ][ ][ ]
NUMBER [ ][ ][ ][ ]
[ ][ ][ ][ ]
C1.19 How much did you earn in Rs. [ ][ ][ ][ ]
cash?
C1.20 How much did you earn in [ ][ ][ ][ ] Kgs of rice……………………………1
kind? [ ][ ][ ][ ] Kgs of ________ (record verbatim)….2
Total Cash Value of in-kind payment: [ ][ ][ ][ ] Rs
C1.21 In the last 24 hours, apart YES…………..1 If YES, what activity?
from resting, did you do NO…………...2
any other activity that took (RECORD WORD FOR WORD)
more than one hour
(besides those already
mentioned)?
C2. WOMEN’S MOBILITY AND ACCESS TO RESOURCES
C2.0 INTERVIEWER CHECKPOINT: IF RESPONDENT FEMALE, ASK QUESTIONS ABOUT
RESPONDENT. FILL IN […..] IN QUESTIONS WITH “YOU” OR “YOUR”.
IF RESPONDENT MALE, ASK QUESTIONS ABOUT THE PRIMARY FEMALE RESPONDENT.
FILL IN [……] IN QUESTIONS WITH “SHE” OR “HER”.
READOUT: Now we would like to ask about some activities you / name of primary female respondent did over
the past 30 days.
C2.1 Name of woman this
module is done for
C2.2 Woman ID number RECORD WOMAN ID FROM FAMILY BOARD
[ ][ ]
C2.3 In the past 30 days, how 0 →C2.5
many times did [ ] go [ ][ ]
outside the village? DON’T KNOW……-999
C2.4 In the past 30 days, how [ ][ ]
many times did […..] take DON’T KNOW…………………...-999
a bus? NO BUS / NO APPLICABLE……. 777
C2.5 Do […..] parents live in YES………………………………….……..1
another village? NO…………………………………………2 →C2.8
THEY HAVE PASSED AWAY…………..3 →C2.8
DON’T KNOW……………………...…-999
C2.6 In the last 12 months, how [ ][ ]
many times did […..] visit DON’T KNOW……-999
[…..] parents’ village?
C2.7 Can […..] go unescorted to YES…………………………………….…..1
[…..] parents’ house / NO…………………………………………2
village?
C2.8 Can […..] go unescorted to YES………………………………….……..1
the next village? NO…………………………………………2
C2.9 Does […..] participate in a YES…………………………1
Self Help Group? NO………………………….2
C2.10 Does […..] have savings / YES…………………………1
loans / other financial NO………………………….2
assets in her own name and
separate from other
household members?

C2.11 Which members of the family decide how much to spend on the following items?
RECORD FAMILY MEMBERS ID FROM BOARD. RECORD MORE THAN
ONE IF APPLICABLE
NOT APPLICABLE……..777 OTHER (Specify)…………..996
1 Food………………. [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777
996______________
2 Clothing…………… [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777
996______________
3 Education…………. [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777
996______________
4 Health…………….. [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777
996______________
5 Home improvement / [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777
repair……………… 996______________

6 Land purchase or [ ][ ] , [ ][ ] , [ ][ ] , [ ][ ] 777

sale…. 996______________
C2.12 INTERVIEWER CHECKPOINT: Are multiple YES…………………1
people listed in any of C2.11 1-6? NO………………….2 →D1.0
C2.13 Who has the major say in how much to spend on the following items?
RECORD FAMILY MEMBER ID FROM BOARD. RECORD ONLY ONE.
NOT APPLICABLE……..777 OTHER (Specify)………….. 996
 1 Food………………. [ ][ ] 777 996______________
2 Clothing…………… [ ][ ] 777 996______________
3 Education…………. [ ][ ] 777 996______________
4 Health…………….. [ ][ ] 777 996______________
5 Home improvement /
repair…….. [ ][ ] 777 996______________
6 Land purchase or sale [ ][ ] 777 996______________

