TO BE COMPLETED FOR EACH PERSON, 14 YEARS AND OLDER, IN THE HOUSEHOLD
2.
3.
INTERVIEWER: COMPLETE BEFORE BEGINNING THE MODULE
1. Household ID number:
Respondent code:
Date of visit: Day Month Year
4. Interviewer code:
5. Location ID number:
6.
Hamlet: …………………………………..
7.
Village: …………………………………..
8.
Zone: …………………………………..
9.
Block: …………………………………..
1

Consent
Now we would like to ask you some questions yourself, including questions about your family history, work, education, income, and health. This form will take about 1 hour. We will also give you a small health checkup.
We will share the results of this health checkup with you. You can choose not to answer a question at any time.
Choosing to do so will not affect your ties with Seva Mandir or Vidya Bhawan in any way. The information you share with us will be kept fully confidential. Will you answer our questions?
Yes.....................1
No......................2
2

SECTION C: PERSONAL DETAILS
C0.0 INTERVIEWER INFORMATION
C0.1 NAMES OF OTHER PERSONS PRESENT DURING THIS MODULE
………………………………………………………………………………………………………
………………………………………………………………………………………………………
C0.2 STARTING TIME OF MODULE HOUR:
MINUTE:
C1.0 INTERVIEWER CHECKPOINT: SKIP TO C2.0 IF THIS RESPONDENT WAS
PRESENT DURING HOUSEHOLD ROSTER AND ALREADY ANSWERED THESE
QUESTIONS.
C1.1 In what year were you born, or how old are you now?
C1.2
C1.3
Are you literate?
What is the highest level of education you have achieved?
YEAR:
AGE:
DO NOT KNOW…–999
NOT LITERATE………..…… 1
LITERATE THROUGH
ATTENDING NFEC/AEC.….. 2
LITERATE THROUGH
ATTENDING TLC………….. 3
LITERATE, OTHERS..….….. 4
CLASS 1….………………. 1
CLASS 2……………….…. 2
CLASS 3….………………. 3
CLASS 4….………………. 4
CLASS 5….………………. 5
CLASS 6….……….………. 6
CLASS 7….…………..…… 7
CLASS 8….……….………. 8
CLASS 9….….……………. 9
CLASS 10…..……………… 10
CLASS 11………………….. 11
CLASS 12….…………….… 12
GRADUATE AND ABOVE... 13
OTHER DIPLOMA................ 14
NEVER ATTENDED SCHOOL/DID
NOT COMPLETE CLASS
1…………………..………….. 15
C1.4 Are you still studying?
C2.0 What is your marital status?
CIRCLE ALL THAT APPLY
YES.................................... 1
NO..................................... 2
MARRIED, LIVING WITH
SPOUSE..................................1
MARRIED, NOT LIVING WITH
SPOUSE YET ........................2.
SEPARATED/DIVORCED...3.
SPOUSE/PARTNER DIED....4
NATA .......................................5
NEVER MARRIED/DONE
NATA......................................6
3
2
3
4

C2.1 INTERVIEWER CHECKPOINT: Has the respondent ever been married?
C2.5 What is the name of your spouse?
(WRITE IN CODE NUMBER FROM
BOARD)
C2.6 In what year, or at what age, did you get married to this person?
YES.................................... 1
NO..................................... 2
C2.2 How many times did you get married?
C2.3 INTERVIEWER CHECKPOINT: ASK QUESTIONS C2.4 TO C2.9 FOR EACH
SPOUSE THE RESPONDENT HAS, STARTING WITH THE FIRST MARRIAGE.
C2.4 Does your spouse live in this household? YES.................................... 1
NO..................................... 2
C2.7
C2.8
C2.9
Are you still married to this person?
In what year or at what age did you become separated/divorced or did your spouse die?
Did you get married again after that?
C2.10 INTERVIEWER CHECKPOINT: Has the respondent ever done nata ?
YEAR
AGE
DO NOT KNOW…–999
YES.........................................1
NO,
DIVORCED/SEPARATED....2
NO, SPOUSE DIED................3
YEAR
AGE
DO NOT KNOW…–999
YES.................................... 1
NO..................................... 2
YES.................................... 1
NO..................................... 2
C2.11 How many times have you done nata ?
C2.12 INTERVIEWER CHECKPOINT: ASK QUESTIONS C2.13 TO C2.18 FOR EACH TIME
THE RESPONDENT HAS DONE NATA, STARTING WITH THE FIRST TIME.
C2.13 Does your nata partner live in this household? YES.................................... 1
NO..................................... 2
C2.14 What is the name of your nata partner?
(WRITE IN CODE NUMBER FROM
BOARD)
C2.15 In what year, or at what age, did you do nata with this person?
C2.16 Are you still in nata with this person?
C2.17 In what year or at what age did you become separated or did your nata partner die?
C2.18 Did you do nata again after that?
YEAR
AGE
DO NOT KNOW…–999
YES.................................... 1
NO, SEPARATED............ 2
NO, PARTNER DIED...... 3
YEAR
AGE
DO NOT KNOW…–999
YES.................................... 1
NO..................................... 2

C2.10

C2.6

C2.9

C2.4

C3.0

C2.15

C2.18

C2.13
4

(1)
2.4 1
2 
C2.6
2.5
2.6
–999
2.7 1 
C2.9
2
3
2.8
–999
2.9 1 
C2.4
2
2.13 1
2 
C2.15
2.14
2.15
–999
2.16 1 
C2.18
2
3
2.17
–999
2.18 1 
C2.13
2
(3)
1
2 
C2.6
–999
1 
C2.9
2
3
–999
1 
C2.4
2
1
2 
C2.15
–999
1 
C2.18
2
3
–999
1 
C2.13
2
(2)
1
2 
C2.6
–999
1 
C2.9
2
3
–999
1 
C2.4
2
1
2 
C2.15
–999
1 
C2.18
2
3
–999
1 
C2.13
2
5
(5)
1
2 
C2.6
–999
1 
C2.9
2
3
–999
1 
C2.4
2
1
2 
C2.15
–999
1 
C2.18
2
3
–999
1 
C2.13
2
(4)
1
2 
C2.6
–999
1 
C2.9
2
3
–999
1 
C2.4
2
1
2 
C2.15
–999
1 
C2.18
2
3
–999
1 
C2.13
2
(6)
1
2 
C2.6
–999
1 
C2.9
2
3
–999
1 
C2.4
2
1
2 
C2.15
–999
1 
C2.18
2
3
–999
1 
C2.13
2

