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"Prerna Project"
UV Society's Initiative
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* Indicates required question
Date of survey
MM
/
DD
/
YYYY
Surveyor Name
*
Your answer
Name of Village
Your answer
PHC Name
Your answer
Head of family
Your answer
Age
Your answer
Gender
Choose
Male
Female
Prefer not to say
Marital Status
Married
Unmarried
Clear selection
Education
Your answer
Is the household income sufficient?
Yes
No
Clear selection
In addition to farming, do you do any side business?
Goat/Cow Grazing
Poultry
Other:
Is there any debt?***
Yes
No
Clear selection
From where did you borrow loan?
Friend/Relatives
Moneylenders
Banks/Society
Does debt lead to family quarrels?***
Yes
No
Clear selection
Does mental stress come from marriage, childbirth or any other reason?***
Yes
No
Clear selection
Is anybody addictive?***
Yes
No
Clear selection
Does anyone in the family have a major illness?***
Yes
No
Clear selection
Has anyone committed suicide in the family?***
Yes
No
Clear selection
Is there any unemployed in the family?***
Yes
No
Clear selection
Is there any financial problem due to infertility, natural calamity or other reasons?***
Yes
No
Clear selection
Rajiv Gandhi/ Mahatma Jyotiba Phule/Ayushyaman Bharat Scheme beneficiary? ***
Yes
No
Clear selection
If any questions in *** are marked YES ?
*
Yes
No
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