SECTION D: POLITICS
D1.0 Are you literate? NOT LITERATE………..…… 1 →D1.23
LITERATE THROUGH ATTENDING
NFEC/AEC………………….. 2
LITERATE THROUGH ATTENDING
TLC…………………………. 3
LITERATE, SCHOOL.….… 4
LITERATE, OTHERS..….… 5
D1.1 Do you read a newspaper? YES…………………………...1
NO……………………………2
D1.2 Did you vote in the last YES…………………………………………….….1
elections for Gram NO………………………………………………...2
Panchayat? DON’T KNOW……………………………......-999
D1.3 Did you ever approach the YES…………………………………………….….1
Booth member about your NO………………………………………………...2 →D1.6
needs or village issues? DON’T KNOW……………………………......-999 →D1.6
D1.4 How many times in the last [ ][ ]
year did you approach your
Booth member about your
needs or village issues?
D1.5 Was it easy to meet the VERY EASY…………………….……………….1
Booth member? EASY…………………………….……………….2
HAD TO WAIT…………………………………..3
HAD TO COME BACK SEVERAL TIMES….…4
FAILED…………………………………………..5
D1.6 Did you ever approach the YES…………………………………………….….1
Gram Pradhan about your NO………………………………………………...2 →E1.0
 needs or village issues?
D1.7 How many times in the last
year did you approach your
Gram Pradhan about your
needs or village issues?
D1.8 Was it easy to meet the
Gram Pradhan?
D1.9 Did the Pradhan or
member solve/try to solve
your Problem?
DON’T KNOW……………………………......-999 →E1.0
[ ][ ]
VERY EASY…………………….……………….1
EASY…………………………….……………….2
HAD TO WAIT…………………………………..3
HAD TO COME BACK SEVERAL TIMES….…4
FAILED…………………………………………..5
YES…………………………………………….….1
NO………………………………………………...2
DON’T KNOW……………………………......-999

SECTION E: PHYSICAL HEALTH

E1.0 INTERVIEWER CHECKPOINT: PRESENT THE PICTURE OF A LADDER TO THE
RESPONDENT AND CIRCLE THE NUMBER THAT CORRESPONDS TO THE
RUNG THEY CHOOSE.
E1.1 How would you classify your health these days? If 1…2…3…4…5…6…7…8…9…10
the top rung of this ladder represents very good
health and the bottom rung represents very bad DONT KNOW..........................-999
health, where would you place yourself?

Compared to the previous year, do you IMPROVED…………………………1

E1.2 think your health has improved, gotten GOTTEN WORSE…………………..2
worse or stayed the same? STAYED THE SAME………………3
DON’T KNOW………………… -999
In the last 30 days, have you been unable to YES.....................................…………1
E1.3 work or perform your usual daily activities NO......................................………... 2  E1.5
because you were sick or injured? DON’T KNOW………………… -999  E1.5

For how many days were you unable to [ ][ ]

E1.4 work or perform your usual daily activities DON’T KNOW………………… -999
because you were sick?
Did you go to a doctor or health provider in YES.....................................…………1
E1.5 the last 30 days? NO......................................………... 2  E1.14
Which type of facility (ies) did you visit, or SUB-CENTER…………………………….…..1
E1.6 which type of health provider(s) did you CHC/PHC...........................................................2
RURAL HOSPITAL.………………………….3
consult? GOVERNMENT DISTRICT HOSPITAL…....4
PRIVATE HOSPITAL..................…....………5
(CIRCLE ALL THAT APPLY) AYURVEDIC HOSPITAL...........….....………6
DISPENSARY…………………….…………..7
AIDPOST/SUBCENTRE..................................8
 ANGANWADI..................................................9
HEALTH CAMP............................
……………………..10
NGO CLINIC..................................................11
PRIVATE QUALIFIED DOCTOR................12
PRIVATE COMPOUNDER/NURSE……….13
PRIVATE PHARMACIST ………................14
UNQUALIFIED DOCTOR............................15
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………………….16
OTHER GOVERNMENT PRACTITIONER,
PRIVATE……................................................17
TBA/DAI............................………………….18
VHW/CHW..........................………………...19
PANCHAYAT RHW..................……….20
HOJHA/TRADITIONAL HEALER……21
DON’T KNOW……………..………..-999
OTHER (SPECIFY) …………………..996

E1.7 Which services did you receive at this MEDICATION……………..1

(these) facility(ies)? INJECTION………………...2
DRIP………………………..3
CIRCLE ALL THAT APPLY LAB TEST………………….4
OPERATION……………….5
HOSPITALIZATION………6
CONSULTATION………….7

