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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
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