C3.0
C3.1
C3.2
C3.3
C3.4
C3.5
C3.6
C3.7
Please remind me, is your mother alive or deceased?
How old was your mother when she died?
Would you say she was older or younger than
50 when she died?
How old is she?
Is/was she literate?
What is the highest level of education she achieved?
Please remind me, is your father alive or deceased?
How old was your father when he died?
C3.8 Would you say he was older or younger than 50 when he died?
C3.9 How old is he?
C3.10 Is/was he literate?
ALIVE................................ 1
DECEASED....................... 2
DO NOT KNOW…–999
AGE
DO NOT KNOW…–999
OLDER THAN 50 ……….. 1
YOUNGER THAN 50……. 2
DON’T KNOW…………….-999
AGE
DO NOT KNOW…–999
NOT LITERATE………..…… 1
LITERATE THROUGH
ATTENDING NFEC/AEC.….. 2
LITERATE THROUGH
ATTENDING TLC………….. 3
LITERATE, OTHERS..….….. 4
CLASS 1….………………. 1
CLASS 2……………….…. 2
CLASS 3….………………. 3
CLASS 4….………………. 4
CLASS 5….………………. 5
CLASS 6….……….………. 6
CLASS 7….…………..…… 7
CLASS 8….……….………. 8
CLASS 9….….……………. 9
CLASS 10…..……………… 10
CLASS 11………………….. 11
CLASS 12….…………….… 12
GRADUATE AND ABOVE... 13
OTHER DIPLOMA................ 14
NEVER ATTENDED SCHOOL/DID
NOT COMPLETE CLASS
1………………………..…...... 15
ALIVE..................................1
DECEASED.........................2
DO NOT KNOW…–999
AGE
DO NOT KNOW…–999
OLDER THAN 50 ……… 1
YOUNGER THAN 50……2
DON’T KNOW………….-999
AGE
DO NOT KNOW…–999
NOT LITERATE………..…… 1
LITERATE THROUGH
ATTENDING NFEC/AEC.….. 2
LITERATE THROUGH
ATTENDING TLC………….. 3
LITERATE, OTHERS..….….. 4

C3.3

C3.4

C3.4

C3.2

C3.4

C3.4

C3.4

C3.9

C3.10

C3.10

C3.8

C3.10

C3.10

C3.10
6

PAGE INTENTIONALLY LEFT BLANK
7

C3.11 What is the highest level of education he/she achieved?
CLASS 1….………………. 1
CLASS 2……………….…. 2
CLASS 3….………………. 3
CLASS 4….………………. 4
CLASS 5….………………. 5
CLASS 6….……….………. 6
CLASS 7….…………..…… 7
CLASS 8….……….………. 8
CLASS 9….….……………. 9
CLASS 10…..……………… 10
CLASS 11………………….. 11
CLASS 12….…………….… 12
GRADUATE AND ABOVE... 13
OTHER DIPLOMA................ 14
NEVER ATTENDED SCHOOL/DID
NOT COMPLETE CLASS
1………………….…………... 15
YES ................................... 1
NO .................................. 2

D1.0
C4.0 INTERVIEWER CHECKPOINT: Is the respondent a woman aged 14 to 50 or a widower aged 14 to 55 ?
C4.1 How many children do you have (whether or not they are living in this household)?
C4.2 INTERVIEWER CHECKPOINT: Is the respondent a woman?
C4.3 Did you ever have any:
1. Stillbirth................................................
2. Spontaneous abortion...........................
3. Induced abortion...................................
C4.4 Have you had any children who have died in the period between their birth and this date?
C4.5 INTERVIEWER CHECKPOINT: Does/did the respondent have any children?
YES ................................... 1
NO .................................. 2
YES NO
1 2
1 2
1 2
IF YES: HOW
MANY
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2

C4.4

C4.26
C4.6 Now I would like to ask you about all the births in your lifetime, whether the child is currently alive or not. Starting with your first birth:
C4.7
INTERVIEWER: RECORD RESPONSES ON GRID
What name was given to your baby? …………………………….
NO NAME………998
C4.8
C4.9
What he/she part of a twin pair?
(INTERVIEWER: RECORD TWINS AS
DIFFERENT CHILDREN)
Is/was this child a boy or a girl?
YES ................................... 1
NO .................................. 2
C4.10 Is __________ still alive?
BOY...……………………..1
GIRL.......………………….2
YES ................................... 1
NO .................................. 2
C4.11 Is _________ a member of the household? YES ................................... 1
NO .................................. 2

C4.14

C4.13
8

(1)
4.7
……….......
998
4.8 1
2
4.9 1
2
4.10 1
2 
C4.14
4.11 1
2 
C4.13
(2)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(3)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(4)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(5)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(6)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(7)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
(8)
1
2
1
2
……….......
998
1
2 
C4.14
1
2 
C4.13
9

C4.12
C4.13
INTERVIEWER: RECORD CHILD’S
HOUSEHOLD NUMBER FROM THE
BOARD ON THE GRID.
Where does __________ live?
C4.14 How old was _________ when he/she died?
C4.15
C4.16
C4.17
C4.18
C4.19
How long ago did he/she die?
What was the cause of his/her death?
If s/he died due to illness then which illness was it.
What is his/her age?
Is/was he/she literate?
A. CITY/TOWN…………………..
DO NOT KNOW…–999
B. DISTRICT……………………..
DO NOT KNOW…–999
C. TEHSIL………………………..
DO NOT KNOW…–999
D. VILLAGE……………………..
DO NOT KNOW…–999
YEARS……………………… 1
MONTHS…………………… 2
DAYS………..……………… 3
YEARS……………………… 1
MONTHS…………………… 2
DAYS………..……………… 3
DONT KNOW...........................-999
ILLNESS……………………. 1
SUICIDE……………………. 2
ACCIDENT………………… 3
DELIVERY............................. 4
OTHER:__________________ 996
DO NOT KNOW…–999
……………………………………
……………………………………
DO NOT KNOW…–999
YEARS……………………… 1
MONTHS…………………… 2
DAYS………..……………… 3
NOT LITERATE………..…… 1
LITERATE THROUGH
ATTENDING NFEC/AEC.….. 2
LITERATE THROUGH
ATTENDING TLC………….. 3
LITERATE, OTHERS..….….. 4

C4.18

C4.18

C4.18

C4.18

C4.18

C4.19

C4.19

C4.19

C4.19

C4.19

C4.19

C4.19
10

(1)
4.12

C4.18
(2)

C4.18
(3)

C4.18
(4)

C4.18
(5)

C4.18
(6)

C4.18
(7)

C4.18
(8)

C4.18
4.13 A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
4.14
1
2
3
4.15
1
2
3
-999
4.16 1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
4.17 .................
.................
4.18
.................

C4.19
-999 
C4.19
1
2
3
4.19 1
2
3
4
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
A 
C4.18
.................
–999

C4.18
B 
C4.18
.................
–999

C4.18
C 
C4.18
.................
–999

C4.18
D 
C4.18
.................
–999

C4.18
1
2
3
1
2
3
-999
1
2 
C4.19
3 
C4.19
4 
C4.19
996 
C4.19
–999

C4.19
1
2
3
4
1
2
3
.................
.................
.................