OTHER (Specify)………...996

E1.8 How much did you pay in total for these Rs. [ ][ ][ ][ ][ ][ ]
services?
INTERVIEWER CHECKPOINT: IS YES.....................................…………1
TOTAL EXPENSES E1.7 ITEM 10 NO......................................………... 2 E1.11
E1.9 GREATER THAN ZERO?
What was the source of money used to pay SAVINGS……………………….1
E1.10 for these expenditures? LOAN (MONEYLENDER)…….2
LOAN (MFI)……………………3
LOAN (FRIEND/FAMILY)……4
GIFT/ CHARITY……………… 5
SELF HELP GROUP/OTHER
SAVINGS GROUP......................6
SOLD OR PAWNED ANY
PROPERTY….........................….7
OTHER(SPECIFY)…………..996
 DON’T KNOW……………..-999
E1.11 Was the problem for which you went for NEW…………………………………..1  E1.14
treatment a new ailment or a recurring RECURRING………………………....2
problem? DON’T KNOW……………………-999
For how long has this ailment been [ ][ ]
E1.12 bothering you? DAYS................... 1
MONTHS………. 2
YEARS…………. 3
In the last 12 months, how many times have [ ][ ]
E1.13 you visited a health care provider about this
ailment?
In the last 12 months, have any members of YES.....................................…………1
the household had to be admitted to a NO......................................………... 2  E2.0
E1.14 hospital, clinic or health center (inpatient)? DON’T KNOW…………………..-999  E2.0
Who was How What was (were) the For how many Have they
it? many reason(s)? days in total recovered from
E1.15 (ID NO. times (INDICATE ALL were they this (these)
FROM were they THAT APPLY) ill/disabled? event(s)?
BOARD) admitted? YES =1
ILLNESS=1 NO=2
ACCIDENT=2
MATERNITY=3
OTHER(Specify)=996
[ ][ ] [ ][ ] 1 2 3 [ ][ ][ ] 1 2
996 _______________
[ ][ ] [ ][ ] 1 2 3 [ ][ ][ ] 1 2
[ ][ ] [ ][ ] 996 _______________ [ ] [ ] [ ] 1 2
[ ][ ] [ ][ ] 1 2 3 [ ][ ][ ] 1 2
[ ][ ] [ ][ ] 996 _______________ [ ] [ ] [ ] 1 2
[ ][ ] [ ][ ] 1 2 3 [ ][ ][ ] 1 2
In the last 12 months, have any other YES.....................................…………1  E1.14
E1.16 members of the household had to be NO......................................………... 2
admitted to a hospital, clinic or health center DON’T KNOW…………………..-999
(inpatient)?
E2.0 What level of difficulty do you have in carrying out the following activities by yourself right now?
For each activity, please say whether you have no difficulty, have difficulty but can do it without help,
can only do it with help, cannot do this activity, or are able to do it but never do.
Difficult Can do,
but can only Able to,
No do with with but Don’t
Difficulty no help help Can’t do never do know

1 Dressing……………… 1 2 3 4 5 -999

2 Bathing……………….. 1 2 3 4 5 -999

3 Eating…………………. 1 2 3 4 5 -999

4 Toileting……………… 1 2 3 4 5 -999

5 Doing light work in or

around the house (if you
had to)………….... 1 2 3 4 5 -999

6 Climbing a small hill…. 1 2 3 4 5 -999

7 Lifting or carrying heavy

objects (e.g. a bag weighing
5 kg)….……. 1 2 3 4 5 -999

8 Walking 200-300
meters………………… 1 2 3 4 5 -999

9 Walk for 5 kilometers…. 1 2 3 4 5 -999

10 Bow, squat or kneel…… 1 2 3 4 5 -999

11 Draw water from a well (if

 you had do)…………. 1 2 3 4 5 -999

12 Stand up from sitting on the

floor……………….. 1 2 3 4 5 -999

13 Work in a field for one day

(if you had to)…….. 1 2 3 4 5 -999

14 Managing money (if you 1 2 3 4 5 -999

had to)…..……..………

15 Take a bus, train or taxi. 1 2 3 4 5 -999

……………………..

SECTION F: KNOWLEDGE
F1.0 Do all HH members wash their hands with
ash or soap after using the latrine?
F1.1 Does everyone wear sandals to the latrine?
F1.2 Why is wearing sandals/shoes important?
EVERYONE ALWAYS DOES………1
SOME DO / SOMETIMES …….…… 2
NO ONE DOES EVER……………….3
DON’T KNOW…………………...-999
EVERYONE ALWAYS DOES………1
SOME DO / SOMETIMES …….…… 2
NO ONE DOES EVER……………….3
DON’T KNOW…………………...-999

(INTERVIEWER: DON’T PROMPT)

(RECORD WORD FOR WORD)

CAN NOT GIVE REASON………......0

F1.3 Are you aware that there are many diseases YES…………………………………1
which are caused by water? → F1.5
NO………………………………….2
F1.34 How can you prevent waterborne diseases?

