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Name of District
Name of Village Development
Committee (As per CBS 2011)
Ward Number
Name of Villages
Name of Ward Citizen Forum
(WCF) Chairperson
Phone Number of WCF
Chairperson
Surveyor’s Name Phone Numbers Address
1. 1.
2. 2.
Master Trainers’ Name Phone Number Date of Survey
1.
2.
Total Number of Household Surveyed:
3.
Was this ward monitored?
Yes No If Yes
Name of the Monitor
Phone Number
Was this ward rechecked?
Yes No If Yes
Name of the rechecker
Phone Number
Survey Booklet
Map Sheet
Draw map of the ward here:
First, draw a rough map in other paper. Once everyone agrees that the rough map is a good representation of the ward (village), and it matches with your experiences of walking around the whole village, then copy the map to this sheet.
Village Information Sheet
District Name VDC Name
Ward # Villages
Surveyor’s Names 1.
2.
Date of Survey Day of Survey
BA
SIC
SE
RV
ICE
S
Did you see the following services in the village? Please tick the relevant boxes (based on observation)
Blacktopped road leading to the ward YES NO
Electricity in the ward YES NO
Post Office in the ward YES NO
Bank or cooperative in the ward? YES NO
Government Primary Health Center in the village? YES NO
Private medical shop in the village? YES NO
Computer center/ internet cafe in the ward? YES NO
Equipment/ facility using solar energy in the ward? YES NO
SC
HO
OL
S
Government Primary School (class 1-5) in the ward? YES NO
Government Basic School (class 1-8) in the ward? YES NO
Government Secondary School (class 1-10) in the ward? YES NO
Government plus-two in the ward? YES NO
Private School in the ward? YES NO
Preschool (Early Childhood Development Center/ Balsikshya/ Nursery/ LKG/ UKG) in the ward?
YES NO
School Information Sheet
Name of School
District Name
VDC Name Ward #
Surveyor’s Names
1.
2.
Date of Survey
Day of Survey
Arrival time in school
Type of school (tick)
Primary (class 1-5) Basic (class 1-8) Class 1-10 Secondary (class 1-12)
Respondent Name
Designation (tick)
Head Master Teacher
Contact Information
School Ph. No.
Mobile number
Children’s Enrollment and
Attendance Class 1 Class 2 Class 3 Class 4 Class 5 Class 6 Class 7 Class 8
Children’s enrollment (from register)
Children’s attendance today
(observe)
Official Medium of Instruction in the School
1.
2.
3.
Teachers Number appointed
Number present today
1. Head Master 2. Permanent 3. Government-funded other
4. Niji Shrot
Classroom Observations
Tick the relevant box Class 2 Class 4 YES NO YES NO
Are the students of this class sitting with students from any other class?
Is there a blackboard/ whiteboard?
If yes, could you write on the blackboard/ whiteboard?
Are the desks modular?
Did you see any other teaching-learning materials in the classroom?
Where is this class seated?
Classroom
Verandah
Outside
Facilities Observation Yes No
Did you see an office/ store?
Did you see a playground?
Did you see library books in the school?
If yes, did you see library books being used by children?
If there drinking water in the school?
Do you see a complete boundary wall or fencing?
Is there electricity connection in the school?
If yes, was there electricity in the school today (observe/ask)
Did you see computers for students to use?
If yes, did you see students using computers?
Classrooms
Condition of Classrooms
Good Need upgrade
Unusable
Total number of rooms
Total number of rooms used for Teaching?
Any rooms unusable because of--
Earthquake Fire Flood/landslide Storm Other (mention)
Toilets (by observation)
TOILETS Is there a toilet? If there is a toilet, is it
locked? If unlocked, is it in usable
condition? Yes No Yes No Yes No
Girl
Boy
Common
Teacher
Continuous Assessment System
Have you heard about Continuous Assessment System (CAS) (ask) Yes No
If yes,
How many teachers in this school have received a Continuous Assessment System (CAS) manual or format? (ask)
All Some None Don’t Know
If manual or format was received, ask respondent to show it.
Could you see a Continuous Assessment System (CAS) manual or format in the school? Yes No
School Management Committee (SMC)
Currently is there a School Management Committee for the School? (ask) Yes No
If yes, then when was the last meeting of the SMC held? __/__/____
(dd/mm/yyyy)
School Improvement Plan (SIP) Was a SIP made for the current period? Yes No
When was the SIP for the current five-year period made? __/__/____
(dd/mm/yyyy) Was the SIP for the current five-year period updated for this year? Yes No
School Grants
Baisakh- Chaitra 2072
School Grants
Baisakh 2073 till date of survey
Did you get the grant? If yes, did you spend the full amount?
Did you get the grant? If yes, did you spend the full amount?
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Yes No Don’t Know
Girl child Scholarship Girl child Scholarship
Marginalized student Scholarship
Marginalized student Scholarship
Dalit Scholarship Dalit Scholarship
Disabled students Scholarship Disabled students Scholarship
Activities Carried Out in the School Which of the following activities were carried out since April 2015? (Tick
the relevant box) Yes No
Don’t Know
CONSTRUCTION Construction of new classroom
REPAIR
Repair of classrooms/ White wash/plastering
Repair of drinking water facility
Repair of toilets
PURCHASE
Purchase of furniture
Purchase of sitting mats
Purchase of teaching-learning materials
Departure time from school
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Household Survey Sheet
District Name VDC Name Date/ Day of Survey
Ward # Villages
Surveyor’s Names 1. 2.
