Multidimensional Poverty Index Questionnaire

Household No :
Surveyor Name :
……………………………………………………………..............................
1. Age :
2 . Gender :
3. No. Of household members:
Adults :
Children :
4. Has anyone in your household completed 6 years of schooling?
YES / NO
5. i) Any child of age 14? YES / NO
ii) Is he/she going to school? YES / NO
6. i) What type of fuel does your household mainly use for cooking
Cow-Dung ☐
Charcoal ☐
Coal ☐

Woods ☐

Agricultural crops ☐

ii) Do you have any gas cylinder or gas pipes:

YES / NO
7. Do you have any child between the ages of 0 to 59 months, or women
between the ages of 15 to 49 years, or man between the ages of 15 to 54 years
in your family?
YES / NO
8. A child /adolescent under 18 years of age has died in the family in the five-
year period preceding the survey ?
YES / NO
9. Any women in the household who has given birth in the 5 years preceding
the survey as not received at least four antenatal care visits for the most
recent birth or has not received assistance from the trained skilled medical
personnel during the most recent childbirth.
YES / NO
10. The household has unimproved or no sanitation facility or it is improved
but shared with other households.
YES / NO
11. The household does not have access to improved drinking water or safe
drinking water is at least at 30 minutes walk from home (As a round trip )?
YES / NO
12. Do you have any electricity?
YES / NO
13. The household has inadequate housing:
the floor is made of natural materials or the roof or wall are made of
rudimentary materials.
YES / NO
14. The household does not own more than one of these assets:
Radio ☐

Television ☐

Telephone ☐

2
 Computer ☐

Animal Cart ☐

Bicycle ☐

Motorbike ☐

Refrigerator ☐

Does not own a car or truck ☐

15. Do you have a bank account or Post Office account ?

YES / NO