C4.19
-999 
C4.19
11

C4.20 What is the highest level of education he/she achieved?
C4.21
What is/was ___________’s marital status?
(CIRCLE ALL THAT APPLY)
CLASS 1….………………. 1
CLASS 2……………….…. 2
CLASS 3….………………. 3
CLASS 4….………………. 4
CLASS 5….………………. 5
CLASS 6….……….………. 6
CLASS 7….…………..…… 7
CLASS 8….……….………. 8
CLASS 9….….……………. 9
CLASS 10…..……………… 10
CLASS 11………………….. 11
CLASS 12….…………….… 12
GRADUATE AND ABOVE... 13
OTHER DIPLOMA................ 14
NEVER ATTENDED
SCHOOL/DID NOT COMPLETE
CLASS 1…………………...... 15
MARRIED, LIVING WITH
SPOUSE..................................1
MARRIED, NOT LIVING WITH
SPOUSE YET ........................2.
SEPARATED/DIVORCED...3.
SPOUSE/PARTNER DIED....4
NATA .......................................5
NEVER MARRIED/DONE
NATA......................................6
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
C4.22 INTERVIEWER CHECKPOINT: IS THE
RESPONDENT A WOMAN?
C4.23
INTERVIEWER CHECKPOINT:
Did the respondent have any stillbirth, spontaneous abortion, or induced abortion?
C4.24
Between the birth of __________ [NAME
OF PREVIOUS CHILD] and the birth of
________, did you have any:
[INTERVIEWER: IF IT IS THE FIRST
CHILD: ASK ONLY "BEFORE THE
BIRTH OF ___________"]
1. Stillbirth................................................
2. Spontaneous abortion...........................
3. Induced abortion...................................
C4.25 Was any child born after________?
C4.26
C4.27
INTERVIEWER CHECKPOINT: Is the respondent a woman?
Are you pregnant?
YES NO
1 2
1 2
1 2
IF YES: HOW
MANY
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
12


C4.25
C4.25

C4.7

D1.0
2
3
4

4.20 1
2
3
7
8
9
4
5
6
10
11
12
13
14
15
(1)
4.21 1
2
3
4
5
6
4.22 1
2 
C4.25
4.23 1
2 
C4.25
(2)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(4)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(3)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(6)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(5)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(8)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
(7)
7
8
9
10
11
12
13
14
15
1
2
3
4
5
6
1
2
3
4
5
6
1
2 
C4.25
1
2 
C4.25
4.24
1 2
1 2
1 2
4.25 1 
C4.7
2 
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
1 2
1 2
1 2
1
2


C4.7
C4.26
1 2
1 2
1 2
1 
C4.7
2 
C4.26
13

SECTION D: INDIVIDUAL INCOME AND EXPENDITURES
D1.0 In the last year, did you earn any income by yourself (in cash or in kind) from the following sources, not including joint activities?:
1
YES NO regular salary job (specify………………….)
1 2
2
3
4
Individual income from non farm business
(including making/fixing goods)
(specify…………………………..) working on someone else’s farm or business throughout the year working on someone else’s farm or business seasonally or contractually
1 2
1 2
1 2
1 2
5 working on someone else farm or business as a day laborer
6 working on EGS (JRY, EGS, JRSY, JFM,
SEVA MANDIR WORK…..)
7 Personal income from land, house or other property
8 interest from bank account, savings group, or other money holder
9 old age pension
1 2
1 2
1 2
1 2
1 2
D2.0
10 disability pension
11 widow’s pension
12 any other welfare scheme
13 Remittances
14 any other source (specify………………)
Do you have an outstanding loan from a commercial bank?
1 2
1 2
1 2
1 2
IF YES: how much income did this person earn from this source in the last year?
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
Rs.
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
D2.1 For how much money is this commercial bank loan?
D2.2 Have you had any loan from a commercial bank in the past that you have repaid?
D2.3 Do you participate in a savings group or SHG?
Rs.
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999

D2.2

D2.2

D2.7

D2.7
14

D2.4
D2.5
D2.6
D2.7
How much did you contribute to the savings group or SHG in the last 30 days?
Do you have an outstanding loan from the savings group or SHG?
For how much money is the savings group or SHG loan?
Are you a member of a Bisi ?
D2.8 How much did you contribute to the Bisi in the last
30 days?
D2.9 Do you have an outstanding loan from a Bisi ?
D2.10 For how much money is this loan?
D2.11 Do you have life insurance?
D2.12 Do you ever deposit money in any other institution or savings group?
D2.13 How much did you deposit in the last 30 days?
Rs.
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
Rs.
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
Rs.
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
Rs.
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
Rs.

D2.11

D2.11

E1

E1

D2.7

D2.7

D2.11

D2.11
15

SECTION E: PHYSICAL HEALTH
E1 How would you classify your health these days? If the top rung of this ladder represents very good health and the bottom rung represents very bad health, where would you place yourself?
INTERVIEWER CHECKPOINT: PRESENT THE
PICTURE OF A LADDER TO THE
RESPONDENT AND CIRCLE THE NUMBER
THAT CORRESPONDS TO THE RUNG THEY
CHOOSE.
1…2…3…4…5…6…7…8…9…10
DONT KNOW..........................999
10
9
8
7
6
5
2
1
4
3
16

E2 What level of difficulty do you have in carrying out the following activities by yourself right now?
For each activity, please say whether you have no difficulty, have difficulty but can do it without help, can only do it with help, cannot do this activity, or are able to do it but never do.
Dressing………………
Bathing………………..
Eating………………….
Toileting………………
Doing light work in or around the house (if you had to)…………....
Climbing a small hill….
Lifting or carrying heavy objects (e.g. a bag weighing 5 kg)….…….
Walking 200-300 meters…………………
Walk for 5 kilometers….
Bow, squat or kneel……
Draw a water from a well
(if you had do)………….
Stand up from sitting on the floor………………..
Work in a field for one day (if you had to)……..
IF THE RESPONDENT
IS A MAN:
Managing money (if you had to)…..……..………
Take a bus, train, or taxi.……………………..
13
14
15
9
10
11
8
12
5
3
4
1
2
6
7
No
Difficulty
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
Difficult but can do with no help
2
2
Can do, only with help
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
Can’t do
4
4
4
4
4
4
4
4
4
4
5
5
5
5
5
Able to, but never do
5
5
5
5
5
5
5
5
5
5
-999
-999
-999
-999
-999
-999
-999
-999
Don’t know
-999
-999
-999
-999
-999
-999
-999
17

E3.0 Now I would like to ask you about some health conditions that people sometimes complain about. Have you experienced __________ in the last 30 days?
YES NO
IF YES:
Is/was the condition serious?
YES NO
15
16
17
18
19
20
11
12
13
14
21
22
23
24
4
5
6
7
1
2
3
8
9
10
29
30
25
26
27
28
996
Dry cough…..……………
Productive cough………...
Cough with blood………..
Blood in spit......................
Hot fever………...……….
Diarrhea………………….
Body ache................……..
Weakness/fatigue...............
Problems with vision…….
Headache………….….…..
Back ache……………..….
Vomiting…………………
Worms in stool…………..
Trouble breathing….……..
Pain in upper abdomen...…
Pain in lower abdomen...…
Genital ulcers…………..…
Painful urination……….…
Swelling ankles…………..
Hearing problems………...
Skin problems………...…..
Chest pain……………...…
Memory loss………….….
Full paralysis…………..…
Partial paralysis……….….
Night sweats.......................
Weight loss.........................
Other (specify).……….….
IF RESPONDENT IS
FEMALE:
Menstrual problems…….
White discharge…………
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
X X
X X
X X
1 2
1 2
1 2
1 2
1 2
18

PAGE INTENTIONALLY LEFT BLANK
19

E3.1 INTERVIEWER CHECKPOINT:
Was there any condition checked in E3.0?
YES..................................... 1
NO...................................... 2

