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  1. Surveys
  2. 2012
  3. May
  4. B
  5. Baseline Survey
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Interview Date: ………………………….Time ……………………
V.D.C ………………….Area #.......................... Village/Neighborhood ………………..
House #................................ (As per the map)
Researcher’s name: ……………………..
Interviewee’s name: ……………………..
Head of the family: …………………………….
Caste/Ethnicity: ………………………….
Number of family members: Female ……. Male…………Children…………
 
 
 
1. Family Details :
S.N.
 
 
1. What is the main source of income in the family?
According to the income source
Source of Income
 
 
2. How much of real state/land do you have?
Area in Ropanies
Type of land
 
 
3. Annual harvest?
Harvest quantity
Crop
 
 
4. For how long does the harvest feed you ? ………………Months
Harvest quantity
Crop
 
 
 
6. Do you grow any vegetables? 1. Yes (fill in KG- below) 2. No.
 
a. Potatoes ………………. b. Onions …………… c. Garlic ………….. d. Ginger ………….. e. Cauli flower ………………. f. Cabbage ………………… g. Cucumber ……………….h. Pumpkin …………….. i. Others…………
 
 
 
7. What type of Cash crops do you grow and how much ?
 
a. Tobacco …………. Kg b. Cotton ……………….. Kg c. Black Cardamom …………….Kg d. Pepper ……………Kg
 
e. Others……………..
 
 
 
8. How many cattle do you have?
 
a. Buffalo .....................b. Cow ……….. c. Ox ………….. d. Goat ………….. e. Pigs …………. f. Chicken ………. g. Calves …………….
 
h. Others ………..
 
 
 
9. What do you use to prepare food at home ?
 
a. Wood………….. b. Gas……………. c. Kerosene ……………. d. Others
 
 
 
10. What is your house made of ?
 
a. Bamboo/ Hay …………. b. Stone/Mud bricks………… c. Cement ………………… d. Others ………………………..
 
 
 
11. What is the roof made of?
 
a. Hay ……………..b. Slate ………… c. Aluminium …………..d. Tiles …………. e. Others ………………..
 
 
 
12. What facilities do you have at home? (Circle below)
 
a. Radio b. TV c. Computer d. Cell Phone e. Home Phone f. Motor bikes g. Other vehicles
 
h. Solar power i. Gas Plant j. Others……..……………… 13. What is the annual income of the family? In NRS……………………
 
c. Cleanliness details:
 
 
 
1. Where do you keep the cattle?
 
a. Barn b. Basement c. Others …………………
 
 
 
2. What is the source of drinking water ?
 
a. Tap/Pipe b. Well c. Stone tap/Water spring d. River e. Others
 
 
 
4. If yes, what process do you use to purify water?
 
a. Boil b. Filter c. Chlorination d. SODIS Process e. Others
 
 
 
5. How many times a week your family members take shower?
 
a. Childres ………..times b. Female………..times c. Male………times
 
 
 
7. What do you use to brush your teeth ?
 
a. Tooth paste b. Tooth Brush c. Dental Plants d. Coal e. Others………….
 
 
 
8. Where do you go for toilet?
 
a. Toilet b. Open field c. by River d. Forest e. Others
 
 
 
9. How does the toilet look?
 
a. Sturdy b. Frail (hole on ground/ walls in poor condition)
 
 
 
10. When does the family membr wash their hands ?
 
a. Before and after eating b. After Toilet c. After working with manure/fertilizers
 
d. Others……………..
 
 
 
11. What do you use to wash your hands ?
 
a. Soap b. Ash c. Mud d. Others…………………..
 
d. Nutrition Details :
 
 
 
1. What do you eat normally?
 
a. Rice/Bread/Porridge b. Lentil Soup c. Vegetables/greens d. Fruits e. Meat/Fish/Egg
 
f. All of the above g. Others………………………………………..
 
 
 
2. How many times a week do you eat the followings?
 
Lentils/Beans ……………….. Meat/Fish ………………….. Egg …………………….. Milk/Yogurt …………….
 
Vegetables/Greens ……………………. Fruits…………….. Others…………………….
 
e. Vices Details
 
 
 
1. Does anyone in the family smoke cigarette or chew tobacco?
 
YES a. Cigarette ……….. # Person b. Tobacco……………….. #Person NO
 
 
 
2. Does anyone in the family drink alcohol?
 
YES ………..# Person NO
 
 
 
3. Does anyone in the family use recreational medicines like drugs, marijuana?
 
YES……..# Person NO
 
f. Health related details
 
 
 
1. Is there anyone in the family who is sick?
 
a. Yes…………. b. No
 
 
 
2. Is there anyone in the family who has been sick for a long time?
 
a. Yes…………. b. No
 
 
 
3. Is this member being treated?
 
a. Yes ……………………………………………………………….. b. No
 
 
 
4. If there is someone sick in your family where do you take him/her for the treatment?
 
a. Health Centers b. Hospital c. Herbal Practitioner d. Traditional healer e. Others ………………..
 
