Name First Last Leikai/Address NO. OF STRUCTURE/S UNDER SAME HOUSEHOLD LANDMARK Male Female TYPE OF FAMILY — Select — Joint Nuclear OCCUPATION/S Male Female TYPE OF HOUSE — Select — Kutcha Pucca DOES THE HOUSEHOLD HAVE WEAVING LOOM — Select — Yes No If Yes specify the type of loom DISTANCE FROM MAIN ROAD APPROACH ROAD WITH SUFFICIENT ACCESSBILITY FOR 4-WHEELER VEHICLES — Select — Yes No TIME SINCE FIRST SETTLEMENT — Select — 0-5 Years 5-10 Years 10-15 Years More than 15 Years KITCHEN GARDEN — Select — Yes No SOURCE OF PORTABLE WATER — Select — Yes No AVAILABILITY OF SANITARY TOILETS WITH SEPTIC TANK OF THE HOUSEHOLD — Select — Yes No ACCESS TO PUBLIC/ PRIVATE DRAIN — Select — Yes No ACCESS TO SOLID WASTE MANAGEMENT — Select — Yes No IF NO SPECIFY MEANS OF WASTE DISPOSAL WHETHER HOUSEHOLD IS PRONE TO FLOOD — Select — Yes No
