Date: Block ID:
Name of Surveyor: Code:
Survey Form for Participating Households
Muha;r;rpapy; g’;nfw;Fk; FLk;g’;fSf;fhd fzf;bfLg;g[g; gotk;
1. Type: tif ☐ Household (Stand-alone jdp tPL) ☐ Household (Apartment mLf;Fkho) ☐ Slum Foirfs;
2. Number of people residing: ___ adults (18 & above) and ____ children (below 18)
trpf;Fk; FLk;g cWg;gpdu;fspd; vz;zpf;if ??? bgupatu;fs; (18 Koe;j taJ kw;Wk; mjw;Fk; nky;)
??? FHe;ijfs; (17 Koe;j taJ kw;Wk; mjw;F fPnH cs;stu;fs; bjhl;oy; FHe;ij cl;gl)
3. Number of rooms: Living Room ☐ Bedroom ☐ Kitchen ☐ Bathroom ☐ Others ☐
(tPl;oYs;s miwfspd; vz;zpf;if? trpf;Fk; miw. gLf;if miw. rikaiw. Fspayiw kw;witfs;)
4. Does your house have a private bathroom? (For slum households only) ☐ Yes ☐ No
(Foir tPLfSf;F kl;Lk; nfl;ft[k;) c’;fs; tPl;oy; xU jdpg;gl;l Fspayiw ,Uf;fpwjh>
5. How do you dispose your garbage (CHECK ALL APPLICABLE): c’;fs; tPl;oy; nrUk; Fg;igf; fHpt[fis eP’;fs; vg;go mg;g[wg;gLj;JfpwPu;fs;> (bghUe;Jk; vy;yhtw;iwa[k; FwpaPL bra;at[k;)
☐ Corporation Dustbin khefuhl;rp Fg;igj; bjhl;o
(ask what if it is full?) Fg;igj; bjhl;o epuk;gp tHpe;jhy; vd;d bra;tPu;fs;> ______
☐ Collected from doorstep (tricycle) tPl;L thrypy; nrfupj;Jr; bry;yg;gLfpwJ (K:d;W rf;fu tz;o)
☐ Thrown on the street/river bjUtpy ; /fhy;thapy; tPrg;gLfpwJ
☐ Others: kw;wit Fwpg;gplt[k;)______
6. How often do you dispose your garbage? eP’;fs; vt;tst[ Kiw c’;fs; Fg;igf; fHpt[fis mg;g[wg;gLj;JfpwPu;fs;> ☐ Daily jpde;njhWk; ☐ Twice Daily jpdk; ,UKiw ☐ More often kpf mof;fo (Fwpg;gplt[k;) ______☐ Irregular Kiwahf my;y ☐ Other kw;wit (Fwpg;gplt[k;)______
7. If door-to-door collection is in place, is waste collected: tPl;L thrYf;nf te;J Fg;ig fHpt[fisr; nrfupf;Fk; eilKiw tHf;fj;jpypUe;jhy; Fg;igf; fHpt[fs; vg;go nrfupf;fg;gLfpwJ>
☐ segregated, or tifg;gLj;jp (m) ☐ mixed fyg;ghf
8. Do you separate your food waste from other waste? kw;w fHpt[fspy; ,Ue;J czt[f; fHpt[fis eP’;fs; jdpahfg; gpupj;J itf;fpwPu;fsh> ☐ Yes Mk; ☐ No ,y;iy
9. What do you do with your: c’;fs; tPl;oy; nrUk; fHpt[g; bghUl;fis eP’;fs; vd;d bra;fpwPu;fs;>
a. Food waste? czt[f; fHpt[fs;______
b. Newspapers, magazines, etc.? bra;jpj;jhs; gj;jpupiffs; nghd;wit>
☐ Dispose with the rest; (kw;w fHpt[fSld; nru;j;J mg;g[wg;gLj;Jfpnwhk) ;
Sell to (tpw;WtpLnthk; vd;why; v’;nf>) ☐ waste paper mart; (giHa ngg;gu; filapy;)
☐ ‘pazhaiya paperkaaran’; (giHa ngg;gu;fhud;?bjU tpahghup)
☐ kuppathotti.com, etc.; Fg;igj; bjhl;o/fhk; nghd;wit
☐ Give to domestic worker (ntiyahl;fsplk; jug;gLfpwJ)
c. Plastic waste? gpsh!;of; fHpt[fs;>
☐ Dispose with the rest; (kw;w fHpt[fSld; nru;j;J mg;g[wg;gLj;jg;gLfpwJ)