(INTERVIEWER: DON’T PROMPT)

(RECORD WORD FOR WORD) CAN NOT GIVE METHOD………......0

F1.54 Do you know what HIV/AIDS is? YES…………………………………1

 → F1.6
NO………………………………….2
F1.6 Do you know how to prevent HIV/AIDS?

(INTERVIEWER: DON’T PROMPT)

(RECORD WORD FOR WORD)

Do you have soap in your house? YES………………………….……...1

NO………………………………….2
DON’T KNOW…………………-999
F1.7 Do you have soap in your house? Is it for YES, DISHES………………………1
washing dishes, clothes or yourselves? YES, CLOTHES.…………………...2
YES, SELVES...……………………3
NO………………………………….4
DON’T KNOW…………………-999
F1.85 Do you have toothpaste and brush? YES…………………………………1
NO………………………………….2
DON’T KNOW…………………-999
F1.96 Do you have or use iodized salt? YES…………………………………1
NO………………………………….2
DON’T KNOW…………………-999
F1.10 Do you know the benefits of using iodized YES…………………………………1
salt? NO………………………………….2

F1.11 INTERVIEWER CHECKPOINT: Does YES…………………………………1

7 respondent have a daughter? → F1.11
NO………………………………….2

F1.12 Do you think you have to pay dowry for YES…………………………………1

8 your daughter’s wedding? → F1.11
NO………………………………….2
DON’T KNOW…………………-999 → F1.11
F1.13 If yes, what is the minimum amount you RS. [ ][ ][ ][ ][ ][ ]
9 might have to pay? DON’T KNOW…………………-999
F1.14 What is the maximum amount you can pay? RS. [ ][ ][ ][ ][ ][ ]
0 DON’T KNOW…………………-999
What are the sources of money which you SAVINGS……………………….1
will use for the dowry? LOAN (MONEYLENDER)…….2
LOAN (MFI)……………………3
LOAN (FRIEND/FAMILY)……4
GIFT/ CHARITY……………… 5
SELF HELP GROUP/OTHER SAVINGS
GROUP........................................6
SELL OR PAWN ANY
PROPERTY…........................….7
OTHER(SPECIFY)…………..996

F1.15 INTERVIEWER CHECKPOINT: Does YES…………………………………1

1 respondent have a son? → F1.14
NO………………………………….2

F1.16 Will you take dowry for your son’s YES…………………………………1

2 wedding? → F1.14
NO………………………………….2
DON’T KNOW…………………-999 → F1.14
F1.17 If yes, what is the maximum you think you RS. [ ][ ][ ][ ][ ][ ]
3 will get? DON’T KNOW…………………-999
F1.18 Is there any punishment for giving and YES…………………………………1
4 taking dowry at marriage? NO………………………………….2
DON’T KNOW…………………-999
F1.19 How many children is a “good” number for [ ][ ]
5 a family to have? DON’T KNOW…………………-999
F1.20 Who should decide when to have children? FATHER………………………………..1
16 MOTHER……………………………….2
BOTH (FATHER AND MOTHER)……3
OTHER(SPECIFY)…………………..996

__________________________________
DON’T KNOW……………………-999
F1.21 What is the legal age of marriage for a boy? [ ][ ]
17 DON’T KNOW……………………-999
F1.22 What is the legal age of marriage for a girl? [ ][ ]
18 DON’T KNOW……………………-999
F1.19 What are legal reasons sufficient for ???????
divorce? DON’T KNOW……………………-999
F1.20 What is the lowest age for casting vote? [ ][ ]

F1.21 What is the name of the document
according to which youra country is
governed?
F1.22 What is the role of police?
(INTERVIEWER: DON’T PROMPT)
18(?)
DON’T KNOW……………………-999
CONSTITUTION……………………..1
OTHER(SPECIFY)…………………996
__________________________________
DON’T KNOW……………………-999

(RECORD WORD FOR WORD)

Do you get your child administered to

vaccines?
F1.23 How will giving vaccines help your child? YES…………………………………1
NO………………………………….2

