(This information would be based for study purpose, Thank you for your

cooperation)

Parul Institute of Architecture and

Research
MASTERS OF PLANNING
REGIONAL PLANNING STUDIO

HOUSEHOLD SURVEY FORM

VILLAGE: INVESTIGATOR NAME:
LOCALITY: DATE:
A. RESPONDENT PROFILE:
NAME:
AGE:
SEX:
EDUCATION:
OCCUPATION:
B. FAMILY INFORMATION:
Sr. Member/Relation Marital Nature of Place of
Sex Age Education
No. with respondent status Work work/institute
1
2
3
4
5
6
7
8
9
10

Education: a) never attended school b) primary (1-5) c) secondary (6-10) d) higher sec. (11-12) e) UG 6) PG & above
Marital Status: a) Unmarried b) Married c) Widow/er
Nature of activity: a) working b) school c) college d) housewife e) retired f) work from home g) other

C. (a) DETAILS OF LAND OWNERSHIP:

Owner Cropping Commerciali Loan/ Cropping Value of
Sr. Area Under Cropping
ship zation (Y/N) Credit insurance Sale/crop
No. (Ha) irrigation Kharif Rabi Cycle
status (Y/N) (Y/N)
1
2
3
4
5

(b) SOURCE OF
(i) Loan: (ii) Insurance
Ownership Status: a) Owned b) Rented c) Landless
Under irrigation: a) less than 10% b) 10-25 % c) 25-50 % d) 50-75 % e) More than 75%
Commercialization: a) less than 10% b) 10-25 % c) 25-50 % e) 50-75 % f) More than 75%
Crop Cycle: a) Single b) Double c) Multiple
Input cost:
Fertilizer:
 Pesticides:
Labour:
Other:
D. HOUSING:

Sr. Typol Owner Material

Age Loan/Rent
No. ogy ship Roof Walls Floor
1

Typology: a) Kutcha b) Pucca c) Semi-Pucca

Ownership: a) Owned New b) Rented New c) Owned Old d) Rented Old e) Owned Hereditary
Age: a) 0-2 yrs b) 2-5 yrs c) 5-10 yrs d) 10-20 yrs e) 20-50 yrs f) More than 50 yrs

E. OCCUPATIONAL DETAILS
Nos. of Earning member: (M/F)

Agriculture Business Job

Sr. Member/Relation Source of
Occupation Turnover Salary per
No. with respondent Income Production Sales
(per annum) annum
1
2
3
4
5
6
7
8
9
10

Source of income: a) Agriculture b) Business c) Job d) Self Employment

Nos. of People who Migrate: (Shifted or working outside of the village)
Place: Occupation: Type:
(Daily, Seasonal, Permanent)
F. (a) ANIMAL HUSBANDARY

Sr. Production Milk Production

No Type of animals Total Lit/day
Minching Non-Minching
.
1
2
3
4
5
6
7
(b) Approximate value of Animals _____________________Rs.
(c) Animal sold last year _______________nos. On what price: _____________________Rs.

G. HEALTH PROFILE:

Sr. Member/Relation Sickness/Deceas Duration Place of Source of

Cost
No. with respondent e (Days) Treatment Fund

1
2
3
4
 5
6
7
8
9
10

Weeks: a) Less than week b)1-2 weeks C) 2-4 weeks d) 1-6 months e) 6-12 months f) More than 12 months
Source of treatment: a) Private Clinic b) Govt. Clinic c) Private Hospital d) Govt. Hospital
Cost: a) Less than 1000 b) 1000-5000 c) 5000-10,000 d) 10,000-20,000 e) 20,000-50,000 f) 50,000-1,00,000 g) More than
1,00,000>
Source: a) Private b) Govt. Program c) Other: _________________________

H. EDUCATION PROFILE:

Other
Sr. Member/Relation Fees Source of Loan
Education Institution Expenses
No. with respondent (annual) Fund (Y/N)
(annual)
1
2
3
4
5
6
7
8
9
10

Typology: a) Private b) Govt. c) Other: ___________________

Level of pursuing: a) Primary b) Secondary c) High school d) Undergrad e) Post Grad f) Doctorate
Source of Fund: a) Self b) Govt. Scholarship c) Private Scholarship d) Govt. Programme e) Other: _____________

Any Student studying outside village: Y/N: _______________

If Yes, Place: _________________________ Years: __________________________________
Stay: Hostel/Private: _______________________________
INVENTORY OF ASSETS.

Sr.
Item Ownership Type Financing
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Ownership Type: 1) Old 2) New 3) Hereditary

Financing: 1) Self 2) Govt. Loan 3) Private Loan

Member/Relation
with respondant Post
part of panchayat
Help taken from
Panchayat
Participation in
Meeting