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WORLD SMILE TRUST - Keep Smile And Keep Shine

B-2/5, BEHIND SANKHWAR HOSPITAL OLD KONDLI EAST DELHI-110096

Registration No. - IN-DL45656975968496V
DARPAN : MP/2018/0196860

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Home
About Us
Get Involved
Projects
Our Team
Gallery
Survey Application Form
Donate
Contact Us

Home
About Us
Get Involved
Projects
Our Team
Gallery
Survey Application Form
Donate
Contact Us

सर्वेक्षण आवेदन प्रपत्र- 2024-25
RESEARCH PURPOSE ONLY

Survey of Peoples and Communities

Survey of Peoples and Communities

Language change

DATE:

State

Tehsil/taluka/sub-district -

city/town/village -

Type of Address -

A. Basic Information:-

Name of Head of Household:-

Caste :

Religion

Reservation Category :

House address:-

Ward no. -

Contact no. -

1. General Health and Medical Awareness Survey :-

Number of family members:-

Any child aged 0-5 years

Out of 18+ members:-

Any child aged 6-1 7 years

Name

Height/Weight

Blood pressure(BP)

Communicable Diseases

HIV Polio TB Thyphoid Chicken pox Influenza Hepatitis OTHERS

Non-Communicable Diseases

Parkisons diseases Cancer Respiratory related Kidney related Cardiac/Heart related Brain relate Liver/Gall bladder related stomach and intestine related others

Is there a disabled person?

Yes No

if yes, state the nature of disability -

2. Education, Skill and Development Survey :-

A skill center near you

Yes NO

Is there any e-mitra center near you-

Yes NO

This centeF solves all related problems-

Yes NO

Name

Education qualifications

Are you preparing for any competitive exam?

Do you know about digital latforms and Any skill you're ’nterested in

3.Socio-Economic Status Family Awareness Survey

Your financial condition

Above Poverty Line Below Poverty Line

Number of members using the smartphone

Do you have any transport vehicle -

Household Type -

Semi-pucca pacca Soil composition

What type of cooking fuel is

LPG Gas Firewood Other

Source of income for your family

type of business to earn a living

Is your house well connected to the following points?

Electricity LPG Gas Water Source

If not, why (please describe);

Do you know about UPI transactions and digital payment methods (banking and financial information)

4. Agriculture and Farmers Survey : -

do you do agriculture?

Yes No

Is agriculture your main occupation?

Yes No

Apart from farming, do you do any other work for earning?

Yes No

(If yes) What do you do apart from farming?

Are you the only member of your family involved in farming?

Yes No

(if not) then other than you

How many members of your household are involved in farming?

women school going children

Do you or your family own any land?

Yes No

(If yes) How much land do you have?

Out of the total land, how much land do you cultivate? (in acre)

Have you rented out your land?

Yes NO

How much land did you rent (acre) :-

Do you farm on sharecropping?

Yes NO

(if so) how much land do you cultivate on sharecropping? (in Bigha)

How many crops do you grow in a year?

Which crops do you mainly grow?

How many times a year do you farm?

Are you satisfied with the rates of crops fixed by the government?

Yes No Can't say

Do you sell your produce at government procurement centres?

Yes No

Then, what is the reason for not selling it to them?

Low profits/good prices in the open market

Q Comiption in business Q One has to wait for several days at the centre to sell the crop Q There is no arrangement for storage of the crop brought by the farmer at the center. Q Delay in receipt of payment Q The government agency does not have the facility to buy my crop Q There is no government procurement centre nearby

Other (specify) :-

What type of soil do your agricultural fields have?

Alluvial soil Black cotton soil Red and yellow soil Laterite soil Hill or forest soil Arid or desert soil Saline and alkaline soils Peat and marshy soils Others

What kind of seeds do you usually use for farming?

Local/Traditional Seeds Hybrid Seeds Exotic Seeds Other (specify

What is the main reason for using local/traditional seeds?

Low consumption of water, fertilizers etc. Good for the soil Long life of seeds Good Quality Low cost Good Output Quick Production Protection from pests Greater ability to tolerate hot-cold weather Standardized increase until harvest Lack of availability of hybrid seeds Cannot buy expensive seeds

Other (specify)

What is the main reason for the use of hybrid seeds?

Over-production Prompt Production Protection from pests Greater ability to tolerate hot-cold weather Standardized growth until harvest Lack of availability of local seeds Use of hybrid seed is the only option Low consumption of water, fertilizers etc. Good for soil health Life span of seeds Good Quality Low Cost More profitable

Other (specify)

How much of your agricultural land has irrigation facility available? (in acre)

Do you have Kisan Credit Card?

Yes No

Do you get the benefit of Pradhan Mantri Kisan Samman Nidhi Yojana?

Yes No

Do you know tha ariyone in your village or area has committed suicide in the last five years?

Yes No

Do you know the main reason why he committed suicide?

Credit/Debt Crop Destniction Family/Domestic Problems

In your opinion, what is the biggest problem of Indian farmers to

Any person of the family works in the MNREGA scheme

Yes No

Survey of Infrastructure and Basic Development

Survey of Infrastructure and Basic Development

Transport Facility is Available

CHC/CHC/PHC/Subcentre-

Yes No

School Facility/Anganwadi/Asha Kendra

हां नहीं

Surrounding Waste Control and Management Facility

Yes No

Any bio-gas power plant nearby

Yes No

Survey Results

Name the most serious problems facing your community? Any suggestions for the government

(Specify areas and issues — health, pandemic, environment, pollution, education, drainage, agriculture, roads, electricity, drinking water, stray animals, sanitation, price of LPG cylinders and petrol, service delivery of government programmes etc.)

The area of your problems

Detailed report of the issue

Survey Results

Public survey of political knowledge and issues :

What is an Assembly Constituency -

What is a parliamentary constituency?

Which is your favorite government and their policies, schemes-

Which is your favorite political party and ideology? -

Important issues of youth, women and farmers :-

Your favourite is a political person who is knowledgeable in all qualities such as - working style, speaking style, educated choice and all socially and politically mature body languages -

World Smile Trust is a non-governmental organization committed to making a positive impact in the fields of Health, Education, Environment, and Social Work.

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+91 8306372600 +91 9773773592 +91 9602139979
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