F1.24 Are you aware of the different Government YES…………………………………1

schemes/ NO………………………………….2

F1.25 Do you know who is the Chief Minister of YES…………………………………1

West Bengal? NO………………………………….2
SECTION G: MENTAL HEALTH
G1.0 INTERVIEWER CHECKPOINT: PRESENT THE PICTURE OF THE FACES TO THE
RESPONDENT AND CIRCLE THE NUMBER THAT CORRESPONDS TO THE FACE THEY
CHOOSE.
G1.1 Which picture best describes how satisfied you are
with your life right now if the smiling face is very
satisfied and the frowning-crying face is very
dissatisfied?
1……….2………3……....4……..5

DON’T KNOW…–999
G2.0 From time to time, everyone feels sad or down. I am
going to read a list of statements that may express NOT AT HARDLY ALL SOME
these feelings. I would like to know how often you ALL EVER OF OF
have felt this way in the past week. Please indicate for THE MOST
each statement whether in the past week you felt this TIME OF
way not at all, hardly ever, some of the time, or most THE THE
of the time. TIME TIME

1 I felt sad……………………….…...................... 0 1 2 3

2 I cried a lot………………………………..….… 0 1 2 3

3 I did not feel like eating……………………….… 0 1 2 3

4 I did not feel like doing my work......................... 0 1 2 3

5 My sleep was restless………………………….… 0 1 2 3

G3.0 During the past 12 months, did you ever YES ................................... 1
have a period lasting one month or longer NO .................................. 2  G4.0
when most of the time you felt worried, REFUSES TO SAY........ 998  G4.0
tense, or anxious? DON’T KNOW…….....–999  G4.0
G3.1 What was the source of these worries or
tensions?

G3.2 Has that period ended or is it still going ENDED ............................ 1

on?
G3.3 How much did/do these worries interfere
with your ability to carry out your normal
activities – a lot, some, a little, or not at
all?
G3.4 During the last 12 months, have you
visited a health facility or seen a health
provider (including bhopas) for reasons
related to your worries?
STILL GOING ON............ 2
REFUSES TO SAY..........998
DO NOT KNOW…–999
A LOT...................................1.
SOME................................ 2
A LITTLE..................……..3
NOT AT ALL.................... 4
REFUSES TO SAY..........998
DO NOT KNOW…–999
YES ................................... 1
NO .................................. 2  G4.0
REFUSES TO SAY........ 998  G4.0
G3.5 Which type of health facility did you visit CHC/PHC...............................………...1
or which type of health provider did you GOVERNMENT REFERRAL
see? HOSPITAL…………………………...2
PRIVATE HOSPITAL..................……3
ARYUVEDIC HOSPITAL...........……4
T.B. HOSPITAL……………………...5
CIRCLE ALL THAT APPLY DISPENSARY………………………..6
AIDPOST/SUBCENTRE.....................7
ANGANWADI......................................8
HEALTH CAMP...............................…9
NGO CLINIC......................................10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI.........................................…17
VHW/CHW...................................…..18
HRW...............................................….19
BHOPA/TRADITIONAL HEALER...20
DON’T KNOW…………………....-999
OTHER (SPECIFY) …………………...996
_______________________________
G4.0 What are the issues that sometimes are reasons of concern for you?

G5.0 Do you expect that life will get better for you NO, I EXPECT THINGS TO GET
and your family in the next few years? WORSE………………………….1
NO, I DON’T EXPECT MUCH
CHANGE………………………..2  G5.2
YES, I EXPECT LIFE TO GET
BETTER…...................................3  G5.2
CAN’T SAY…………………….4
G5.1 Why do you expect your life to get worse or
why can’t you say whether or not life will get
better?

G5.2 Do you have plans to do things to make life YES .................................. 1

