convergent planning households survey base...

Convergent Planning Households Survey Base Form

State

District Tehsil/ Taluk Block NRLM Intensive YES / NO

Gram Panchayat

Village

SECC TIN NUMBER

Household Size 18-59: <18 >60

Name of the Head of the HH

Age Gender Social Category

Fathers Name

Mothers Name

Automatically Included with Criteria Codes or Deprivation with Criteria Codes

Contact Mobile Number

Does the Household have a Job Card: Yes / No If Yes: No. of Job Cards in the Household:

GP Code Village Code Household Code

Job Card 1

Job Card 2

Job Card 3

1. Fill Demand Projection form (Form A – Green Colour) for each Job Card in the Household:

a. If No, does the Household want to get a Job Card? Yes/No If Yes, provide Form

after filling Unique Form Number :

2. Fill Form B – Household Livelihood Plan ( Colour – Blue)

3. Has the family been already surveyed under Project LIFE? : Yes / No

a. If Yes, fill last two columns of the Project LIFE checklist against the name of the

Youth

b. If No, is any member in the Household interested in Skill Development: Yes/No

i. If Interested : Fill Form C ( Colour Grey)

4. Is the Household already an IAY Beneficiary or Eligible for IAY? If Yes: Fill Form D (Colour

Yellow)

5. Is there any eligible member for NSAP (IGNOAPS / IGNWPS /IGNDPS)? If Yes: Fill Form E

(Colour Pink)

Unique Form Number

Name & Signature of Surveyor Signature /Thumb Impression of Respondent

Form A: Demand Estimation for Job Cards

Job Card Household Code

Name of Job Card Holder

FRA Beneficiary Yes / No Yes / No Yes / No

April

May

June

July

August

September

October

November

December

January

February

March

Total

Unique Form Number


Form B: For Household Livelihood Plan in NRLM Blocks (Page 1)

1. Name of the Head of the Household:

2. Landholding details of the family: (Identified Local Unit)

Own Land Leased Land

Low land Medium land Up land

Homestead land

Non-Cultivable

Irrigated

Non irrigated

Define Identified Local Unit in Acres (1 acre = _________ Local Units)

3. Agriculture related opportunities

3.a Is the family willing to take up Land Development work [Use codes: Land levelling work -1; Farm bunding -2; Other-3]

3.b Individual irrigation assets required [Use codes: Farm pond-1;Dug well -2; Others -3]

3.c Is the HH willing to construct (1) NADEP compost pit (2) Azolla Pit? [Use codes: YES – 1; NO-2]

3.d Is the family willing to take up block plantation for horticulture/fodder/timber in her land if any? [Use codes horticulture -1, fodder-2, timber -3]

3.e Is the family willing to take plantation activity on Government land/ road side? [Use codes YES – 1; NO-2]

3.f If landless, is the family interested in taking land on lease? [Use codes YES – 1; NO-2]

4. A. Livestock related opportunities: Number of Animals

Buffalo Cows Bullocks Goats/ Sheep Pigs Poultry Other

Adult

Calf/ Kids

4. B. Livestock related Needs:Does the family require shelter for animals? [YES – 1; NO-2]

Cattle shed Goat/Sheep shed Pig sty Poultry shed

5. Non Timber Forest Produce (NTFP) based Livelihoods [Only if village is close to forests]

5.a Is the Village in close proximity of forests? [Use codes YES – 1; NO-2]

5.b Is the family engaged or was engaged in NTFPrelated activities? [Use code YES /No)

Tasar Lac Others

5.c Will the family take up block plantation linked to NTFP related activities? Yes / No

Unique Form Number


Form B: For Household Livelihood Plan in NRLM Blocks (Page 2) Priority List of Household Level Productive Works (Prioritise up to 3)

List of Asset Building (If required, add to the list from Permissible List of Works as provided in BPT Checklist)

Priority Number

Land Levelling

Farm Bunding

Other Land Development Work if any (Specify Work):

Farm /Fishery Pond

Dug Well

Other Irrigation Structure (Specify Work)

Water Conservation Work in Agricultural Land

NADEP Composting

Azolla Pit

Plantation on Own Land

Plantation on Public Land

Cattle Shed

Goat / Sheep Shed

Poultry / Duck Shed

Pig Sty

Unique Form Number


Form B: For Household Livelihood Plan in NRLM Blocks (Page 3)

6. Enterprise related livelihoods activities

6.a Is the family engaged in some HH enterprise? [Use codes: YES – 1; NO-2]

Handloom Handicraft Others

6.b Is the family willing to set up an enterprise as a livelihood option? [Use codes YES – 1; NO-2]

Livelihoods mapping

Livelihood Sources

Agriculture

Income Months of Food Security

Livestock Wage Migration NTFP Others

Annual Income

8. Indebtedness Analysis

Source of credit Money lender/trader

MFI/ Finance Company

Friend/ Relative

Bank Direct

SHG

8.a Amount Outstanding

8.d Annualized Rate of interest (%)