E4.1
E3.2
E3.3
Did you consult anyone about any of these conditions in the last 30 days?
How many times did you consult someone about these conditions in the last 30 days?
YES..................................... 1
NO...................................... 2

E3.24
ASK QUESTIONS E3.3 TO E3.17 FOR EACH CONSULTATION THAT RESULTED FROM THE
ONSET OF THE ABOVE MARKED CONDITIONS IN THE LAST 30 DAYS.
E3.4 FOR EACH CONSULTATION: Which
CHC/PHC...............................………...1
E3.5
E3.6 type of facility did you visit, or which type of health provider did you consult?
Was this facility/health provider private or public?
What is the name of the facility or health provider?
GOVERNMENT REFERRAL
HOSPITAL…………………………...2
PRIVATE HOSPITAL..................……3
ARYUVEDIC HOSPITAL...........……4
T.B. HOSPITAL……………………...5
DISPENSARY………………………..6
AIDPOST/SUBCENTRE.....................7
ANGANWADI......................................8
HEALTH CAMP...............................…9
NGO CLINIC......................................10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
GOVERNMENT DOCTOR, PRIVATE

E3.6
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI.........................................…17
VHW/CHW...................................…..18
HRW...............................................….19
BHOPA/TRADITIONAL HEALER..20
DON’T KNOW……………..…….-999
OTHER (SPECIFY) _______________ 996
Private……………………………..1
Public………………………………2
Don’t know……………………..-999
………………………………………….

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6

E3.6
E3.7 Where is this facility located, or where did you consult this health provider?
E3.8 FOR EACH CONSULTATION: How long ago was this consultation?
VILLAGE/TOWN …………………
TEHSIL ……………………………
DISTRICT ……………………….…
STATE…………………………….…
DAYS
20

3.4 1 
E3.6
2 
E3.6
3 
E3.6
4 
E3.6
5 
E3.6
6 
E3.6
7 
E3.6
8 
E3.6
9 
E3.6
10 
E3.6
11 
E3.6
12 
E3.6
13 
E3.6
14 
E3.6
15 
E3.6
16 
E3.6
17 
E3.6
18 
E3.6
19 
E3.6
20 
E3.6
(1)
-999
996________________
3.5 1
2
-999
3.6
………………………
3.7
3.8
DONT KNOW .....999
Village/Town ……......
.…………….…………
Tehsil ……...................
……………….………
District …….................
..………………………
State ………………….
.……………................
1 
E3.6
2 
E3.6
3 
E3.6
4 
E3.6
5 
E3.6
6 
E3.6
7 
E3.6
8 
E3.6
9 
E3.6
10 
E3.6
11 
E3.6
12 
E3.6
13 
E3.6
14 
E3.6
15 
E3.6
16 
E3.6
17 
E3.6
18 
E3.6
19 
E3.6
20 
E3.6
(2)
-999
996________________
1
2
-999
1 
E3.6
2 
E3.6
3 
E3.6
4 
E3.6
5 
E3.6
6 
E3.6
7 
E3.6
8 
E3.6
9 
E3.6
10 
E3.6
11 
E3.6
12 
E3.6
13 
E3.6
14 
E3.6
15 
E3.6
16 
E3.6
17 
E3.6
18 
E3.6
19 
E3.6
20 
E3.6
(3)
-999
996________________
1
2
-999
1 
E3.6
2 
E3.6
3 
E3.6
4 
E3.6
5 
E3.6
6 
E3.6
7 
E3.6
8 
E3.6
9 
E3.6
10 
E3.6
11 
E3.6
12 
E3.6
13 
E3.6
14 
E3.6
15 
E3.6
16 
E3.6
17 
E3.6
18 
E3.6
19 
E3.6
20 
E3.6
(4)
-999
996________________
1
2
-999
………………………
DONT KNOW .....999
Village/Town ……......
.…………….…………
Tehsil ……...................
……………….………
District …….................
..………………………
State ………………….
.……………................
………………………
DONT KNOW .....999
Village/Town ……......
.…………….…………
Tehsil ……...................
……………….………
District …….................
..………………………
State ………………….
.……………................
………………………
DONT KNOW .....999
Village/Town ……......
.…………….…………
Tehsil ……...................
……………….………
District …….................
..………………………
State ………………….
.……………................
21

E3.9 INTERVIEWER CHECKPOINT:Was this consultation more than 30 days ago?
E3.10 FOR EACH CONSULTATION: Was anyone from this household with you during this consultation?
E3.11 FOR EACH CONSULTATION: Who was with you?
INTERVIEWER: RECORD HOUSEHOLD
NUMBER FROM BOARD FOR EACH
PERSON FROM THE HOUSEHOLD
WHO WAS PRESENT AT THIS
CONSULTATION
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
E3.12 FOR EACH CONSULTATION: For which conditions did you make this consultation?
INTERVIEWER: RECORD THE
NUMBER OF EACH CONDITION FROM
E3.0 IN THE GRID
E3.13
E3.14
6
7
5
2
3
4
1
8
9
10
INTERVIEWER CHECKPOINT: Was this consultation a consultation to a bhopa?
FOR EACH CONSULTATION: Did you get________?
Consultation………………….………
Medication given in facility………….
Medication bought outside the facility
Injection………………………..…….
Drip…………………………..………
Operation…………………..…………
Lab test………………………...……..
Other treatment……………………....
Transportation (round trip)…………...
Total expense incurred……………….
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
3
4
1
2
5
6
1 7
2 8
3 9
4 10
5 11
6 12
YES ................................... 1
NO .................................. 2
YES NO
IF YES:
Did you have to pay for
______?
YES NO
IF YES:
How much did you have to pay for _____?
(Rs.)
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX

E3.2

E3.12

E3.15
 E3.17

E3.17

E3.17

E3.17
 E3.17

E3.17

E3.17

E3.17

E3.17
XXXX
22

(1)
3.9 1 
E3.2
2
3.10 1
2 
E3.12
3.11 1
2
3
4
5
6
3.12 1 7
2 8
3 9
4 10
5 11
6 12
3.13 1 
E3.15
3.14
2
1
9
7
8
5
6
2
3
4
1
0
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
(2)
1 
E3.2
2
1
2 
E3.12
4
5
6
1
2
3
1 7
2 8
3 9
4 10
5 11
6 12
1 
E3.15
2
(3)
1 
E3.2
2
1
2 
E3.12
4
5
6
1
2
3
1 7
2 8
3 9
4 10
5 11
6 12
1 
E3.15
2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
23
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XX
(4)
1 
E3.2
2
1
2 
E3.12
4
5
6
1
2
3
1 7
2 8
3 9
4 10
5 11
6 12
1 
E3.15
2

