Respondent Number PART A: SOCIO-ECONOMIC AND DEMOGRAPHIC PROFILE Name of the Respondent: Marital Status ..

Address:

1. Sex:

I. Male

II. Female

2. Age (in completed years) 3. Religion: .. 5. Do you have a Phone: I. Yes 6. Do you have a Mobile: I. Yes 4. Cast: II. No II. No II. No IV. Bullock Cart V.None

7. Does your Mobile Phone have a Radio? I. Yes. 8. Do you have transport? I. Car 9. Education of the respondent: I. II. III. IV. V. VI. VII. VIII. IX. X. Illiterate Literate but no formal education School up to 5 years (Class1-5) School up to 6-9 years (Class 6-9) SSC/HSC Under Graduate Graduate /Post Graduate (General) Professional (Doctor, Engg, LLB,MBA) Technical (Diploma/IT) Others (Specify) _______________ II.Jeep

III.Tractor

10. Occupation of the respondent I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Farmer Daily wage worker Skilled worker Petty Trader(shop keeper) Self employed Service Government Service Private Homemaker Student Retired Unemployed Others II. No

11. Does the respondents house have electricity? I. Yes. 12. Type of House I. II. III. IV. V. Hut Semi Pucca Pucca Apartment Independent house/Bungalow

13. Where do you get your Drinking Water? I. II. III. IV. V. VI. Tap in the House Common Tap Hand pump / Bore well Well Tank/ Pond Others: (specify):_____________

14. What type of cooking fuel do you use? I. II. III. IV. V. LPG/Gas Kerosene Firewood Gobar gas/bio fuels Others: Specify:___________

15. What toilet arrangements do you have? I. II. III. IV. Private (in your own house) Common (shared by others) Open fields Others: Specify:___________

16. Are there any persons with disabilities in the house? I. Yes. II.No

17. If yes, state nature of disability: I.Visual II.Speech

18. Currently are you member of a Self Help Group? I. Yes. II.No Activity:

If yes indicate name:

Is the group holding regular meeting: I. Yes. II.No

Does the group have a Bank Account? I. Yes. II.No

19. Indicate your economic status I. BPL II. APL III. Red Card 20. Assets owned by the Household I. II. III. IV. V. VI. VII. VIII. IX. X. XI. Tape Recorder CD Player Two wheeler Electric Mixer/Grinder/Food Processor Air cooler Washing Machine Car/jeep Computer Air conditioner Refrigerator Geyser

21. Income of the earner I. Daily wages (specify).. II. Fixed monthly wages (specify).. III. Any other (specify).