No Name Age

(completed years)

Sex Marital

Status

Education Occupation Income (monthly)

1

2

3

4

5

6

7

8

Birth / Death / Vital events in the family (during last 1 year) Details:

1. PLACE: 2. CENTRE: 1: RHTC 2 :UHTC 3: OTHER

3. FAMILY REGISTRATION NO.:_________________

4. NAME OF THE HEAD OF FAMILY :

5. TYPES OF FAMILY: 1 = NUCLEAR 2 = JOINT 3 = THREE GENERATION

6. ADDRESS:

STREET/ FALIYA / SOCIETY:

VILLAGE :

TALUKA :

DISTRICT :

OR URBAN AREA :

OR UHTC WARD :

OR DISTRICT :

8. BPL CARD : YES / NO / NR 9. RATION CARD : YES / NO / NR 10. RSBY CARD : YES / NO / NR

11. MUKHYAMANTRI AMRUTAM (MA) CARD : YES / NO / NR

12. CASTE:- 1. ST 2. SC 3.SEBC 4. OTHER

13. RELIGION : 1. HINDU 2. MUSLIM 3. CHRISTIAN 4. JAIN 5. OTHER

SPECIAL NOTE:

COMMUNITY MEDICINE DEPARTMENT GMERS MEDICAL COLLEGE,SOLA

RAPID FAMILY/HOUSEHOLD SURVEY

Spiritual Orientation : Rituals / Prayer / Meditation

Food : (Vegetarian / Non vegetarian / Mixed) 1. Breakfast 2. Lunch 3. Snacks 4. Dinner

Social : (Court case, Quarrel, Customs, Celebration of festival)

Total Income per Month : Other Sources of Income :

Bank Account : ( 1. Yes / 2. No ) Liability 1.Debt. 2. Bank Loan 3. Other

Is there any Pet/Domestic animal in the house? 1. Yes / 2. No

Type and no of animals:

Where do you keep animals? Inside Outside Distance from house(If Outside)

Agricultural Land owned & Details if any : Yes / No . If Yes,

Facility for Agriculture : 1. Tractor 2. Water 3. Light 4. Thresher 5. Cart 6. Animals 7. Others

Facility : 1.Radio/Audio system 2.TV 3.Cycle 5.Scooter 6.Car 7.Refrigerator 8.Air Cooler 9.AC

Type of House : 1) Kuccha 2) Pucca 3) Kuccha +Pucca

No. of living rooms: Separate Kitchen : 1. Yes 2. No

Type of Kitchen : 1) Standing 2) sitting

What type of fuel is used for cooking? (1)LPG/Piped Gas (2) Wood (3) Cow Dung (4) Kerosene (5) Others _____________________

Over Crowding : 1. Yes 2. No

Schematic Layout of House:

Electricity : 1. Yes 2. No

Addiction : Tobacco (Chewed / Smoked) - Yes / No Alcohol - Yes / No

Water source : Drinking 1. Tap 2. Bore 3. Other Potable 1. Tap 2. Bore 3. Other

Storage of Drinking Water : 1. Pot 2. Plastic drums/vessels 3.Other

1. Yes 2. NoDo you use any water purification methods?

If yes, Which one : 1) Straining 2) Boiling 3) Chlorine tablets 4) RO/ Filter 5) Other

Bathroom Type: Close / Semi Closed / Open Toilet Type: 1) Personal 2) Public 3) Open

Liquid Waste Disposal:

Solid Waste disposal : 1. Open air 2. Public Bin 3. Door to Door collection 4. Other

Ventilation : 1. Adequate 2. Inadequate

Insect : (Housefly / Mosquitoes / Rat / Cockroach / Others)

Is there any ”Differently Abled” person in the house ? 1.Yes 2. No If Yes, then Details:

EC 1 EC2 EC 3 If eligible couple present,

Type of Family Planning:

Health care facility Type Utilization Distance from house(major/minor/emergency/none) (km)

1. Govt.

2. Non Govt

Note/Remarks :

Sewered / Non sewered

Natural Lighting : 1. Adequate 2. Inadequate

Specific Medical Condition in the family: ANC / PNC / Comm. Dz: Non Comm. Dz (NCD) :

Interviewer Name Roll No. Batch Signature 1.

2.

Date:

Name