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Census
Data Collection Form
(One form to be used for one family only)
- Name
of the head of the family
_________________________________________________
- Address
___________________________________________________________________
_____________________________________________________________________
- Details
of the Family:
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S/No
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Name
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Relation
with the Head of the Family
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Age
(in Years)
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Sex
(M/F)
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Marital
Status (M/ UM)
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Education
Qualification
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Occupation
(Source of Income)
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Income
(Per Month)
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- Type
Of Family – Joint/ Nuclear/ Extended-
_______________________
- Per
capita income – Rs. ___________________________per month
- Total
Number of dependent (non earning) members in the family
-_______________________
- If
education incomplete – list the reasons for each of the
members with incomplete education-
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- Details
of Occupation
| S. No. |
Please mention the place of work
i.
Local (in the village, local town)
ii.
Distant (other state or city)
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Type of work
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- Fertility
details
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1st
woman
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2nd
woman
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3rd
woman
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4th
woman
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Age
at marriage
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Age
at 1st childbirth
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Total
no. of pregnancies of the woman
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Total
no. of children ever born alive
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No.
of children alive at present
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Age
of the youngest child
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Age
of the eldest child
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(If
there is more than four married woman in the reproductive age
group (15 – 49 years) in the same family, kindly collect the
fertility details for all of them in similar manner)
10. Breast
feeding and weaning details:
| Sl.
No. |
Name
of child |
Age |
Duration
of breastfeeding |
Age
at weaning |
Mothers
name |
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11. Details
of the Immunization status of the children in the family (use ü for immunization received and û
for immunization not received.)
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Immunisation
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Receiving age
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Child’s name
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Child’s name
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Child’s name
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Child’s name
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Child’s name
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Child’s name
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BCG, zero dose
OPV (optional)
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At birth or at
6weeks
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OPV/DPT 1
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6 weeks
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OPV/DPT 2
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10 weeks
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OPV/DPT 3
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14 weeks
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Measles
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9 months
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OPV/DPT 4
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18-24 months
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If
there are more children in the family please collect similar
detail
13.
If
there is a pregnant woman in the family
·
is she
getting antenatal care YES / NO
·
if YES
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Whether
registered in the health centre
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YES
/ NO
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Whether
going for regular health check ups
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YES
/ NO
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Whether
receiving Iron and folic acid tablets
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YES
/ NO
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Whether
TT Immunization received
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YES
/ NO
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14.
Any
illness in the family in the past 6 months
15.
What
treatment taken for the same
16.
Any
mental/physical disability in the family members
17.
Land
possession (area)- _______________in acres
18.
How
much of it used for cultivation purpose ______________in acres
19.
What
all is grown and which season/part of the year
20.
Material
assets owned by the family (write the Names)
21.
Source
of drinking water
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