Baseline Village Assessment Survey

Introduction & Declaration

Namaste. My name is ___ and I am from Sixth Sense Research Company. We are conducting a study on the daily lives, challenges, and experiences of people in this village. Your responses are completely confidential and will only be used for research purposes. There are no right or wrong answers. Participation is voluntary and the interview will take 35–40 minutes. Your responses will help NGOs plan better support and programs for village development.

Surveyor Name *

Survey Date

Survey Time

Respondent Information

Q.1 Respondent's Full Name *

Q.2 Village Name

Q.3 Gram Panchayat

Q.4 Tehsil / Taluka

Q.5 District

Q.6 State

Q.7 Post Office

Q.8 Mobile Number (Optional)

Q.9 Other Reference Points

📍 GPS Location (Submitted to Google Sheet)

Detecting location...

Latitude

Longitude

Accuracy

Google Maps Link

Detected Address (approx.)

Section 1: Household Profile

Q.10 Age (completed years) *

Q.11 Total household members

Q.12 Gender *

Male Female Other

Q.13 Highest Education Level

Q.14 Role in Household

Members by Age Group

Q.15 Children (<15)

Q.16 Youth (15–29)

Q.17 Adults (30–59)

Q.18 Elderly (60+)

Q.19 Caste Category

ST SC OBC General

Q.20 How long have you lived in this village?

Since birth More than 10 years Less than 10 years

Q.21 One major change in your life in last 5 years?

Section 2: Socio-Economic Status

Q.22 Type of house

Kutcha (temporary) Semi-pucca Pucca (permanent)

Q.23 Do you own this house?

Yes No

Q.24 Approximate monthly household income

Less than ₹5,000 / ₹५,०००पेक्षा कमी ₹5,001 – ₹10,000 ₹10,001 – ₹20,000 ₹20,001 – ₹40,000 Above ₹40,000 / ₹४०,०००पेक्षा जास्त

Q.25 Toilet at home?

Yes No

Q.26 Electricity per day

<4 hrs 4–8 hrs >8 hrs

Q.27 Cooking fuel

LPG / गॅस Firewood Mixed

Q.28 Drinking water source

Q.29 Distance to water source

At home <100m 100–500m >500m

Q.30 Overall economic condition of household

Q.31 What makes you say that?

Livestock

Cows

Buffaloes

Poultry

Goats / Sheep

Section 3: Education

Q.32 Are all children attending school?

Yes No

Q.33 If No, main reason for not attending school

Financial constraints Lack of interest Distance to school Household responsibilities Safety concerns

Q.34 Distance to nearest school

<1 km 1–3 km 3–5 km >5 km

Q.35 Top 3 education challenges (rank 1–3)

Lack of teachers

Poor infrastructure

Distance to school

Financial constraints

Low interest among children

Safety concerns

Section 4: Health

Q.36 In last 3 months, has anyone fallen ill?

Yes No

Q.37 Where do you go for treatment?

Government hospital Private clinic Traditional healer Pharmacy only

Q.38 Do you have health insurance?

Yes No

Rank top 3 health problems in village

Fever/Infections

Malnutrition

Maternal health issues

Chronic diseases

Lack of facilities

Q.39 ASHA/Health workers visiting?

Regularly Sometimes Never

Q.40 (For Females) Menstrual products used

Sanitary pads Cloth Both Not Applicable

Section 5: Livelihood

Q.41 Primary occupation

Q.42 Work days in a month

<10 days 10–20 days >20 days

Q.43 Income stability

Q.44 Rank top 3 livelihood challenges

Lack of jobs

Low wages

Seasonal work

Lack of skills

Market access issues

Section 6: Financial Inclusion

Q.45 Bank account in your name?

Yes No

Q.46 Bank account usage frequency

Regularly Occasionally Rarely

Q.47 Use UPI/Digital payments?

Yes No

Q.48 Top 3 factors stopping from earning more

Lack of skills

No capital

No market access

Household duties

Family restrictions

Health issues

Section 7: Government Schemes & Social

Q.49 Aware of government schemes?

Yes No

Q.50 Part of Mahila Bachat Gat?

Yes No

Q.51 Problems in getting scheme benefits?

Q.52 Ration received monthly?

Q.53 Part of any group?

SHG / SGT Mahila Mandal Religious None

Q.54 Attended Gram Sabha?

Yes No

Q.55 Spoken in public meeting?

Yes No

Section 8: Infrastructure

Q.56 Rank top 3 infrastructure needs

Roads

Water supply

Electricity

Transport

Internet

Q.57 Distance to nearest bus stop

<1 km 1–2 km 3–4 km >4 km

Q.58 Alternative transport if bus missed

Walk Private Auto Shared Auto/TAMTAM Other

Section 9: Migration

Q.59 Any member migrate for seasonal work?

Yes No

Q.60 Migration improved income?

Section 10: Women Empowerment

Questions in this section are primarily for female respondents.

Special skills (select all that apply)

Water Fetching

Trips per day

1 to 2 3 to 4 More than 5

Time spent fetching water

<30 min 30–60 min >1 hr

Health problems from water carrying

Safety & Decision Making

Q.61 Feel safe inside home?

Always Sometimes Rarely Never

Q.62 Feel safe outside home?

Always Sometimes Rarely Never

Q.63 Who decides family planning?

Self Husband Jointly Elders

Q.64 (For Females) Alcohol common among men?

Yes No

Q.65 Pressure to have male child?

Yes No

Q.66 Describe condition of women in this village

Section 11: Youth

Q.67 Current status

Studying Working Not engaged

Q.68 Enrolled in any course/training?

Yes No

Q.69 Main career aspiration

Q.70 Move out for better opportunities?

Yes No Not sure

Q.71 What support would help you most?

Section 12: Wellbeing

Q.72 Which deity/bhagwan do you follow?

Q.73 Visit temple/place of worship regularly?

Yes No

Q.74 Family rituals and key festivals

Q.75 Overall life satisfaction

Q.76 Life change compared to 3 years ago

Q.77 Top 3 things to improve quality of life

Better employment

Higher income

Better healthcare

Better education

Improved infrastructure

Skill development

Women empowerment

Q.78 Biggest problem affecting wellbeing in village?

Introduction & Declaration

Respondent Information

Section 1: Household Profile

Section 2: Socio-Economic Status

Section 3: Education

Section 4: Health

Section 5: Livelihood

Section 6: Financial Inclusion

Section 7: Government Schemes & Social

Section 8: Infrastructure

Section 9: Migration

Section 10: Women Empowerment

Section 11: Youth

Section 12: Wellbeing

Survey Submitted!

Pending Submissions