better for you and your family? NO ....................................2  H1.0
G5.3 If YES, what are these plans?
SECTION H: SOCIAL INTEGRATION
H1.0 First, I would like to ask about your participation in any clubs or associations.
H1a. Do you currently participate in or are you now a H1b. How often do you participate in
member of a ______?
YES, PARTICIPANT…..……1
1 Traditional village
YES, POSITION HOLDER….2
committee? NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
2 YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
Caste committee?
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
3 YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
Church, temple, mosque,
NO……………………..……..3
devra, sect, or guru? REFUSES TO SAY……… 998
DO NOT KNOW….................–999
4 YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
OTHER: Joint Forest
NO……………………..……..3
Management committee? REFUSES TO SAY……… 998
DO NOT KNOW….................–999
54 YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
OTHER: Women’s
NO……………………..……..3
organization/cooperative, REFUSES TO SAY……… 998
savings group, or
DO NOT KNOW….................–999
income-generating
group?
56 YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
Any groups or activities
NO……………………..……..3
with another NGO? REFUSES TO SAY……… 998
DO NOT KNOW….................–999
67 YES, PARTICIPANT…..……1
Youth club, including
YES, POSITION HOLDER….2
Navyug mandal? NO……………………..……..3
REFUSES □TO SAY……… 998
DO NOT KNOW….................–999
activities at ____?
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3
ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3 ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3 ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3 ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3 ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3 ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3
ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999

YES, PARTICIPANT…..……1
78 Bhajan mandal, sat song?
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
8
YES, PARTICIPANT…..……1
89 Political party?
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3
ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3
ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999

YES, PARTICIPANT…..……1
109 Other?
YES, POSITION HOLDER….2
NO……………………..……..3
(SPECIFY__________)
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
DAILY.............................. 1 GO TO NEXT
WEEKLY...............…....... 2 CLUB/
FEW TIMES A MONTH... 3
ASSOCI-
MONTHLY.........………... 4
ATION
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999

101.a Is there a group of people DAILY.............................. 1

YES………………...… 1
(besides family) with NO……………………. 2 H2.0 WEEKLY...............…....... 2
whom you share regular FEW TIMES A MONTH... 3
REFUSES TO SAY…. 998H2.0 MONTHLY.........………... 4
activities (like fetching DON’T KNOW…...... –999H2.0 FEW TIMES A YEAR....... 5
water, wood gathering, ANNUALLY...................... 6
go to the market etc.?) DO NOT KNOW…–999
And if yes, how often do
you meet?
101.b If yes: what is this
regular activity?

H2.0 Did you attend the last Gram Sabah?
H2.1 Did you attend the last Ward Sabah?
H3.0 In the past 12 months, have you or anyone in
your family been the victim of a crime
(including robbery, murder, attack, rape,
sexual abuse, domestic violence or any other
crime)?
H3.1 What crimes have been committed against
you or your family in the past 12 months?
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
YES .................................. 1
NO .................................. 2  H4.0
DO NOT KNOW……..–999  H4.0
REFUSES TO SAY........ 998  H4.0

H4.0 I would like to ask more about your family and the people in your village or falla.
H4.1 Do people in your (close) family respect you? YES ................................... 1
NO .................................. 2
DON’T KNOW…..…...–999
REFUSES TO SAY........ 998
N/A (no family)………... 777
H4.2 Do the people in your falla respect you? YES ................................... 1
NO ................................... 2
DON’T KNOW…..…...–999
REFUSES TO SAY........ 998
H4.3 Generally speaking, would you say that the YES, TRUST ALL........... 1
people in your falla can be trusted? YES, TRUST SOME........ 2
NO .................................. 3
DON’T KNOW…..…...–999
REFUSES TO SAY........ 998
H4.4 What are the major causes of conflict in your
localityfalla?

NO CONFLICT/QUARRLES…777
H5.0 Do you discuss personal issues with anyone YES .......................................... 1
outside your close family? NO ......................................... 2  I1.0
DON’T KNOW…..….........–999  I1.0
H5.1 How often do you usually speak to this DAILY................................ 1
person? WEEKLY.............................. 2
A FEW TIMES A MONTH...3
ONCE A MONTH………… 4
A FEW TIMES A YEAR...... 5
ONCE A YEAR…………… 6
OTHER(Specify)…………996

DON’T KNOW……….. –999

H5.2 What is this person’s relationship to you
(village leader, friend, religious leader, etc.)?