Sell to (tpw;WtpLnthk; vd;why; v’;nf>) ☐ waste paper mart; (giHa ngg;gu; filapy;
☐ ‘pazhaiya paperkaaran’; (giHa ngg;gu;fhud;?bjU tpahghup)
☐ kuppathotti.com, etc.; (Fg;igj; bjhl;o/fhk; nghd;wit)
☐ Give to domestic worker (ntiyahl;fsplk; jug;gLfpwJ)
d. Glass waste? fz;zhof; fHpt[fs;>
☐ Dispose with the rest; (kw;witfSld; nru;j;J mg;g[wg;gLj;jg;gLfpwJ)
Sell to (tpw;WtpLnthk; vd;why; v’;nf>) ☐ waste paper mart; (giHa ngg;gu; filapy;)
☐ ‘pazhaiya paperkaaran’; (giHa ngg;gu;fhud;?bjU tpahghup)
☐ kuppathotti.com, etc.; (Fg;igj; bjhl;o/fhk; nghd;wit)
☐ Give to domestic worker (ntiyahl;fsplk; jug;gLfpwJ)
e. E-waste (wires, batteries, tube lights, etc.)? vyf;l;uhdpf; fHpt[fs; (xau;fs; ngl;lupfs; oa{g; iyl;Lfs; nghd;wit>
☐ Dispose with the rest; (kw;w fHpt[fSld; nru;j;J mg;g[wg;gLj;jg;gLfpwJ)
Sell to (tpw;WtpLnthk; vd;why; v’;nf>) ☐ waste paper mart; (giHa ngg;gu; filapy;)
☐ ‘pazhaiya paperkaaran’; (giHa ngg;gu;fhud;?bjU tpahghup)
☐ kuppathotti.com, etc.; (Fg;igj; bjhl;o/fhk; nghd;wit) ☐
☐ Give to domestic worker (ntiyahl;fsplk; jug;gLfpwJ)
10. Please take a look at this list and tell me which of these items do you have at home? (It could be owned by you, your family, or provided by the employer or it could be available in the house you live in; but it should be for the use of just you or your family). EXPLAIN, IF NECESSARY: We have a standard list of items that we use in all kinds of cities and villages. So don’t worry if an item appears irrelevant for you, or too ordinary- just go ahead and tell me which items you do have. We need this information just for survey purpose only.
Do you have a...(ITEM) in your home (which is in working condition)? Circle items owned/ have at home. Tick the item if owned. Add the number of ticks in the box.
Items Owned/Have at homebrhe;jkhf cs;s-tPl;oy; ,Uf;Fk; rhjd’;fs; / Circle tl;lkplt[k; / Tick of; bra;at[k;
Electricity Connection kpd; ,izg;g[ / 01
Ceiling Fan rPyp’; `ngd; / 02
LPG Stove nf!; !;lt; / 03
Two Wheeler ,Urf;fu thfdk; / 04
Colour TV fyu; blyptp|d; / 05
Refrigerator Fspu; rhjdg; bgl;o / 06
Washing Machine th|p’; bk|pd; / 07
Personal Computer/ Laptop
gu;rdy; fk;g;a{l;lu;-nyg;lhg; / 08
Car/Jeep/Van fhu;-$Pg; -ntd; / 09
Air Conditioner Vu; fd;o|du; (Vrp) / 10
Agricultural Land tptrha epyk; / 11
NUMBER OF STANDARD 11 OWNED? rhjd’;fsp;y; vj;jid brhe;jkhf cs;sJ>
,e;j fhu;ilg; ghU’;fs;/ ,tw;wpy; ve;bje;j tPl;L cgnahfr; rhjd’;fis c’;fs; tPl;oy; itj;jpUf;fpwPu;fs;> (mJ c’;fSf;nfh (m) c’;fs; FLk;gj;jpw;nfh brhe;jkhditahf ,Uf;fyhk; (m) eP’;fs; ntiy bra;a[k; bjhHpy; epWtdk; bfhLj;jjhf ,Uf;fyhk; (m) eP’;fs; trpf;Fk; tPl;oy; mJ Kd;dkna ,Ue;jpUf;fyhk;/ Mdhy; mJ c’;fSila (m) c’;fs; FLk;gj;jpdUila gad;ghl;ow;fhf ,Uf;fntz;Lk;)/ njitahdhy; tpsf;ft[k; ?v’;fsplk; vy;yh tpjkhd efu’;fs; kw;Wk; fpuhk’;fSf;Fg; gad;gLj;jf;Toa xU epiyahd