E3.15 Did you get any jalibuti or any other treatment bhopa ?
E3.16 How much did this consultation to the bhopa cost you in total (including transportation, fees, jali buti , offerings and other costs)?
E3.17 FOR EACH CONSULTATION: After this consultation did you feel better?
E3.18 INTERVIEWER CHECKPOINT: FOR
EACH CONSULTATION: Was any medication or treatment received or prescribed at this consultation with a health provider?
E3.19 FOR EACH CONSULTATION: Did you finish this medication/treatment?
E3.27 What kind of treatment did you undertake without consulting a health provider first?
(CIRCLE ALL THAT APPLY)
YES ................................... 1
NO .................................. 2
Rs.
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
E3.20 Why did you interrupt this medication/treatment?
E3.21 INTERVIEWER CHECKPOINT: Did the respondent have any other consultation in the last 30 days regarding any of checked conditions in E3.0?
E3.22 Facility ID from PRA
(FILL AFTER SURVEY)
E3.23 INTERVIEWER CHECKPOINT:
Are there any conditions checked in E3.0 for which he/she did not seek consultation from anyone?
E3.24 Why did you not seek consultation for those conditions?
YES………………………………1
NO, STILL GOING ON..………..2
NO, INTERRUPTED…………….3
..............................................................
..............................................................
YES ................................... 1
NO .................................. 2
[ ][ ][ ][ ]
YES ................................... 1
NO .................................. 2
..............................................................
..............................................................
YES ................................... 1
NO .................................. 2
E3.25 Did you undergo treatment for any of the conditions checked in E3.0 without consulting a health provider first?
E3.26 For which conditions checked in E3.0 did you undergo treatment without consulting a health provider first?
INTERVIEWER: RECORD THE
NUMBER OF EACH CONDITION FROM
E3.0 IN THE GRID
1
2
3
4
5
6
Tablets/bottled medicine………..1
Home remedy…………………..2
Jali buti
…………………………3
Other (specify) ____________996



E3.21
E3.21

E3.4


E3.21
E3.25
E4.1
24

3.15 1
3.16
2
(1)
1
2
(2)
1
2
(3)
1
2
1
2
(4)
3.17 1
2
1
2
1
2
3.18 1
2

E3.21
3.19 1

E3.21
2

E3.21
3
3.20
......................................
......................................
3.21 1 
E3.4
2
3.22 [ ][ ][ ][ ]
1
2

E3.21
1

E3.21
2

E3.21
3
......................................
......................................
1 
E3.4
2
[ ][ ][ ][ ]
1
2

E3.21
1

E3.21
2

E3.21
3
......................................
......................................
1 
E3.4
2
[ ][ ][ ][ ]
1
2

E3.21
1
2

E3.21

E3.21
3
......................................
......................................
1 
E3.4
2
[ ][ ][ ][ ]
25

E3.28 Why did you decide to undertake this treatment without consulting a health provider first?
E3.29 How much did you pay for this treatment you undertook without consulting a health provider first?
E4.1 Have you ever been tested for Tuberculosis (TB)?
Advised by family member…….1
Advised by neighbor/friend……2
Past experience…………………3
Other (specify) ____________996
Rs.
YES .................................. 1
NO .................................. 2
DO NOT KNOW…–999
E4.2 Have you ever been diagnosed with Tuberculosis
(TB)?
YES .................................. 1
NO .................................. 2
DO NOT KNOW…–999
E4.3 When was the first time that you were told you had
TB?
E4.4 In the past 12 months, have you received any
E4.6
E4.7 medication or treatment for TB from a doctor, nurse, clinic or hospital?
E4.5 INTERVIEWER CHECKPOINT: Has the respondent suffered from cough in last 30 days
If yes then are you still suffering from cough?
If yes then has the cough been continuing for more than past two weeks?
IN PAST 12 MONTHS..... 1
> 12 MONTHS AGO...........2
DO NOT KNOW…–999
YES ................................... 1
NO ................................... 2
DO NOT KNOW…–999
YES .................................. 1
NO .................................. 2
YES .................................. 1
NO .................................. 2
YES .................................. 1
NO .................................. 2

E4.5

E4.5

E4.5

E4.5

E5.0

E5.0
26

PAGE INTENTIONALLY LEFT BLANK
27

E5.0 Have you ever been to health facility or consulted a health provider?
Yes………………………………..1
No…………………………………2
Don’t know…………………….-999

E5.37

F1.0
E5.1
E5.2
E5.3
E5.4
E5.5
E5.6
E5.7
Now I would like to ask you about your last two visits to a health facility or consultations with a health provider either for your own health or for someone else’s, starting with the last visit/consultation.
INTERVIEWER CHECKPOINT: FILL RESPONSES FOR E5.2 TO E5.28 IN THE GRID.
How much time ago was it?
INTERVIEWER CHECKPOINT:
When was the respondent’s last visit to a health facility or consultation with a health provider?
For whose health condition did you visit this health facility?
CIRCLE ALL THAT APPLY
YEARS……………………… 1
MONTHS…………………… 2
DAYS………..……………… 3
DONT KNOW..........................-999
NEVER.....................................998
<1 WEEK AGO...…………………1
1 TO 4 WEEKS AGO...…………..2
1 TO 6 MONTHS AGO…..………3
6 TO 12 MONTHS AGO…………4
1 TO 2 YEARS AGO……………..5
>2 YEARS AGO………………….6
OWN…………................................….1
SPOUSE………………………….......2
CHILD........................……….............3
PARENT..............................……........4
OTHER RELATIVE............................5
NEIGHBOR...............................……..6
OTHER(SPECIFY) _____________996

E5.29

E5.29
Was anyone from this household with you during this visit/consultation?
Who was with you?
INTERVIEWER: RECORD HOUSEHOLD
NUMBER FROM BOARD FOR EACH
PERSON FROM THE HOUSEHOLD
WHO WAS PRESENT AT THIS
CONSULTATION
Why did you visit a health facility or consult a health provider?
INTERVIEWER: LIST CONDITIONS OR
NAME OF ILLNESS IF KNOWN
YES ................................... 1
NO .................................. 2
1
2
3
6
4
5
..............................................................
..............................................................
..............................................................

E5.7
28
1
2
3
5

LAST
5.2 1
2
3
–999
998 
E5.29
5.3 1
2
3
4
5
6 
E5.29
5.4 1
2
3
4
5
6
996_______________________
5.5 1
2 
E5.7
5.6 1
2
3
4
5
6
5.7
.............................................................................
.............................................................................
.............................................................................
BEFORE LAST
1
2
3
–999
998 
E5.29
1
2
3
4
5
6 
E5.29
1
2
3
4
5
6
996_______________________
1
2 
E5.7
3
4
5
1
2
6
.............................................................................
.............................................................................
.............................................................................
29

E5.8
E5.9
E5.10
E5.11 Was this consultation with a health provider in your own home?
E5.12 Where is this health provider based?
INTERVIEWER: WRITE THE NAME
AND PLACE OF THIS HEALTH
PROVIDER’S PRIMARY LOCATION
E5.13
Which type of facility did you visit, or which type of health provider did you consult?
Was this facility/health provider public or private?
What is the name of the facility or health provider?
Where is this facility located, or where did you consult this health provider?
CHC/PHC...............................………...1
GOVERNMENT REFERRAL
HOSPITAL…………………………...2
PRIVATE HOSPITAL..................……3
ARYUVEDIC HOSPITAL...........……4
T.B. HOSPITAL……………………...5
DISPENSARY………………………..6
AIDPOST/SUBCENTRE.....................7
ANGANWADI......................................8
HEALTH CAMP...............................…9
NGO CLINIC......................................10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI.........................................…17
VHW/CHW...................................…..18
HRW...............................................….19
BHOPA/TRADITIONAL HEALER..20
DON’T KNOW……………………-999
OTHER (SPECIFY) ____________996
Private……………………………….1
Public………………………………..2
Don’t know………………………..-999
………………………………………
DO NOT KNOW…–999
YES ................................... 1
NO .................................. 2
FACILITY NAME.………………
VILLAGE/TOWN……..…………
TEHSIL…………………………..
DISTRICT…………………….….
STATE………………………….…
DO NOT KNOW…–999
VILLAGE/TOWN …………………
TEHSIL ……………………………
DISTRICT ……………………….…
STATE…………………………….…