 
 
6. Does anyone in your family intake regular medications ?
 
a. Yes ………………… b. No
 
 
 
7. Within the past year, has anyone been admitted to a hospital for treatment?
 
a. Yes ………………… b. No
 
 
 
8. Within the past year, has anyone been infected by any communicable diseases?
 
a. Yes …………………………………. b. No
 
Communicable diseases – Diarrhea, Influenza, Flu, Chicken pox, Pink eye, Measles, Rubella …………..
 
 
 
9. Is there anyone infected by TB?
 
a. Yes ……………. b. No
 
 
 
11. Does everyone in the family intake medicine against tapeworm every 6 months?
 
a. Yes ……………. b. No c. Unknown
 
 
 
12. What is the most frequent disease in the family?
 
a. Diarrhea b. Stomach aches c. Influenza d. Fever e. Others ………………..
 
 
 
13. In past 5 years, has there been a death in the family?
 
a. Yes b. No
 
If Yes, ……………….Year …………… Age ………………. Disease
 
g. Vaccination Details
 
 
 
1. Has everyone in the family received vaccination?
 
a. Yes b. No
 
 
 
2. Do the little kids get vaccination one time?
 
a Yes b. No
 
 
 
4. What vaccines are given to the little kids?
 
a. Polio b. Chicken pox c. Tetanus d. D.P.T 5. B.C.G 6 Hepatitis B/A 7. All 8. Others……………
 
h. Family Planning Details
 
 
 
1. Does anyone in the family follow family planning methods?
 
a. Yes b. No c. Unknown
 
If yes, what type of method a. Permanent b. Temporary …………………….
 
 
 
2. Where do the members go for the family planning service ?
 
…………………………………………………………………………………………..
 
i. Women Health and Sexually Transmitted diseases details
 
 
 
1. Do the women go for regular health checkups?
 
a. Yes…………. Times/yr b. No c. Unaware of the necessity
 
 
 
2. Are the women/girls in the family being taught about menstruation cycles?
 
a. Yes ……… b. No
 
Where do you stay/sleep during menstruation period?
 
a. Home b. Outside of home c. Others
 
What type of food you eat during menstruation period?
 
a. Regular b. Nutritious c. Non nutritious than rest of the family
 
What type of work do you do during menstruation period?
 
a. Regular b. Farming/Heavy work c. Light work d. Others
 
 
 
3. Are the family members aware of the HIV aids ?
 
a. Very well b. Fairly c. No
 
 
 
4. Are the family members aware of STDs ?
 
a. Very well b. Fair c. No
 
 
 
5. Where are the children being delivered ?
 
a. at home ………. b. at Hospital......................
 
 
 
6. Who helped during the delivery at home ?
 
a. Family members/neighbors b. Trained mid wife
 
 
 
7. What equipments do you use to cut umbilical cord?
 
a. Sterilize blades/other weapons b. Normal weapons c. Tools included in maternity package
 
d. Others……………………………
 
 
 
9. How long does it take for you to go to the closest health post for the delivery?
 
……………………………………..Minutes/hours
 
 
 
10. In past year, has there been any case of miscarriage?
 
a. Yes ……………..times b. No
 
 
 
11. Did the mom go for regular checkups before and after the delivery?
 
a. Yes ……….. times b. No
 
 
 
12. What type of food did the pregnant woman is served?
 
a. Regular b. Nutritious c. Others ……….
 
 
 
13. Had there been any difference between the tasks for the pregnant woman before and after?
 
If yes, how and for how long?................................................................................
 
 
 
14. Are the women in family aware of the hygiene and sanitation required during pregnancy and after giving birth?
 
a. Very well b. Fairly c. No
 
- If yes, what do they know? ...............................................................................................
 
 
 
15. Is there any woman in your family with cfªv:g] problem ?
 
a. Yes …………………………. b. No
 
 
 
16. Do the women in your family suffer from following problems?
 
a. difficulties during pregnancy b. Menstruation problems c . infertility d. skin diseases
 
e. Acidity f. Sugar g. Blood Pressure h. Others…………….
 
j. Mental Health
 
 
 
4. Does anyone in your family have issues such as aggression and violent behavior?
 
a. Yes ……………. b. No
 
 
 
5. Is anyone in your family suicidal? a. Yes …………….(# Person) b. No
 
k. Women Empowerment
 
 
 
1. Are the women in your family member of the women community/group ?
 
a. Yes …………………………… …………………. b. No
 
 
 
2. Do the women (above 16) in your family who are above 16 posses citizenship card ?
 
a. All of them b. ………. # person c. No Reason…………………
 
 
 
3. Are the women in your family involved in other social work besides household?
 
a. Yes ………………………………………………………………… b. No
 
 
 