tifg;gLj;jg;gl;Ls;s bghUl;fspd; gl;oay; ,Uf;fpwJ/ vdnt xU Fwpg;gpl;l bghUs; c’;fSf;Fr; rk;ge;jk; ,y;yhjjhf ,Ue;jhnyh (m) c’;fSf;Fr; kpfr; rhjhuzkhf ,Ue;jhnyh mJgw;wp eP’;fs; ftiyg;glj; njitapy;iy/ eh’;fs; gl;oaiyg; gof;Fk;nghJ c’;fsplk; vJ cs;snjh mijr; brhy;Y’;fs;/ ,e;j jfty;fs; v’;fspd; Muha;r;rpf;fhd fhuz’;fsSf;fhf kl;Lnk njitg;gLfpwJ/
c’;fs; tPl;oy; xU??? (bghUisg; gof;ft[k;) ,Uf;fpwjh (mJ ntiybra;a[k; tpjj;jpy;)> brhe;jkhf (m) tPl;oy; ,Uf;Fk; bghUl;fis tl;lf;FwpaPL bra;at[k;/ nkYk; mJ brhe;jkhf ,Ug;gpd; bgl;oapy; of; bra;at[k;/ bgl;ofspy; cs;s of; khu;f;Ffspd; vz;zpf;iffisf; Tl;o vGjt[k;/
11. Does your family own any agricultural land, by agricultural land I mean land that is currently under cultivation or plantation?
c’;fs; FLk;gj;jpw;F tptrha epyk; VjhtJ brhe;jkhf ,Uf;fpwjh> tptrha epyk; vd;W eh’;fs; Fwpg;gpLtJ jw;rkak; gapu; rhFgo (m) njhl;lg; gapu; tsu;f;Fk; epiyikapy; cs;s epyk;/
12. Could you tell me something about the person who makes the biggest contribution to the running of the household. To what level has he studied? RECORD IN GRID. USE GRID TO DETERMINE NEW SEC.
FLk;gj;ij epu;thfk; bra;tjw;F mjpfgl;rk; epjp g’;fspg;g[ bra;a[k; egiug;gw;wp rpy tpu’;fisf; TW’;fs;/ mtu; mjpfgl;rk; vd;d goj;jpUf;fpwhu;> ml;ltizapy; bghUj;jkhd vz;iz tl;lkplt[k;/ ml;ltiziag; gad;gLj;jp me;j FLk;gj;jpDila ?I fz;lwpe;J tl;lkplt[k;/
Chief Earner: Education (Q11) Kf;fpa tUkhdjhuu; (nf/11 )No. of Durables (TRANSFER FROM Q10)
rhjd’;fspd; vz;zpf;if (nf/10 ghu;f;f) / Illiterate
vGjg; gof;fj; bjupahJ / Literate but no formal schooling/ School- Upto 4 years vGj;jwpt[
cs;stu; Mdhy; Kiwahd gs;spg; gog;g[ ,y;iy- gs;spg; og;g[ ?4Mk; tFg;g[ tiu / School- 5 to 9 years
gs;spg;gog;g[
5 ?9Mz;Lfs; tiu / SSC/ HSC
v!;v!;rp- vr; v!;rp / Some College (incl a Diploma) but not Grad
fy;Y}up gog;g[ Kof;f
tpy;iy (xU og;snkh cl;gl) / Graduate/ Post Graduate: General
gl;lg; gog;g[
,s’;fiy- KJfiy ?
bghJthdit / Graduate/ Post Graduate: Professional
gl;lg; gog;g[?
,s’;fiy- KJfiy ?
bjhHpy;
rhu;e;jit
1 / 2 / 3 / 4 / 5 / 6 / 7
None / E3 / E2 / E2 / E2 / E2 / E1 / D2
1 / E2 / E1 / E1 / E1 / D2 / D2 / D2
2 / E1 / E1 / D2 / D2 / D1 / D1 / D1
3 / D2 / D2 / D1 / D1 / C2 / C2 / C2
4 / D1 / C2 / C2 / C1 / C1 / B2 / B2
5 / C2 / C1 / C1 / B2 / B1 / B1 / B1
6 / C1 / B2 / B2 / B1 / A3 / A3 / A3
7 / C1 / B1 / B1 / A3 / A3 / A2 / A2
8 / B1 / A3 / A3 / A3 / A2 / A2 / A2
9+ / B1 / A3 / A3 / A2 / A2 / A1 / A1
NEW SEC: _____