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.10

E5.13

E5.17

E5.17

E5.17

E5.17

E5.17

E5.17
30

LAST
E5.8 1 
E5.10
2 
E5.10
3 
E5.10
4 
E5.10
5 
E5.10
6 
E5.10
7 
E5.10
8 
E5.10
9 
E5.10
10 
E5.10
11 
E5.10
12 
E5.10
13 
E5.10
14 
E5.10
15 
E5.10
16 
E5.10
17 
E5.10
18 
E5.10
19 
E5.10
20 
E5.10
-999
996____________________________
E5.9 1
2
-999
E5.10
………………………………………
–999
E5.11 1
2 
E5.13
E5.12
Facility’s name …...................……… 
E5.17
Village ……..……...................…… 
E5.17
tehsil ……………………......…….. 
E5.17
E5.13
District ……………………..............…. 
E5.17
State ………………….......……….… 
E5.17
irk ugha ........................–999
Village/Town …………….….....………
Tehsil ……………….……....…….
District …………………………....….
State …..……………………....……
BEFORE LAST
1 
E5.10
2 
E5.10
3 
E5.10
4 
E5.10
5 
E5.10
6 
E5.10
7 
E5.10
8 
E5.10
9 
E5.10
10 
E5.10
11 
E5.10
12 
E5.10
13 
E5.10
14 
E5.10
15 
E5.10
16 
E5.10
17 
E5.10
18 
E5.10
19 
E5.10
20 
E5.10
-999
996____________________________
1
2
-999
………………………………………
–999
1
2 
E5.13
Facility’s name …...................……… 
E5.17
Village ……..……...................…… 
E5.17
tehsil ……………………......…….. 
E5.17
District ……………………..............…. 
E5.17
State ………………….......……….… 
E5.17
irk ugha ........................–999
Village/Town …………….….....………
Tehsil ……………….……....…….
District …………………………....….
State …..……………………....……
31

E5.14
E5.18
INTERVIEWER CHECKPOINT: Was this consultation a visit to a public facility?
E5.15 At your last visit to a public health facility, was any health provider there?
E5.16 At your last visit to a public health facility, how long did you have to wait before you could meet with a health provider?
E5.17 Who did you see at your last visit to a health facility or consultation with a health provider?
(CIRCLE ALL THAT APPLY)
Would you ever go back to this facility or visit this same health provider again if necessary?
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
HOURS:
MINUTES:
GOVERNMENT DOCTOR/M.O…….1
COMPOUNDER OR MALE NURSE..2
PHARMACIST……………………….3
MPW…………………………….……4
ANM………………………………….5
STAFF NURSE…………………….…6
LHV…………………………….……..7
LAB TECHNICIAN……………….....8
RADIOGRAPHER……………………9
CLERK………………………………10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
TBA/DAI.........................................…15
VHW/CHW...................................…..16
HRW...............................................….17
BHOPA/TRADITIONAL HEALER..18
DONT KNOW…………………..-999
OTHER, SPECIFY____________996
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
E5.19 Why would you not go back to this facility?
..............................................................
..............................................................
..............................................................

E5.17

E5.18

E5.20

E5.20
32

LAST
E5.14 1
2

E5.17
E5.15 1
2

E5.18
E5.16
Hours :
Minutes :
E5.17 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
-999
996_______________________________
E5.18 1 
E5.20
2
-999 
E5.20
E5.19
............................................................
............................................................
............................................................
BEFORE LAST
1
2

E5.17
1
2

E5.18
Hours :
Minutes :
7
8
9
10
11
12
13
1
2
3
4
5
6
14
15
16
17
18
-999
996_______________________________
1 
E5.20
2
-999 
E5.20
............................................................
............................................................
............................................................
33

E5.20 INTERVIEWER CHECKPOINT: Was this consultation a visit to a bhopa?
E5.21
At the visit or consultation, did you (or the person who was ill) get________?And if yes did you have to pay for, and how much?
YES ................................... 1
NO .................................. 2
Did
You……?
YES NO
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
Rs.
IF YES:
Did you have to pay for
______?
YES NO
1
2
3
Consultation……………………
Medication given in facility………….
Medication bought outside the facility
4
5
Injection…………………………….
Drip…………………………………
6
7
Operation……………………………
Lab test……………………………..
Other treatment……………………..
8
9
10
Transportation (round trip)…………
Total expense incurred………………
E5.22 How much did this visit cost in total
(including transportation, fees, jali buti , offerings and other costs)?
E5.23 At this visit, where you (or the person who was ill) referred to another health facility?
YES ................................... 1
NO .................................. 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
IF YES:
How much did you have to pay for _____?
(Rs.)

E5.22

E5.23

E5.27
34

6
7
8
9
10
1
2
3
4
5
LAST
E5.20 1 
E5.22
2
E5.21
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
E5.22
E5.23 1
2 
E5.27
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
BEFORE LAST
1 
E5.22
2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
1
2 
E5.27
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
XXXX
35

E5.24
E5.25
To which type of health facility were you
(or the person who was ill) referred?
Where is this facility located?
E5.26 Did you go to this facility where you were referred?
CHC/PHC...............................………...1
GOVERNMENT REFERRAL
HOSPITAL…………………………...2
PRIVATE HOSPITAL..................……3
ARYUVEDIC HOSPITAL...........……4
T.B. HOSPITAL……………………...5
DISPENSARY………………………..6
AIDPOST/SUBCENTRE.....................7
ANGANWADI......................................8
HEALTH CAMP...............................…9
NGO CLINIC......................................10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI.........................................…17
VHW/CHW...................................…..18
HRW...............................................….19
BHOPA/TRADITIONAL HEALER..20
DON’T KNOW……………………-999
OTHER (SPECIFY) _______________ 996
VILLAGE/TOWN …………………
TEHSIL ……………..…………….
DISTRICT ……………...………….
STATE………………………………
YES ................................... 1
NO .................................. 2
E5.27 INTERVIEWER CHECKPOINT: Have you asked about the next to last visit to a health facility?
E5.28 Facility ID from PRA
FILL AFTER THE SURVEY
YES ................................... 1
NO .................................. 2
[ ][ ][ ]

E5.2
36

E5.25
LAST
E5.24 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
-999
996_________________________
Village/Town …………….….....………
Tehsil ……………….……....…….
District …………………………....….
State …..……………………....……
E5.26 1
2
E5.27 1
2 
E5.2
E5.28
[ ][ ][ ][ ]
BEFORE LAST
6
7
8
9
10
11
12
13
14
15
1
2
3
4
5
16
17
18
19
20
-999
996_________________________
Village/Town …………….….....………
Tehsil ……………….……....…….
District …………………………....….
State …..……………………....……
1
2
1
2 
E5.2
[ ][ ][ ][ ]
37