Household # Hamlet Total number of family members that eat from the same HH
Name of Respondent Full Name of family head
S. N
o.
Name
of
child
Age
Sex
For children
age 3-6 For children age 5-16
Mother’s
name
Father’s background
information
Preschool
children
In-School
children
Out-of-School
children
Tuitions
Does the
child go
to the
surveyed
school?
Med
ium
of
Inst
ruct
ion i
n s
chool
Lan
guag
e in
whic
h t
he
chil
d w
as
test
ed
Whic
h s
ample
was
use
d t
o t
est?
Basic Learning Levels
EC
D (
publi
c)
Pri
vat
e
Not
atte
ndin
g
Cla
ss
Publi
c
Pri
vat
e
Oth
er
Nev
er e
nro
lled
Dro
p o
ut
Gra
de
dro
pped
out
in
Yea
r d
ropped
out
Does the
child
currently
take
paid
tuition?
Cost
per
month
Reading (highest
level only)
Math (highest
level only)
English
Age
Has the
father
ever
attended
school?
If
yes Reading (highest
level only)
Meaning
Word Sentence
Beg
inner
Let
ter
Wo
rd
Sen
ten
ce
Par
agra
ph
Beg
inner
Nu
mber
Rec
og
nit
ion
(1
-9)
Nu
mber
Rec
og
nit
ion
(1
0-9
9)
Su
btr
acti
on
Div
isio
n
Beg
inner
Cap
ital
Let
ter
Sm
all
Let
ter
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
Cla
ss c
om
ple
ted?
Y N Y N Y N
1
2
3
4
5
6
7
8
Mother’s Background Information
S.No. Mother’s Name
Age Has the Mother ever attended School?
If attended school, which class completed?
Yes No
1
2
3
4
Household indicators (please tick the appropriate columns)
Motorized 2 wheeler (scooter, motorcycle, etc.)
Motorized 4 wheeler (car, jeep, etc.)
Electricity connection (look or wires and fittings)
If electricity in household, was there electricity today?
Toilet in the household
TV in the household
If TV in household, is there cable TV?
Reading materials (other than textbooks)
Gets Newspaper daily
Other (books, magazines, religious books, etc)
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has anyone in the family completed SLC?*
Yes No Don’t Know
*Note: do not include mother(s) and father(s) mentioned above
Does anyone in the HH know how to use a computer?
Yes No
Does anyone in the Household have a mobile phone?
Yes No If yes, what is the mobile number?
Start time of survey
End time of survey
Village Compilation Sheet
District Name VDC Name
Ward # Villages
General Information Number of children and their schooling status Number of children tested
If the number of households
surveyed was less than 20,
give reasons in
this column
HH
No
.
Ham
let/
Sect
ion
nu
mb
er o
f H
H
fro
m t
he
map
Number of surveyed
children in the HH
Pre-school status (Age
3-6)
Schooling status (Age 5-16)
Out of school
children (currently
not enrolled)
(Age 5-16)
Basic Learning Level
Reading
Math
English
English
Meaning
Word Sentence
Age
3 a
nd
4
year
s
Age
5 t
o 1
6
year
s
ECD
Nu
rser
y/
LKG
/ U
KG
Pu
blic
Pri
vate
Oth
er
Nev
er
enro
lled
Dro
p o
ut
Beg
inn
er
Lett
er
Wo
rd
Par
a
Sto
ry
Beg
inn
er
Nu
m (
1-9
)
reco
gnit
ion
Nu
m (
10
-99
)
reco
gnit
ion
Sub
trac
tio
n
Div
isio
n
Beg
inn
er
Cap
ital
lett
ers
Smal
l let
ters
Wo
rd
Sen
ten
ce
Can
say
Can
no
t sa
y
Can
say
Can
no
t sa
y
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
SURVEYOR CHECKLIST
Did you remember to do the following during the survey? Tick
1 Have you filled all the information on the cover page?
2 Have you written the name and phone of the respondent in the school as well as the landline phone number of the school?
3 Have you numbered the hamlets/ sections on the map, and do they correspond to the section numbers filled in the household survey sheet? Have you also written the HH no. on each household survey sheet?
4 Have you written the name of the respondent, name of family head, and phone number for each surveyed household in the household survey sheet?
5 Have you recorded the age and sex of each surveyed child?
6 Have you ticked the schooling status of each surveyed child?
7 If the child is in school, have you written what class the child is in?
8 Surveyed children in the age group 5-16 must be tested. Have you tested all children between ages 5-16? If not, have you written the reason in the household survey sheet?
9 During testing, did you make children solve arithmetic problems (subtraction/ division) on the back of the household survey sheet?
10 Have you marked ONLY the highest learning level for each child in all the testing column (Reading/ Math/ English)?
