SURVEY- QUESTIONNAIRE: CHINNAMPATHY

1. Total members of the family :

2. Income to the Head of the Family :
3. Type of Family : Nuclear/ Joint
4. Type of Marriage :
a. Relations
b. Within the community
c. Outside the community
5. Age at Marriage
a. Husband’s age_________
b. Wife’s age____________
6. Religion / Caste :
7. Family Details

Sl.No Name Relation to Marital Age in Education Occupation Income per

the Head of Status years Month
the Family (in Rs)

8. Do you own a vehicle : Yes/ No

9. Do you have own land : Yes/ No
10. Your profession :
11. Your place of Work :
12. Sector of work : Formal/Informal
13. Is anyone unemployed :
14. Is anyone Self-employed :
15. Number of days of work in a year :
16. Do all members in family have Election Card : Yes/ No
a. If no, why you didn’t apply yet :
b. Have you ever voted in Elections? : Yes/ No
17. Do you have a Ration Card : Yes/ No
a. If yes, what benefits do you get? :
18. Are you benefited from any welfare schemes from Government? : Yes/ No
a. If Yes, In What schemes_________________
19. Do your sons/daughter receive any scholarship/welfare for their Education?: Yes/ No
a. If Yes, give details ________________
20. Did you get free color television from TN Govt.? : Yes/ No
21. Phone Connection/ Mobile : Yes/ No
22. Mode of Cooking : Gas/ Wood/ others
a. If Gas, Number of gas cylinder in House_________
23. Nature of Housing : Own/ Rent
24. Type of Housing : Hut/ Concrete/Tin sheet/Others
25. Do you have any animals at Household : Yes/ No
a. If yes, How many animals __________ (numbers)
26. Bus frequency (Transportation facility) :
27. Nearby PHC location :
28. Do you go to PHC for treatment? : Yes/No
a. If No, what traditional methods do you follow? ___________
29. Does the doctor regular to PHC? : Yes/ No
30. How pregnancies are taken care? : Hospital/Home
31. Are you satisfied with the PHC services? : Yes/ No
32. What facilities do you want in your PHC? :
33. Nearby Post office? :
a. Do you have savings in Post Office :
34. Nearby Police station location :
35. Nearby Bank location :
36. Do you have a bank account? : Yes/ No
37. Do you have the habit of savings? : Yes/ No
38. Name the source of Debt? :
39. Celebrating festivals in the village :
40. Suggestions/ opinion for improvements of :
Your village.