SECTION I: CHILDREN’S USE OF TIME

I1.0 INTERVIEWER CHECKPOINT: ARE YES………….1
THERE CHILDREN IN THE HOUSEHOLD NO…………...2  J1.0
BETWEEN 8 AND 14 YEARS OLD?
READOUT: Now we would like to ask about some of your children’s activities in the last 24 hours
I1.1 INTERVIEWER: ASK FOR EACH CHILD BETWEEN 8 AND 14 YEARS. RECORD RESPONSES
ON GRID
I1.2 INTERVIEWER: RECORD CHILD’S NAME
INTERVIEWER: RECORD CHILD ID NO.
I1.3 Please remind me, how old is _________? [ ][ ]
I1.4 INTERVIEWER CHECKPOINT: AGE IS 8-14? NO SKIP CHILD
PROCEED TO NEXT
I1.5 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
collecting water for this NO…………...2 you spend? MINUTES………..1
household? HOURS…………..2
I1.6 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
cooking / helping to cook NO…………...2 you spend? MINUTES………..1
for your household? HOURS…………..2
I1.7 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
cleaning your home? NO…………...2 you spend? MINUTES………..1
HOURS…………..2
I1.8 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
cleaning or caring for your NO…………...2 you spend? MINUTES………..1
household’s clothes? HOURS…………..2
I1.9 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
caring for younger NO…………...2 you spend? MINUTES………..1
children, elderly, or HOURS…………..2
disabled persons in your
household?
I1.10 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
gathering fuel for cooking NO…………...2 you spend? MINUTES………..1
or lighting for your HOURS…………..2
household?
I1.11 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
shopping for your NO…………...2 you spend? MINUTES………..1
household? HOURS…………..2
I1.12 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
watching TV / listening to NO…………...2 you spend? MINUTES………..1
the radio? HOURS…………..2
I1.13 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
working on a field owned NO…………...2 you spend? MINUTES………..1
or sharecropped by the HOURS…………..2
household?
I1.14 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
tending any animals owned NO…………...2 you spend? MINUTES………..1
or leased in by the HOURS…………..2
household?
I1.15 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
working at a business NO…………...2 you spend? MINUTES………..1
owned by the household HOURS…………..2
(other than farm/animals)?
I1.16 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
fishing? NO…………...2 you spend? MINUTES………..1
HOURS…………..2
I1.17 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
working as an agricultural NO…………...2 you spend? MINUTES………..1
laborer (outside HOURS…………..2
household)?
I1.18 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
doing housework in NO…………...2 you spend? MINUTES………..1
someone else’s home? HOURS…………..2
I1.19 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
working as a non- NO…………...2 you spend? MINUTES………..1
agricultural laborer (other HOURS…………..2
than housework)?
I1.20 Did _____ spend any time YES……….….1 If YES, how much time did [ ][ ]
doing any other work for NO…………...2 you spend? MINUTES………..1
pay (money or in kind: HOURS…………..2
food, etc.)?
I1.21 Did _____ earn any money YES……….….1
or food from your activities NO…………...2 →I1.25
yesterday?
I1.22 Which activities? [ ][ ][ ][ ]
WRITE QUESTION [ ][ ][ ][ ]
NUMBER [ ][ ][ ][ ]
[ ][ ][ ][ ]
I1.23 How much did _____ earn Rs. [ ][ ][ ][ ]
in cash?
I1.24 How much did _____ earn [ ][ ][ ][ ] Kgs of rice……………………………1
in kind? [ ][ ][ ][ ] Kgs of ________ (record verbatim)….2
Total Cash Value of in-kind payment: [ ][ ][ ][ ] Rs
I1.25 Did _____ spend any time YES…………. 1 If YES, how much time did HOURS [ ][ ]
playing with other children NO…………...2 _____ spend? MINUTES[ ][ ]
without any other
responsibilities?
I1.26 In a normal school day, YES…………. 1 If YES, how much time does HOURS [ ][ ]
does _____ spend any time NO…………...2 _____ spend? MINUTES[ ][ ]
attending school?
I1.27 Does _____ spend any YES…………. 1 If YES, how much time did HOURS [ ][ ]
time studying outside of NO…………...2 _____ spend (per day)? MINUTES[ ][ ]
school?
I1.28 In the last 24 hours, apart YES…………..1 If YES, what activity?
from resting, did _____ do NO…………...2
 any other activity that took RECORD WORD FOR WORD
more than one hour
(besides those already
mentioned)?

I1.29 Are there are any other YES……………1 → I1.2

children aged 8-14 in the NO…………….2 → J1.0
household?

