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NO.OF FRUITS
NAME OF HEAD OF FAMILY NO.OF MEALS PER
HH HOUSE NO CASTE MEMBERS PER DAY WEEK
FOOD POVERTY INCOME POVERTY
IF YES
DAIRY PULSES EGGS MEAT (AMT
VEGEABLES PER PER PER PER CEREALS DAILY PER
PER WEEK WEEK WEEK WEEK WEEK PER WEEK WAGER DAY) FARMER
NCOME POVERTY SHELTER POVERTY SAFE DRINKIN
MINERAL
WATER QUALITY CHARGES WELL BOREWELL RMP ANM MBBS DOC
T PROJECT- LAXMIPURAM(BHUPALAPALLY)
BUILT
THROUGH
TOILETS TOILETS IN GOVT IN PLACE
GOVT.H GOVT PHC PVT H AVAILBILITY USE SCHEME REPAIR AVAILABLE
EDUCATION POVERTY ELECTRICITY POVERTY CLEAN COOKING FUEL POVERTY
NO.OF SCHOOL
CHILDREN GOING ELECTRICITY METER SOLAR ELECTRICS
UNDER 6 - 14 CHILDREN CONNECTION AVAILABILITY LPG STOVE TOVE
FUEL POVERTY MOBILITY POVERTY SANITATION POVERTY INFRASTRUCTURE POVERY
CLEANING
FIRE VEHICLE IF YES HANDS SANITARY OPEN
WOOD AVAILABILITY IN VEHICLE BEFORE PADS DRAINAGE
USE 5 MINS NAME EATING USAGE SYSTEM
ASTRUCTURE POVERY LIVESTOCK DETAILS REMARKS
CLOSED
DRAINAGE DISTANCE
SYSTEM OF PHC HENS COWS OX BUFFALOES
SURVEY MODE Primary survey SURVEY done by -
DATE OF SURVEY 29-11-2017 and 30-11-2017 FORMAT
No.Of No.Of
Fruits Per Vegeables Dairy Per Pulses Per Eggs Per
House No Caste Family Meals Per
Week Per Week Week Week Week
Members Day
Availability
Irrigation Own Area Of Type Of Type Of Type Of
Irrigation Source Of Mineral
mode House Land Roof Floor Walls
Water
No.Of
Place School Going Electricity
In Repair Children Meter Availability
Available Children Connection
Under 6 - 14
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0 NA 1 1Y N
0 NA 2 2Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 2 2Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 3 3Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0Y 0 0Y N
0 NA 2 2Y N
0 NA 0 0Y N
0 NA 0 0N N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0Y 0 0Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 2 2Y N
0 NA 0 0Y N
0 NA 3 3Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 2 2Y N
0 NA 0 0Y N
0 NA 1 1Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 1 0Y N
0 NA 1 1Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 0 0Y N
0 NA 2 2Y N
0 NA 2 2N N
0 NA 1 1Y N
0 NA 1 0Y N
CLEAN COOKING FUEL POVERTY MOBILITY POVERTY SANITATION POVERTY
Vehicle
If Yes Vehicle Cleaning Hands Sanitary Pads
Option 1 Option 2 Availability In
Name Before Eating Usage
5 Mins
REMARKS
Others
0 cookingfuefamily members
0 LPG live stock details
0 Solar Stove 0 distance of phc
0 Electric St 1 in 500m drainage
0 Fire wood 2 0.5km - 1 Open
0 Not Applic 3 1km - 2kmClosed
0 HEALTH 4 2km - 3kmsanitation
0 RMP 5 3km - 5kmY
0 ANM 6 5km - 7kmN
0 MBBS Doc 7 7km 10kmmobility
0 Govt.H 8 > 10km in 5mins
0 Govt.PHC 9 in 1hr
0 Pvt.H 10 in 2hrs
0 Not Applic> 10 > 2hrs
0 roof floor walls area
0 Thatched Mud Mud <1G
0 Tiles Stone Wood 1-5G
0 Stone Tiles Cement 5 - 10 G
0 Mud Brick 10 - 40 G
0 RCC Slab Others > 1 AC
0
0 village district ward occupation
0 Sthambampalle 1 Dailywager
0 2 Farmer
0 3 agriculture labour
0 4 Teacher
0 5 Pensioner
0 6 Driver
0 Others
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 SEPTIC TANK AVAILABLE
0
0
0
0 SARPANCH
0
0
0
0
0
0
0
0
0
0 POST MASTER
0
0
0
0
0
0
0
0
0
0
0
0
0 POLICE MEN
0
0
charges
NA
< 30Rs
30 Rs irrigation type
> 30 Rs source none mode
quality Handpump canal Drip
good Overhead Water Tankrainwater Sprinkler
ok/avg Bore Well tank None
bad Tap Connection borewell NA
electricity Communityown placeother
education toilets place NA
0 0Y
1 1N
2 2 NA well/borewell
3 availability mw
4 meals caste
5 0 SC
week 1 ST
daily(7) 2 BC
once a we 3 income amt
twice a week Y 150 Rs
once a month N 200 Rs
rarely >200 Rs
never
occupation VILLAGENAME
Dailywager Sthambampalle
Laxmipuram
agriculture labour Ankannagudem
SURVEY MODE Primary survey SURVEY done by -
DATE OF SURVEY 29-11-2017 and 30-11-2017 FORMAT
FAMILY IDENTITY AN
No.Of No.Of
Fruits Per Vegeables Per Dairy Per Pulses Per
House No Caste Family Meals Per
Week Week Week Week
Members Day
Usage of chemical
Irrigation Own Area Of Type Of Type Of Type Of
fertilizer, insect & Irrigation
mode House Land Roof Floor Walls
weedicide
Availability
Charges Toilets
Source Of Mineral Quality Well Borewell Option 1 Option 2
per month Availbility
Water
Vehicle
If Yes Vehicle Cleaning Hands Sanitary Pads
Option 1 Option 2 Availability In
Name Before Eating Usage
5 Mins
< 30Rs
cookingfuelfamily members 30 Rs
LPG live stock details > 30 Rs
Solar Stove 0 distance of phc quality
Electric Sto 1 in 500m drainage good
Fire wood 2 0.5km - 1k Open ok/avg
Not Applica 3 1km - 2km Closed bad
HEALTH 4 2km - 3km sanitation electricity
RMP 5 3km - 5km Y education
ANM 6 5km - 7km N 0
MBBS Doc 7 7km 10kmmobility 1
Govt.H 8 > 10km in 5mins 2
Govt.PHC 9 in 1hr 3
Pvt.H 10 in 2hrs 4
Not Applica> 10 > 2hrs 5
roof floor walls area week
Thatched Mud Mud <1G daily(7)
Tiles Stone Wood 1-5G once a wee
Stone Tiles Cement 5 - 10 G twice a week
Mud Brick 10 - 40 G once a month
RCC Slab Others > 1 AC rarely
never
village district ward occupation
Sthambampalle 1 Dailywager
2 Farmer
3 agriculture labour
4 Teacher
5 Pensioner
6 Driver
Others
SEPTIC TANK AVAILABLE
SARPANCH
POST MASTER
POLICE MEN
irrigation type
source none mode
Handpump canal Drip
Overhead Water Tank rainwater Sprinkler
Bore Well tank None
Tap Connection borewell NA
Communityown place other
toilets place NA
0Y
1N
2 NA well/borewell
availability mw
meals caste
0 SC
1 ST
2 BC
3 income amt
twice a week Y 150 Rs
once a month N 200 Rs
>200 Rs
VILLAGENAME
Sthambampalle
Laxmipuram
Ankannagudem