Base line format

Part A: General Information

Members interview Schedule

1.Ferderation : …………………………... 2. S.NO:………………………………….

3.Village :…………………………… 4. Panchayat:……………………………..
5.Block:……………………………...

6. Members Detail :

6.1 Name of women: ……………………Husbands Name :………………………….

6.2 Name of SHG: …………………………………………..
6.3 Members Age :………………………………………….
6.4 Education Status : Illiterate /literatae /Primary / Middle/ Secondary
6.5 Caste : SC / ST / OBC / Minorities / other
6.6 Economic Status: BPL / APL / Antodaya
6.7 Marital Status : Married / Widow / deserted
6.8 Is there a second wife of your Husband : Yes / No

7. Members family Detail

( Note : Take the detail of family head at S.No. 1 )

S.No. Members Name Age Sex Educational Occupation

Status code
1
2
3
4
5
6
7

Occupation Code : 1 - 0&5 Age group 2 – Studying 3 – Agriculture 4- Livestock

Rearing 5 – Business 6 – Daily Wagse 7 – Migration 8 – Job 9 – Not fit for work 10 –
Household Chores 11 – Others ( Provide Details )

8. Animal details:
Last date
Species of of
animal Breed Age Lactation Pregnant Cost Current status parturition

A.I Natural Dry/ milking

 Buffalo

Cow

Heifer

9. Seasonality of occupation:

Crop
name/Month
wise Jan Feb Mar apr May Jun July Aug Sep Oct Nov Dec
Kharif

Rabi

10-Membership Details (if any):

10-1 Membership Month: …………………………Year :…………………………
10-2 Rank in the group: President /Secretary/ Treasurer/ Member
10-3 Rank in cluster: President /Secretary/ Treasurer/ Member
10-4 Rank in Federation: President /Secretary/ Treasurer/ Member
10-5 Saving amount:
At the beginning of Group: Rs……………………..Per Month
At Present: Rs ……………………Per month
10-6 Total saving Amount: …………………………(Till Dec , 2010)
11-Year wise Detail of loan taken from SHGs
Loan Year Amount Use Source Interest Loan Present status of
No. Code of loan rate period loan
(paid/remaining)

Use Code: 01- Agriculture 02 -Animal Husbandary 03 -Irrigation 04- Occupation

05- Health 06- Education 07- House construction / repairs 08 - Old Debt Payment
09 -Asset Purchase 10- Food grain Purchase 11 -Social Events 12- Household expense
13 – Others

12- Present social status

12-1 Important Events /Incidents in the household

S.No. Details Decision S.N Details Decision
Code Code
1 Asset Purchase 9 Irrigation
2 Marriage 10 Health
3 Taking Loan 11 New Business
4 Giving room 12 Casting Vote
5 Big expenditure 13 Fighting election
6 Asset sale/ lease 14 Nata
7 Education 15 Migration
8 House const/ repair
Code : 1. self Decision 2.joint Decision 3. Without your consultation

12-2 : Physical Assest

S.No. Asset Quantity Amount Amount Ownership

source code
code
1 Land New Purchase
2 Home New construction

Repairs

3 Jewell New Purchase

ary
4 Livestock
5 Cycle
6 Radio
7 Television
8 Truck
9 Auto
10 Motorcycle
11 Push Cart
12 Pump set
13 Shop
14 Flour Mill
15 Computer
16 Bullock cart
17 Jeep
18 Telephone
19 LPG
20 Well Deepening
Ownership code : 1. Self 2. Joints 3. other
Amount source code : 1. Group 2. Bank 3. Moneylendre 4. Relatives / Friends 5.
Cooperative 6. Self – capital 7 . Social Contacts. 8. Maitree Mahila Mandal

12-3. Access to village level Govt ./ Non Govt . Organisation .

Pariculars Yes No
Where is Anganwadi
Do you know Anganwadi worker?
Do you go to Anganwadi
Have you taken service from Anganwadi
Do you have any role in management of Anganwadi
Where is school
Upto which standard
Have you visited School
How You meet the school teacher
Where is Panchayat Bhawan
How you gone to Panchayat Bhawan meeting
Have you casted vote
Have you ever contested in election
Whether you were elected
Where is post office
Name of Post Master
Have you visited Post Office
Have you ever transected in Post Office
Where is Primary Health Centre?
Do you go to PHC
Have you even taken service from PHC
Where is nearest market
Do you go to market
Do you purchase household items yourself ?
Do you sell produce in market

12-4. Asses to Govt . / Non Govt. organization.

Organisation Have you visited this organization and Have you taken
at what level. service from this
organization?
Panchayat Samiti Yes No Village Biock District
Tehsil
Women & Child
Development
Hospital
District Collector
Zilla Parishad
Agriculture Dept.
Animal Husbandary
Dep.
SC/ST Development
Dep.
Police Station

12-5. Details of events in your family after joining the group.

