Household Survey Form

UNNAT BHARAT ABHIYAN (UBA) Baseline Household Survey Form
Village: ___________________________________ Gram Panchayat: _______________________________
Ward No.__________________________________ Block: ________________________________________
District: ___________________________________ State: ________________________________________
1. Respondent’s Profile
Name: Gender: Male / Female / Others Age (Yrs.):
Relationship with Head of Household: Contact Number:
2. General Household Information (Tick appropriate option)

Name of the Head (Household): Male / Female No. of family members:
Category: Gen / SC / ST / OBC Poverty Status: APL / BPL

Own House: Yes / No Type of House: Kutcha / Semi Toilet: Private / Community / Drainage linked to House:
Pucca / Pucca/Homeless Open Defecation Covered / Open / None
Waste Collection System - Compost Pit - Biogas Plant:
Door Step / Common Point / No Collection System Individual / Group/ None Individual / Group / Community
/ None
3. Family Member Information (Fill appropriate option)

Sr. No. Name Age Sex Level of Going to Aadhaar Bank Compute Social Major MNREGA Self Help Occupa
(Yrs.) M/ F / Educatio AWC/ Card A/C r Literate Security Health Job Card Groups tions
(First name) O n Code1 School (Y/ N) (Y/N) Y/N Pension4 Proble Y/N Tick Code6
/College ms, against
Code3 if any member
involved
4. Migration Status in a family

Does any member of the household migrate for Work? Yes / No
If Yes How many members of the family migrated
Family migrates for how many days/ months?
Since how many years the migration is taking place? Yes / No
1Not Married – 1, Married – 2, Widowed – 3, Divorced/Separated – 4
2Not Literate – 01, Literate – 02, Completed Class 5 – 03, Class 8th – 04, Class 10th- 05, Class 12th- 06, ITI Diploma-07, Graduate-08, Post
Graduate/Professional – 09 (write the highest level applicable)
3Going to AWC – 01, School – 02, College – 03, Not Going – 04, Not Applicable- 05 (write the highest level applicable)
4 No Pension – 0, Old Age Pension – 1, Widow Pension – 2, Disability Pension – 3, Other Pension – 4 (mention)
5Gen – 01, SC – 02, ST – 03, OBC – 04
6 Farming on own Land-01, Sharecropping /Farming Leased Land-02, Animal Husbandry-03,Pisci-culture/Poultry-04,Fishing-05, Skilled Wage Worker-06,
Unskilled Wage Worker-07, Salaried Employment in Government-08, Salaried Employment in Private Sector-09, Weaving-10, Other Artisan (mention)-11,
Other Trade & Business-12
UNNAT BHARAT ABHIYAN (UBA) Baseline Household Survey Form
6.
5. Information of Government Schemes 7.
S. No. Name Beneficiary 8.
Individuals 9.
(In Number)
1 PM Jan Dhan Yojana
8. Landholding Information (in Acres)
2 Sukanya Samridhi Yojana
3 Mudra Yojana
1. Total 2. Cultivable
4 PM Jivan Jyoti Bima Yojana Area
5 PM Suraksha Bima Yojana 3. Irrigated Area 4. Un irrigated
6 Atal pension Yojana Area
7 Kaushal Vikas Yojana 5. Barren/Waste 6. Uncultivable
8 Janani Suraksha Yojana land area Area
Beneficiary
Household 9. Agricultural Inputs
(Y/N) Particulars Tick If Yes,
9 Fasal Bima Yojana appropriately Fertilizer
10 Kisan Credit Card Use(Kg/Acre)
11 Krishi Sinchai Yojana Do you use Chemical Fertilisers Yes/No
12 Swachh Bharat Mission Toilet Do you use Chemical Yes/No
13 Soil Health Card Insecticides
14 PM Ujjwala Yojana Do you use Chemical Weedicide Yes/No
15 PM Awas Yojana Do You use organic Manures Yes/No
6. Source of Water (Distance from source in km) Irrigation: Canal / Tank / Borewell / River/Other / None
Source of Water Distance Irrigation System: Drip / Sprinkler / Flooding/ None
Piped Water at Home Yes /
No 10. Agricultural Produce in a normal year (Top 5)
Community Water Yes / S. Area under the Producti
Tap No No. Crop in Prev. Year vity (in
Crop
Hand Pump (Public / Private) (Acre) quintals
Yes / No per Acre)
Open Well (Public / Private) 1
Yes / No 2
Mode of Water Storage 3
(Community/Individual) 4
5
Any other source (mention)
11. Livestock Numbers (in numbers)
Goats/
Cows:______ Buffalo:_____ Sheep:______
7. Source of Energy and Power (Tick appropriately) Poultry/
Electricity Connection to Household: Yes / No Calves: _____ Bullocks:_____ Ducks:______
Electricity Availability per day (hours): Others (mention):
Lighting: Electricity / Kerosene / Solar Power Shelter for Livestock: Pucca / Kutcha / Open
Mention if Any Other: _____________________ Average Daily Production of Milk(Litres):_______
Cooking: LPG / Biogas / Kerosene / Wood / Cow Dung / Animal Waste/Cow Dung (in Kg.)_____________
Agro-Residues / Electricity
Mention if Any Other: _____________________ 12. Major problems in village, if any (Top 3)
Problems Possible Suggestions by villagers
If cooking in Chullah: Normal/ Smokeless
SN Appliances Nos. Duration/day
(in hours)
1.
2.
3. Schedule Filled By (Name & Sign):
4. Date of Survey:
5.

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UNNAT BHARAT ABHIYAN (UBA) Baseline Household Survey Form

Village: _____ Gram Panchayat: _

Ward No. Block: ______

District: _ State: ______

2. General Household Information (Tick appropriate option)

Category: Gen / SC / ST / OBC Poverty Status: APL / BPL

3. Family Member Information (Fill appropriate option)

4. Migration Status in a family

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