E5.29 INTERVIEWER CHECKPOINT: Is one of the last two visits a visit to a private health facility (excluding bhopas)?
YES ................................... 1
NO .................................. 2
E5.30 When was your last visit to a private facility either for your own health or someone else’s?
<1 WEEK AGO...…………………1
1 TO 4 WEEKS AGO...…………..2
1 TO 6 MONTHS AGO…..………3
6 TO 12 MONTHS AGO…………4
1 TO 2 YEARS AGO……………..5
>2 YEARS AGO………………….6
NEVER…………………………….998
YES ................................... 1
NO .................................. 2
E5.31 INTERVIEWER CHECKPOINT: Is one of the last two visits a visit to a public health facility?
E5.32 When was your last visit to a public facility either for your own health or someone else’s?
E5.33
Why don’t you go to public health facilities?
<1 WEEK AGO...…………………1
1 TO 4 WEEKS AGO...…………..2
1 TO 6 MONTHS AGO…..………3
6 TO 12 MONTHS AGO…………4
1 TO 2 YEARS AGO……………..5
>2 YEARS AGO………………….6
NEVER…………………………….998
..............................................................
..............................................................
..............................................................
E5.34 INTERVIEWER CHECKPOINT: Is one of the last two visits a visit to a bhopa?
YES ................................... 1
NO .................................. 2

E5.31

E5.34

E5.34

E5.34

E5.34

E5.34

E5.34

E5.36
E5.35 When was your last visit to a bhopa either for your own health or someone else’s?
<1 WEEK AGO...…………………1
1 TO 4 WEEKS AGO...…………..2
1 TO 6 MONTHS AGO…..………3
6 TO 12 MONTHS AGO…………4
1 TO 2 YEARS AGO……………..5
>2 YEARS AGO………………….6
NEVER……………………………888
E5.36 INTERVIEWER CHECKPOINT: If any new visits have been mentioned that are more recent than those entered in the grid as the “last two visits,” go back to E5.1 and correct.
E5.37 Why have you never been to a health facility or never consulted a health provider?
…………………………………………
…………………………………………

F1.0
38

SECTION F: MENTAL HEALTH
F1.0 Which picture best describes how satisfied you are with your life right now if the smiling face is very satisfied and the frowning-crying face is very dissatisfied?
1……….2………3……....4……..5
DO NOT KNOW…–999
39

F2.0 From time to time, everyone feels sad or down. I am going to read a list of statements that may express these feelings. I would like to know how often you have felt this way in the past week. Please indicate for
4
5 each statement whether in the past week you felt this way hardly ever, some of the time, or most of the time.
1
2
I felt sad……………………….…......................
I cried a lot………………………………..….…
3 I did not feel like eating……………………….…
I did not feel like doing my work.........................
My sleep was restless………………………….…
F3.0 During the past 12 months, did you ever have a period lasting one month or longer when most of the time you felt worried, tense, or anxious?
HARDLY
EVER
1
1
1
1
1
YES ................................... 1
NO .................................. 2
REFUSES TO SAY.......... 998
DO NOT KNOW…–999
2
2
2
2
ALL OF
THE SOME OF
TIME THE TIME
2 3
3
3
3
3

F4

F4

F4
F3.1 What was the source of these worries or tensions?
F3.2 Has that period ended or is it still going on?
..............................................................
..............................................................
..............................................................
ENDED ............................ 1
STILL GOING ON............ 2
F3.3 How much did/do these worries interfere with your ability to carry out your normal activities – a lot, some, a little, or not at all?
REFUSES TO SAY..........998
DO NOT KNOW…–999
A LOT...................................1.
SOME................................ 2
A LITTLE..................……..3
NOT AT ALL.................... 4
REFUSES TO SAY..........998
DO NOT KNOW…–999
F3.4 During the last 12 months, have you visited a health facility or seen a health provider (including bhopas) for reasons related to your worrries?
YES ................................... 1
NO .................................. 2

F4
40
MOST OF
1

F3.5 Which type of health facility did you visit
F4 or which type of health provider did you see?
CIRCLE ALL THAT APPLY
CHC/PHC...............................………...1
GOVERNMENT REFERRAL
HOSPITAL…………………………...2
PRIVATE HOSPITAL..................……3
ARYUVEDIC HOSPITAL...........……4
T.B. HOSPITAL……………………...5
DISPENSARY………………………..6
AIDPOST/SUBCENTRE.....................7
ANGANWADI......................................8
HEALTH CAMP...............................…9
NGO CLINIC......................................10
PRIVATE QUALIFIED DOCTOR....11
PRIVATE COMPOUNDER/NURSE.12
PRIVATE PHARMACIST ………....13
BENGALI DOCTOR.........................14
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI.........................................…17
VHW/CHW...................................…..18
HRW...............................................….19
BHOPA/TRADITIONAL HEALER..20
DON’T KNOW…………………..-999
OTHER (SPECIFY) _______________ 996
What are the issues that sometimes are reasons of concern for you?
………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
F5.0
F5.1
F5.2
F5.3
Do you expect that life will get better for you and your family in the next few years?
Why do you expect your life to get worse or why can’t you say whether or not life will get better?
Do you have plans to do things to make life better for you and your family?
If YES, what are these plans?
F6.0 Do you currently smoke cigarettes or bidis, use paan or a hukka, or chew tobacco?
NO, I expect things to get worse….1
NO, I don’t expect much change….2
YES, I expect life to get better…....3
CAN’T SAY………………………4

F5.2

F5.2
…………………………………………
…………………………………………
YES .................................. 1
NO ....................................2

F6.0
…………………………………………
………………………………………….
YES ................................... 1
NO .................................. 2
REFUSES TO SAY..........998
DO NOT KNOW…–999

F6.3

F6.3

F6.3
41

F6.1 What do you smoke/chew/use?
(MULTIPLE ANSWERS ACCEPTABLE)
CIGARETTES.................. 1
BIDIS................................. 2
PAAN................................ 3
HUKKA............................. 4
CHEW TOBACCO........... 5
OTHER ________________ 996
F6.2
If ‘YES’ to any above, how much do you use in a day?
(WRITE IN AMOUNT AND UNITS; FOR
EXAMPLE, “3 CIGARETTES AND 2
PAAN”)
F6.3 Have you ever regularly smoked at least one cigarette or bidi or used any other tobacco/paan product on a daily basis in the past?
F7.0
F7.1
F7.2
F7.3
Do you ever drink alcohol or toddy?
Have you ever drunk alcohol or toddy in the past?
Do you think anyone in this household drinks too much?
What problems does it cause?
……………………………………..
…………………………………….
REFUSES TO SAY......... 998
DO NOT KNOW…–999
YES .................................. 1
NO ................................. 2
REFUSES TO SAY..........998
DO NOT KNOW…–999
YES .................................. 1
NO ................................. 2
REFUSES TO SAY..........998
DO NOT KNOW…–999
YES .................................. 1
NO ................................. 2
REFUSES TO SAY..........998
DO NOT KNOW…–999
YES .................................. 1
NO ................................. 2
REFUSES TO SAY..........998
DO NOT KNOW…–999
……………………………………..
……………………………………..

