NAME

ADDRESS

CONTACT NO
-vvvv 4444444444444444/

Name, gender and age group of all household members (including children) to
occupy the dwelling

Member Male/ AGE EDUCATION OCCUPATION INCOME

Female
1
2
3
4
5
6
7
8

Q 1. What type of house do you live in? Please tick one box
 slum  squatter  row house

 flats  apartment  chawl

Q 2. What type of house do you live in? Please tick one box
 slum  squatter  row house

 flats  apartment  chawl

Q 3. Type of ownership? Please tick one box

 Owned  Rented

Q 4. Duration of residence in the house

Q 5. Land ownership
 Self
Private
Public /Government

Plot size -

Q 6. How many habitable rooms does your house have? Please tick one box
 1  2  3  4  5 or more
Q 7. Type of structure ? Please tick one box

 Pucca
 Semi kuttcha
 Kuttcha

Do u have electricity connection ?

yes
no

Q 8. Where do your children go to school? ( Please tick one box)

 Govt school
 Pvt school
 Govt college
 Pvt college

Q 9. How do you travel

 Cycle
 Foot
 Public transport
 School transport
 car
Q 10. Where do you go for healthcare

 Govt hospital
 Govt clinic
 Pvt hospital
 Pvt clinic

Q 11. What is the source of Water?

 Tanker
 Bore well
 Public tap
 Individual private connection (from govt.)
 other

Q 12. Toilet usage ?

 Individual toilet
 Shared toilet
 Community toilet
 Public toilet
 Open defecation

Q 13. Method of waste disposal ?

 Closed drain
 Open drain
 Discharge to open plots
 Discharge to water bodies

Q 14. Segregate solid waste

 Yes
 No

Q 15. Door to door waste collection ?

 Ye(by municipal)
 Yes(by pvt)
 no
Q 16. What is the cooking energy used ?
 Gas cylinder
 Pipe system
 Kerosene
 Fire wood
 Others

Q 17. Vehicles in home (specify number)

 4 wheeler
 2wheeler
 Bicycle
 Others
 No vehicle