4. Are the women in your family entitled to any real estate properties?
 
a. Yes b. No
 
l. Women’s Income details
 
 
 
1. Do the women in your family work to support financially?
 
a. Yes ………………………………… Annual Income NRS ……………. b. No
 
 
 
2. For such work, did they take any technical training courses?
 
a. Yes ……………..…………………………. b. No
 
 
 
3. Did any organization help to support the women’s income standard ?
 
a. Yes ……………………………………. b. No
 
 
 
4. Did any woman in your family leave for foreign employment ?
 
a. Yes…………………………… b. No
 
 
 
5. Do they receive any properties from their parents?
 
a. Yes ……………………………………………………….. b. No
 
m. Income Potential details:
 
 
 
1. In this community, do the women work together in a group to generate income?
 
a. Yes…………………………………….. b. No
 
 
 
2. Circle the type of works done in this community
 
a. Vegetable farming b. Tobacco farming c. Crop Cultivation d. Cattle e. Others ……………….
 
 
 
3. Where would be the best place to sell the above potential products?
 
a. Local farmer’s market b. Okhaldhunga c. outside the district d. Export internationally
 
e. Others ………………
 
n. Savings and Debt details:
 
 
 
1. Are you aware of the possibilities to start up Savings and Debt Union locally?
 
a. Very well b. Fairly c. No
 
 
 
2. Are the female members of your family members of Women savings and debt union?
 
a. Yes b. No (If no skip 4, jump to 5)
 
 
 
3. What benefits have you received from Women savings and debt union?
 
a. Savings b. Loans to generate income c. Trainings d. Travel e. New information
 
f. Others ……..
 
 
 
4. Who is the director/manager of local savings and debt union?
 
a. Male b. Female
 
 
 
5. How much would you be able to save monthly, if there existed Women savings and debt union?
 
a. Rs 25 to 50 b. Rs 50 to 100 c. Rs 100 to 200 d. Rs 200 to 500 e. More that Rs 500
 
o. Awareness Program
 
 
 
1. Do you know about domestic violence?
 
a. Very well b. Fair c. No
 
If yes, what do you know?................................................................................
 
 
 
2. Who suffers the most from of the domestic violence?
 
a. Female members b. Children c. Male d. Others e. None
 
 
 
3. What are the problems females have to face because of the male in the family?
 
a. Beaten up b. Polygamy/ extra marital affair c. Food d. Properties e. Not letting participate in domestic decisions f . Deprived from attending women empowerment programs g. Others…………….
 
 
 
4. Are you aware of the laws against domestic violence?
 
a. Very well b. Fair c. No
 
If yes, what do you know?................................................................................
 
 
 
5. Is there any female in your family who has been sexually harassed by her husband, neighbors, teachers, friends?
 
a. Yes ……………………………….. b. No
 
p. Child Development:
 
 
 
1. In your family, does everyone from the age of 5 to 16 go to school?
 
a. Yes, all. b. …………… ………………(# not attending)
 
c. None Reason………………………………..
 
 
 
2. Are there any children who dropped school?
 
a. Yes. b. No
 
 
 
3. Do u send your children to school regularly?
 
a. Yes b. No Reason……………………………………………………………..
 
 
 
5. 1. In your family, do the kids from 3 to 5 attend primary school?
 
a. Yes ……………………# kids b. No c. No one is of that age.
 
 
 
6. In your family, is there any child who has been awarded a scholarship to study?
 
a. Yes ………………………………………………………..# Child/from who?
 
b. No c. Partial Scholarship
 
 
 
7. Are you aware of Child Rights?
 
a. Very well b. Fairly c. No
 
If yes, what do you know about?............................................................................................................................................
 
 
 
8. In your family, what kind of works do the children under 16 do?
 
a. Give hands on chores b. tasks in the field/farming c. cut grass/ collect firewood
 
d. Graze cattle e. all of the above e. Others………………………………………………………………..
 
 
 
9. What do you know about the tasks that you can make your kids involved in?
 
a. Any b. Simple domestic tasks c. As per their age d. Others …………………………………..
 
 
 
10. Are your children member of any of the Child groups/clubs in School or Community?
 
a. Yes b. No c. Unknown
 
 
 
11. Are you aware of any kind of mental or physical harassment your children had to go through from his/her teacher in school?
 
a. Yes b.No c. Unknown
 
If yes, ……………………………………………………………………………..
 
q. Environment details:
 
 
 
1. Has there been any differences in the time of the year when crops are cultivated and harvested, within last 10 years?
 
a. Yes b. Fairly c. No
 
 
 
2. Have your crops been plagued by insecticides ad pesticides, within last 10 years?
 
a. Yes b. Fairly c. No
 
If yes, ……………………………………………………………………………………………………………………
 
 
 
3. Has there been significant seasonal patterns changes within last 10 years ?
 
a. Yes b. Fairly c. No
 
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