Socio-economic survey form (For CDEs)

Date -

Normal Information–

1.  Name of Head Person –

2.  Name of Father/Husband –

3.  Name of Village –

4.  Age –

5.  Social group-

6.  BPL family - Yes / No

7.  Savings Account – 1. Post Office

2. Bank

3. Co-operative Bank

4. No

8.  Number of Family members-

S.N. / Name of Family member / Gender / Adhar Card No. / Age / Academic qualification / Occupation

9.  Status of House – A. ⎕Kuccha B. Pucca⎕ C. Homeless ⎕

10.  Family Member related with any Group (SHGs) / Institution

S.N. / Name of Family Member / Name of Group / Name of SHGs / Name of Institution / Government /Private

11.  Source of drinking Water-

A.  Tap ⎕ B. Well ⎕ C. Pond ⎕ D. Other (write the Name)…………….

12.  Status of Power Supply-

A.  Single Phase ⎕ B. Three Phase ⎕ C. No Power Supply ⎕

13.  Migration Status-

A.  Is there any member migrated within last one year. - Yes / No

If Yes, Who?

14.1 Male

14.2 Female

14.3 Children

B.  Family migrates for how many days/ months?

C.  Since how many years the migration is taking place?

14.  Land status –

A.  Data related land-

Land Information / Leased In / Leased out
Total Land
Irrigated
Unirrigated
Arable Land
Waste land
Source of Irrigation

B.  Fertilizer status

S.No. / Fertilizer / Fertilizer Use (KG/Acre)
India
1. / N
2. / P
3. / K
4. / Organic Manure
5. / Other

15.  Main Crops & Their Productivity in Last Year -

Crop / Variety / Total Production (In quintals) / Sold In market
Seed / Crop

16.  Fruits and Vegetables –

Name of fruit / vegetable / Production (In quintals) / Quantity sold in market (In quintals )

17.  Animal Husbandry , Fisheries and others-

S.N. / Activity / Unit/No. / Daily Production / Qnty Consumed / QntySold Out
Qnty Consumed / Sold Out
1. / Dairy (Cow)
2. / Buffalo
3. / Goat
4. / Poultry(Meat)
5. / Poultry (Egg)
6. / Piggery (Meat)
7. / Piggery (Piglets/ Pig)
8. / Fisheries

18.  Health –

S.N. / Activity
1. / Diseases effects family frequently
2. / Any Causality in last one year
3. Completed vaccination of children Yes/No.
If Yes give name
4. / Alcoholism
Drug (substance)
(Any member) Give name/Period
5.Child with malnutrition or with other health problem
Name / Problem / Age\Gender

19.  Economic Status

1. / Total no of individuals earning money
2. / Total no of individuals not earning money
3. / Annual income through agriculture
4. / Annual income through Dairy
5 / Annual income through fisheries and others
6. / Annual income through Labour wage
7. / Annual income through others
8. Expenditure
1. / Agriculture
2. / Dairy
3. / Poultry/piggery/fishery
4. / Family
9. / Total savings