WORKSHEET FOR SECTION H: CHILD TIME USE (1-4 CHILDREN)

I1.2 CHILD NAME: CHILD NAME: CHILD NAME: CHILD NAME:
 ID # (FROM BOARD) ID # (FROM BOARD) ID # (FROM BOARD) ID # (FROM BOARD)
[ ][ ] [ ][ ] [ ][ ] [ ][ ]
I1.3 AGE [ ][ ] AGE [ ][ ] AGE [ ][ ] AGE [ ][ ]
I1.4 INTERVIEWER INTERVIEWER INTERVIEWER INTERVIEWER
CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8-
14? 14? 14? 14?
NO SKIP CHILD NO SKIP CHILD NO SKIP CHILD NO SKIP CHILD

Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN

I1.5 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.6 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.7 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.8 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.9 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.10 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.11 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.12 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.13 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.14 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.15 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.16 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.17 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.18 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.19 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.20 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.21 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX
I1.22 [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
[ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
[ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
I1.23 Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ]
I1.24 Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ]
Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN
I1.25 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.26 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.27 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.28 ____________________ ____________________ ____________________ ____________________
I1.29 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX

WORKSHEET FOR SECTION H: CHILD TIME USE (5-8 CHILDREN)

I1.2 CHILD NAME: CHILD NAME: CHILD NAME: CHILD NAME:
 ID # (FROM BOARD) ID # (FROM BOARD) ID # (FROM BOARD) ID # (FROM BOARD)
[ ][ ] [ ][ ] [ ][ ] [ ][ ]
I1.3 AGE [ ][ ] AGE [ ][ ] AGE [ ][ ] AGE [ ][ ]
I1.4 INTERVIEWER INTERVIEWER INTERVIEWER INTERVIEWER
CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8- CHECKPOINT: AGE IS 8-
14? 14? 14? 14?
NO SKIP CHILD NO SKIP CHILD NO SKIP CHILD NO SKIP CHILD

Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN

I1.5 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.6 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.7 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.8 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.9 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.10 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.11 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.12 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.13 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.14 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.15 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.16 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.17 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.18 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.19 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.20 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.21 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX
I1.22 [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
[ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
[ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
I1.23 Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ]
I1.24 Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ] Rs. [ ][ ][ ][ ]
Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN Y / N HRS MIN
I1.25 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.26 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.27 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ] 1 2 [ ][ ] [ ][ ]
I1.28 ____________________ ____________________ ____________________ ____________________
I1.29 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX 1 2 XXX XXX

SECTION J: INTERVIEWER EVALUATION

J1.0 ENDING TIME OF MODULE
HOUR: [ ][ ]

MINUTE: [ ][ ]

J1.1 Did you have to go back a second time? Yes……………………1

No…………………….2  J1.5
J1.2 When did you go back? Day: [ ][ ]

Month: [ ][ ]

Year: [ ][ ][ ][ ]

J1.3 Starting time of module

HOUR: [ ][ ]

MINUTE: [ ][ ]

J1.4 Ending time of module

HOUR: [ ][ ]

MINUTE: [ ][ ]

J1.5 COMPREHENSION LEVEL OF EXCELLENT............................ 1

RESPONDENT VERY GOOD............................ 2
GOOD.........……....................... 3
FAIR...................…................... 4
POOR....................………......... 5
J1.6 COOPERATION LEVEL OF EXCELLENT............................ 1
RESPONDENT VERY GOOD............................ 2
GOOD.........……....................... 3
FAIR...................….................... 4
POOR....................………......... 5
J1.7 IN ADDITION TO HOUSEHOLD YES……………….................... 1
MEMBERS, WAS ANYONE ELSE NO.......................…………...... 2  J1.11
PRESENT DURING THIS MODULE?
G1.8 IN ADDITION TO HOUSEHOLD RELATIVE................................ 1
MEMBERS, WHO WAS PRESENT FRIEND..................................... 2
DURING THIS MODULE? NEIGHBOR……....................... 3
OTHER (Specify)...................... 996

________________________________
J1.9 HOW MUCH DID OTHERS ASSIST THE NO ASSISTANCE.................... 1  J1.11
RESPONDENT WITH HIS/HER HELP WITH SOME................. 2
ANSWERS? HELP WITH MOST................. 3
J1.10 WHO WAS HELPING THE RESPONDENT 1 [ ][ ]………………………………………..
WITH HIS OR HER ANSWERS? WRITE
IN CODE(S) FROM BOARD IF FROM 2 [ ][ ]………………………………………..
SAME HOUSEHOLD
3 [ ][ ]…………………………………………

4 [ ][ ]………………………………………..

J1.11 ANY ADDITIONAL COMMENTS ABOUT SPECIFIC QUESTIONS OR DATA QUALITY

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J1.12 GO TO COVER SHEET AND COMPLETE IT.