Survey Proforma (Type A)
Village : Tehsil (ie subdiv. of a district): District :

Name of the family head :
Age :
Caste :
Religion :
Type of family : Single / Combined :
No of family members :
Male :
Female :
Children :
Total :

Source of income :
Agriculture / Business / Others
Details
Monthly Income :
No of earning members in the family :
Male :
female :
Total :

No of literate family members :
Male :
Female :
Children :
Total :
Level of education :
Literate
5th standard
8th standard
Matriculate
Graduate
No of children going to school :
Boys :
Girls :
Total :

Bathroom / Toilet facility :
In-House / Joint / CFommunity / not available
Drainage facility :
Available / Unavailable
Constructed / Temporary
Source of drinking water :
Well / Borewell / Handpump / Tap/ water body / others
Fuel for cooking food :
Wood/ LPG / Kerosene / others

Medical facilities
Doctor : available / Unavailable
allopathic / ayurvedic / homeopathic / other
Hospital : available / non available
Facilities : "
Medicines : "

Land holding of family (in acres) :
Land details :
Cultivable / pasture / unfertile / other use
Agricultural land : irrigated / unirrigated
Source of irrigation :
Well / canal / tubewell / river / pond / others
Main crops produced :
Rabi season : 1. 2. 3.
Kharif season : 1. 2. 3.
Mousson : 1. 2. 3.
Details of cattles : available / non available
what kind and number

DATE Signature and name of surveyor