Government of Province, Province-02, Janakpurdham

QUESTIONNAIRE FOR SOCIO-ECONOMIC STATUS

1. How is your current status?
Shelter Food Medicine for
Treatment

2. Land Available for immediate rescue? Yes …………….No……………..

3. Introduction of the Respondent

Name…………
District:………..
Permanent Id…………….
Muncipality/ R. Muncipality…………
Mobile No.:
Status…………………

4. Educational status
Illiterate(nos.)…………. Literate(nos.)

5. Do you have land?

Yes…………. No………….
6. How much land do you have?
Bigha Katha Dhur

7. Do you have any other house/ land for re- construction?

How much Where
Katha
Dhur

8. What are the sources of income?

Farming Business services foreign employment Other

9. Have any member from your family is engaged in foreign employment?

Yes………… No…………
10. Have you got any support? Yes ……… No…………

If Yes( Specify)…………
 Government of Province, Province-02, Janakpurdham

GENERAL INFORMATION

1. Types of buildings Thatch / Brick with cement / Brick with Mud

2. Estimated age of building in yrs …………………..

3. Plan shape
Square Rectangle L Tee Others

4. Height of plinth above Ground Level in 'm' ………………..

5. Band Provided:- yes ( ) No ( )

6. Percentage of opening in front wall …………………..

7. Percentage of opening in rear wall ………………..

8. Percentage of opening on side wall – 1 ……………….

9. Percentage of opening on side wall – 2…………………
10. Roof type

Mono slope Gable Hipped Flat Rounded

11.Roof Materials

Thatch Wood CGI AC Sheet RCC Tile Any other

Sheet Roof

12. Number of storey ………………………….

13. Walling material ……………………………….

14.Length of building ………… Breadth of building …………….. Hight …………

15. Proper Anchorage provided between roof and wall. Yes ( ) No ( )

16. Wall plaster :- yes ( ) No ( )

17. Eaves projection in 'm' ……………………..

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 Government of Province, Province-02, Janakpurdham

18. Eaves projection held back:- yes( ) No ( )

19. Eaves edge restrained using metal straps:- yes……. No……
20. Size of columns (mxm) ……………………..
21. Column spacing in 'm'………………..
22. Connection of members

Nails Nails & Nails & Binding Organic Other

Binding Metal Strap Wire Rope
Wire

DAMAGE ASSESSMENT
A. Complete collapse of building:- Yes ( ) No ( )
If No Specify
1. Damage to roofing material

None Marginal Medium Heavy Total

2. Damage to roof Truss

None Marginal Medium Heavy Total

3. Damage to front wall

None Marginal Medium Heavy Total

4. Damage to side wall -

None Marginal Medium Heavy Total

5. Damage to side wall -2

None Marginal Medium Heavy Total

6. Damage to rear wall

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 Government of Province, Province-02, Janakpurdham

None Marginal Medium Heavy Total

7. Damage to columns: …………………..

8. Total number of columns ……………….

9. Damage to internal walls

Collapsed Collapsed Cracked Cracked few None

most few most

10. Crack locations in Walls ………………………….

11. Crack orientation

Vertical Horizontal Inclined Stepped Composit

e

12. Damage to doors:- Yes …….. No……….

13. Damage to windows/ventilators:- Yes …. No ……………

14. Erosion of wall due to flooding/storm surge:- Yes ……… No…………..

15. Extent of damage, in percent of wall area:- ……………….

16. Damage to eaves region:- Yes ……… No……….

17. Damage to truss/members

Complete Purlins Battens Rafters Tie None

members

18. Damage due to falling of trees:- Yes…….. No…………..

19. Distance of trees from building in 'm' ………………

20. Lifting of roof/failure of roof anchorage in walls/columns:- Yes ……

No………

B. Damage to property No …………..

If Yes :-
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 Government of Province, Province-02, Janakpurdham

_______specify

C. Damage to Life No………

If Yes
Specify ….

D. Others:- (Remarks)