F7.0

F7.0

F7.0

F7.2

G0

G0

G0
42

SECTION G: SOCIAL INTEGRATION
Now I would like to ask you about your relationship with the community. G0
G1
1
2
3
4
5
First, I would like to ask about your participation in any clubs or associations.
G1a. Do you currently participate in or are you now a G1b. How often do you participate in member of a ______?
Traditional village committee?
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999 activities at ____?
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
GO TO
2
3
CLUB/
6
ATION
Caste committee?
Church, temple, mosque, devra, sect, or guru?
SEVA MANDIR?
OTHER: Joint Forest
Management committee?
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
GO TO
2
NEXT
3
6
ATION
GO TO
2
NEXT
3
6
ATION
GO TO
2
3
CLUB/
6
ATION
GO TO
2
3
CLUB/
6
ATION
6
7
OTHER: Women’s organization/cooperative, savings group, or income-generating group?
Any groups or activities with another NGO?
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
GO TO
2
3
CLUB/
6
ATION
GO TO
2
3
CLUB/
6
ATION
43

8
9
10
11
Youth club, including
Navyug mandal ?
Bhajan mandal, sat song ?
Political party?
Other?
(SPECIFY__________)
12.a Is there a group of people
(besides family) with whom you share regular activities (like fetching water, wood gathering, go to the market etc.?
And if yes, how often do you meet?
12.b If yes: what is this regular activity?
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES, PARTICIPANT…..……1
YES, POSITION HOLDER….2
NO……………………..……..3
REFUSES TO SAY……… 998
DO NOT KNOW….................–999
YES………………...… 1
NO……………………. 2 
G2.0
REFUSES TO SAY…. 998 
G2.0
DO NOT KNOW….........–999 
G2.0
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
DAILY.............................. 1
WEEKLY...............…....... 2
FEW TIMES A MONTH... 3
MONTHLY.........………... 4
FEW TIMES A YEAR....... 5
ANNUALLY...................... 6
DO NOT KNOW…–999
...................................................
...................................................
...................................................
GO TO
2
NEXT
3
2
3
4
5
6
6
ATION
GO TO
2
3
CLUB/
6
ATION
GO TO
2
3
CLUB/
6
ATION
GO TO
2
3
CLUB/
6
ATION
44

G2.0 Did you attend the last Gram Sabah ?
G2.1 Did you attend the last Ward Sabah ?
G2.2 INTERVIEWER CHECKPOINT: Is the respondent above 18?
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
YES ................................... 1
NO .................................. 2
G2.3 Did you vote in the last panchayat election? YES .................................. 1
NO .................................. 2
G3.0 In the past 12 months, have you or anyone in your family been the victim of a crime
(including robbery, murder, attack, rape,
YES .................................. 1
NO .................................. 2
DO NOT KNOW…–999 sexual abuse, domestic violence or any other crime)?
G3.1 If “YES,” what crimes have been committed against you or your family in the past 12 months?
………………………………….
………………………………….
G4.0 I would like to ask more about your family and the people in your village or phala .
G4.1 Do people in your (close) family respect you? YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
G4.2 Do the people in your falla respect you?
G4.3 Generally speaking, would you say that the people in your falla can be trusted?
YES ................................... 1
NO ................................... 2
DO NOT KNOW…–999
YES ................................... 1
NO .................................. 2
DO NOT KNOW…–999
G4.4 What are the major causes of conflict in your phala ?
G5.0 Do you discuss personal issues with anyone outside your close family?
………………………………………
………………………………………
YES ......................................... 1
NO ......................................... 2
DO NOT KNOW…–999
G5.1 How often do you usually speak to this person?
DAILY................................ 1
WEEKLY........................... 2
A FEW TIMES A MONTH...3
ONCE A MONTH………. 4
A FEW TIMES A YEAR... 5
ONCE A YEAR………… 6
DO NOT KNOW…–999

G3.0

G4.0

G4.0

H0.1

H0.1
45
1
2
3

SECTION H: INTERVIEWER EVALUATION
H0.1 ENDING TIME OF MODULE
HOUR:
MINUTE:
Yes……………………1
No…………………….2
H0.2 Did you have to go back a second time?

H0.6
H0.3
H0.4
H0.5
When did you go back?
Starting time of module
Ending time of module
Day
Month
Year
HOUR:
MINUTE:
HOUR:
MINUTE:
H0.6 COMPREHENSION LEVEL OF RESPONDENT EXCELLENT..................... 1
VERY GOOD..................... 2
GOOD……........................ 3
FAIR................................... 4
POOR………...................... 5
H0.7 COOPERATION LEVEL OF RESPONDENT EXCELLENT................ 1
VERY GOOD............... 2
GOOD…….................... 3
FAIR.............................. 4
POOR……….................. 5
H0.8
H0.9
HOW MUCH DID OTHERS ASSIST THE
RESPONDENT WITH HIS/HER ANSWERS?
WHO WAS HELPING THE RESPONDENT
WITH HIS OR HER ANSWERS? (IF PERSON IS
A MEMBER OF THE SAME HOUSEHOLD,
ENTER THEIR HOUSEHOLD NUMBER FROM
THE BOARD)
NO ASSISTANCE............. 1
HELP WITH SOME........... 2
HELP WITH MOST........... 3

H0.10
1 ………………………………...
2 ………………………………...
3 ………………………………...
4 ………………………………...
5 ………………………………...
6 ………………………………...
46

H0.10 ANY ADDITIONAL COMMENTS ABOUT SPECIFIC QUESTIONS OR DATA QUALITY
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
47

SECTION K: HEALTH MEASUREMENTS
K.0 Date of health measurements
K.1 Height of the respondent (in cm)
K.2 Weight of the respondent (in kg)
K.3 Is the respondent wearing any heavy item?
K.4 Which of the following item is the respondent wearing:
CIRCLE ALL THAT APPLY
K.5 Blood pressure instrument reading
K.6 Hemo cue reading
K.7 Body Temperature of the respondent (in Celsius)
K.8 In how much time does the respondent squat and stand up 5 times?
K.9 3 Peak flow meter indications
DAY [ ][ ]
MONTH [ ][ ]
YEAR [ ][ ][ ][ ]
[ ][ ][ ] cm
Refused……………….997
Can not do it…………998
[ ][ ][ ] . [ ]kg
Refused……………….997
Can not do it…………998
Yes………………………1
No………………………..2
Anklets…………………..1
Necklace…………………2
Heavy bracelets………….3
Other heavy item………..4
[ ][ ][ ]
[ ][ ][ ]
[ ][ ][ ] (Pulse)
Refused……………..997
Can not do it…………998
[ ][ ] . [ ]
Refused…………..….997
Can not do it…………998
[ ][ ] . [ ]
Refused………………997
Can not do it…………998
[ ][ ]
.
[ ][ ]seconds
Refused………………997
Can not do it…………998
1- [ ][ ][ ]
2- [ ][ ][ ]
3- [ ][ ][ ]
Refused………………..997
Can not do it…………998

K.5
48