Monthly Rate of Interest

8.e Reasons for Borrowing (Code)*

*Use Code: Consumption- 1, Production related- 2, marriage- 3, festival/rituals- 4 9. LIVELIHOODS EXTENSION SERVICES

Type of services

9.a 9.b 9.c 9.d

Animal Health Care Agriculture NTFP Large

Animal Small Ruminants & Poultry

Services providers #

Location of the service providers *

# Use Code: (pashusakhi/ agriculture CRP etc: code 1; Veterinary field assistant/ Gram Sewak/ CSO:

code 2; Block Agriculture Officer/ Veterinary Doctor: code 3; Private: 4

*Use code: (Same Village: code 1; neighbouring village within 2 km: code 2, more than 2 km: code 3;

Block HQ: code 4)

Unique Form Number


Form C: Format on Information of Need for Skill Building (One form to be filled for each Eligible and Interested Youth between 18 to 35 years of age. 18 to 45

years of age in case of SC / ST and Women)

S. No

Name(s) of Youth in the HH

Gender

Age

Disability, if any (Yes/ No)

Educational Qualifications (use code from Table-1)

Interested in Livelihood (Yes/ No)

Enter Three Preferred Skilling options from Table No. 2 in order of priority

1 1 1

2 2 2

3 3 3

Expectation of income after Skilling (use code from Table-3)

Is the youth willing to migrate (Yes/ No)

Codes for filling the form are printed on the backside of this form

Unique Form Number


Codes for Skilling (Form C)

Table 1

Education Qualification Code

12th pass 1

10th pass 2

8th pass 3

Primary 4

Illiterate 5

Table 2

Sl. No.

Trainings/ Skills options Code

1 AGRICULTURE related AGR

2 ALLIED HEALTH CARE related AHC

3 AUTOMOTIVE REPAIR related AUR

4 BANKING & ACCOUNTING related BAN

5 BEAUTY CULTURE & HAIR DRESSING related BEA

6 BUSINESS & COMMERCE related BSC

7 CONSTRUCTION related CON

8 CONSTRUCTION EQUIPMENT related CEQ

9 COURIER & LOGISTICS related COL

10 ELECTRICAL related ELE

11 ELECTRONICS related ELC

12 FABRICATION related FAB

13 FASHION DESIGN related FAD

14 FAST MOVING CONSUMER GOODS (FMCG) related FMG

15 FOOD PROCESSING & PRESERVATION related FPP

16 GARMENT MAKING related GAR

17 GEM AND JEWELLERY related GEM

18 HOSPITALITY related HOS

19 Industrial Electrical related IEL

20 INFORMATION AND COMMUNICATION

TECHNOLOGY related ICT

21 INSURANCE related INS

22 JUTE DIVERSIFIED PRODUCTS SECTOR related JTD

23 LEATHER & SPORTS GOODS related LEA

24 MARINE ENGINEERING related MRN

25 MATERIAL MANAGEMENT related MAM

26 MEDIA related MDA

27 MEDICAL AND NURSING related MED

28 PAINT related PAI

29 PLASTIC PROCESSING related PLA

30 PRINTING related PRI

31 PROCESS INSTRUMENTATION related PRO

32 PRODUCTION AND MANUFACTURING related MAN

33 REFRIGERATION & AIR

CONDITIONING related REF

34 RENEWABLE ENERGY related RNE

35 RETAIL related RET

36 SECURITY related SEC

37 SOFT SKILLS related SS

38 SPA & WELLNESS related SPW

39 TELECOM related TLC

40 TEXTILE –COTTON SPINNING related SPG

41 TRAVEL & TOURISM related TRV

Table 3

Expected monthly income

Code

Less than Rs.3000 1

Rs.3001- Rs.5000 2

Rs.5001- Rs.10,000 3

Rs.10,001 and above 4

Unique Form Number


Form D: Indira Awaas Yojana Household Survey Format

1. Name of the Head of the Household

2. Do you own a Pucca House : Yes / No

3. Have you received Housing Support: Yes (IAY) / Yes (State Scheme) / No

4. If it was for IAY, then

Code for Status - Complete (A)Plinth:(B)Lintel(C) Above Lintel (D)

Sanction Number(If any)

Name of Beneficiary

Status of House Amount Received

If Total amount received(Yes/No)

5. If Answer of Question 3 is No- 1. Are you on the waiting list? Yes / No / Don’t Know/ No Need(Pucca house)

2. Do you know that there is a permanent waiting list? Yes/No

3. Have you seen the IAY permanent Waiting List? Yes / No

Were you part of any Gram Sabha where IAY selection was discussed: Yes/No

Unique Form Number


Form E: National Social Assistance Programme Household Survey Format

1. Name of the Head of the Household:

2. Does anyone in the household receive any Social security Pension: Yes / No

3. If Yes

Name

Gender

Age

Scheme Name (Name State Scheme if received)

Amount per Month

Last Month in which Pension received

Number of Pending Months of Pension

4. Details of anyone who is considered eligible but doesn’t receive any pension

Name

Gender

Age

Category (Old Age/ Widow/ Disability)

convergent planning households survey base...

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