Events Year Spent Amount Details
Amount Source Treatment Code
Code
Health / Illness
Marriage
Litigation
Others
 Treatment Code : 1 . Superstition 2. Herbals 3 . Doctors
Amount source code : 1. Group 2. Banks 3. Moneylenders 4. Relatives/ friends 5 .
cooperatives 6 . Self – Capitals 7. Social Contacts 8. Maitree Mahila Mandal

13. Economic Impact

13.1 : Detail of present loans taken by your family
Source Total Year Amount Outstanding Terms &
loan interest amount condition Purpose
amount rate
Bank Name
Bank Name
Cooperative Samiti
Money lender
Friends / Relatives
SHG
Others
13.2 Details of Assets mortgaged / retrieved
Yea Particulars Mortgaged Retrieved
r Qty Reason Amount Yea Qty Amount Source of
r amount

Amount source code : 1. Group 2. Bank 3. Moneylender 4. Relative/Friend 5.

Cooperative 6. Self Capital 7. Social Contacts.

13.3 Details of Annual Income of family (On the basis of last year)
Agriculture
Particulars Sold Qty. @ Amount
(Quintals)
Food
Grains
Pulse

Vegetable

Fruits

B: Income from Livestock :

Particulars Sold Qty. (Quintal) @ Total Amount/
Month
Milk
Manure
Egg
Poultry
Goats
Sheep
Cow
Buffalo
Bullock
Others
C :Labour
Name of labour Total man @ Total
days Amount/
month
Local

Migratio
n

D Business : Details Of Business Total Annual Income

E Service Details Total Annual Income

F Other Details Total Annual Income

14. Lifestyle of family
S.N. Particulars
Pucca
Kaccha
Half Pucca
Separate Kitchen
1 House Cattle Shed
Bathroom
Latrine
Electricity

Solar

15. Food Security

Details From self field (in months) From market
Food grains
Pulse
Species
Other

Signature of Surveyor
Date :
Part B: Agriculture

16. Livelihood Baseline on Agriculture:

16.1Name of SHG member-

16.2 Village name-

16.3 SHG name-

16.4 Crop Detail

S.No. Crop Variety Area Irrigated Source of Period of

under crop area irrigation irrigation
(Bigga) with
intensity
16.7 Input details:
Input
Credit
Input Cost Source amount

Land preparation

Seed

Seed treatment

Sowing

Irrigation

Pest management

Weed management

Fertilizer

Manure

Implement hiring

Harvesting

Labor in harvesting

Labor in threshing

insurance

Other labor

16.8 Input details:

Financial
source
(type of
credit
Input method Cost provider)

Land preparation

Seed
Seed treatment

Sowing

Irrigation

Pest management

Weed management

Fertilizer

Manure

Implementing hiring

Harvesting

Labour in harvesting

Labour in thresing

insurance

Other labour

Total Cost

16.9 Soil testing (Yes/No)-

16.10 Sowing details:

Sowing

Method of sowing Spacing

16.11 Major diseases in crop-

Crop Name Disease Control

16.12 Output Details

Output details

Crop Production Productivity Sold quantity Quantity consumed selling cost Place of sale

Total

16.13 By product utilization-

16.14 Income by product-

16.15 Net income-

16.16 Service detail (agri)

Sl. Types of
no Name of services Duration Source Quantity services Remarks
Cash/
Kind/technical

1 Crop Advice
Technical
2 Knowledge

3 Seed source

4 Fertilizer

5 Insurance
Marketing
6 information
Disease/pest
7. control
Part C. Dairy

17. Baseline for Dairy:

17.1 Name of the SHG member-

17.2(a) Name of SHG- (b) Village name-

17.3 Name of Panchayat- Survey date-

17.4(a) Animal species- (b) Breed-

17.5(a) Source- (b) Credit accessed from- (c) Amount-

17.6(a) Insurance done (Yes/ No)- (b)Source-

17.7(a) Animal Health facility available (Yes/No)- (b)Source-

17.8(a) Calf mortality- (b) No. of calf-

17.9 Animal status (Dry/Milch)-

17.10 Milk status:

Milk
Morning evening
Volume fat SNF/degree Volume fat SNF/degree Total milk

17.11Volume of milk consumed-

17.12(a) Volume of milk sold- (b) Where- (c) Price obtained-

17.13 Major diseases occurred-

Animal Disease Control

Buffalo
Cow
Goat
17.14 Service details (dairy)

Types of
Sl.no Name of services Duration Source Quantity services Remarks
Cash/
Kind/technical

1 AI

2 health

3 Vaccination

4 Insurance

5 Fodder

6 Milk marketing

7 Input Purchasing

17.15 Input details:

Sourc
INPUT Quantity Unit cost Total cost e

ROUGHAGES

Leguminous Green fodder (Kg) (RAJAKA)

Leguminous dry fodder (Kg)

Non Leguminous Green fodder (Kg) (Jowar)

NON Leguminous dry fodder (Kg) BHOOSA

OTHER

CONCENTRATES

Oil Seed and Cake (KG) (KAKADA)

Grain (dalia)

Grain by product

Animal by products

cattle feed (Godrej/saras/sudana)

Salt
Mineral mixture

Lime

Calcium

Deworming

Vacination

Vet services

Nautre of breeding

Insurance

Labour (hr./day)

any other

17.16 Output details:

Quantity
House hold Total
Output consumption Sold Unit cost cost Source

Milk

Ghee

Calf

Goatry

FYM
Ox
-hirring
Bull
hiring

17.17 Total input cost-

17.18 Total output cost-