Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
1. Name of the Panchayat
*
2. Name of the Habitation
*
3. Ward
4. Street
5. District
*
6. Block / Tehsil
7. Name of the Respondent
*
8. Caste / Tribe
FC
OBC
SC
ST
Other
9. Number of Family Members
10. Do you have a Functional Household Tap Connection (FHTC) under JJM?
*
Yes
No
11. If yes, when did you get the FHTC under JJM? (MM/YYYY)
12. Prior to receiving the tap connection under JJM, what were your primary sources of water?
13. Have you paid the deposit money for FHT connection under JJM?
Yes
No
14. Have you paid annual water tax?
Yes
No
15. Do you maintain cattle at domestic level?
Yes
No
16A. Goat / Sheep count
16B. Milch animal count
17. Quantity of water used during summer and winter
18. For how many days did you not get water after JJM started?
19. What is the reason?
20. How many days did it take to rectify?
21. Is there a Jal Sakhi or designated person responsible for testing water quality in your area?
Yes
No
22. If yes, how frequently is testing conducted?
Weekly
Fortnightly
Monthly
Quarterly
Next
23.1 Relation with Head of Household
23.1 Sex
Male
Female
Other
23.1 Age
23.1 Education Completed
23.1 Education Pursuing
23.1 Primary Occupation
23.1 Subsidiary Occupation
23.1 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
23.2 Relation with Head of Household
23.2 Sex
Male
Female
Other
23.2 Age
23.2 Education Completed
23.2 Education Pursuing
23.2 Primary Occupation
23.2 Subsidiary Occupation
23.2 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
23.3 Relation with Head of Household
23.3 Sex
Male
Female
Other
23.3 Age
23.3 Education Completed
23.3 Education Pursuing
23.3 Primary Occupation
23.3 Subsidiary Occupation
23.3 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
23.4 Relation with Head of Household
23.4 Sex
Male
Female
Other
23.4 Age
23.4 Education Completed
23.4 Education Pursuing
23.4 Primary Occupation
23.4 Subsidiary Occupation
23.4 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
23.5 Relation with Head of Household
23.5 Sex
Male
Female
Other
23.5 Age
23.5 Education Completed
23.5 Education Pursuing
23.5 Primary Occupation
23.5 Subsidiary Occupation
23.5 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
23.6 Relation with Head of Household
23.6 Sex
Male
Female
Other
23.6 Age
23.6 Education Completed
23.6 Education Pursuing
23.6 Primary Occupation
23.6 Subsidiary Occupation
23.6 Membership of CBC
Pani Samiti
Youth Club
Volunteer Group
Traditional Governing Body
Others
None
Previous
Next
24. Did your household have a piped water supply connection before implementation of JJM?
Yes
No
25.1 Before JJM: Are drinking water and domestic usage water the same?
Yes
No
25.2 After JJM - FHTC: Are drinking water and domestic usage water the same?
Yes
No
26. If No for 25.2, which type of water is being supplied through JJM-FHTC?
Drinking
Domestic usage water
27A. Before JJM - how did you manage domestic usage water?
Non-potable water from local borewell/open well through household piped supply
Private irrigation borewell
Hand pump
Public tap
Other
27A Other specify
27B. After JJM-FHTC - how do you manage domestic usage water?
Non-potable water from local borewell/open well through piped supply
Private irrigation borewell
Hand pump
Public tap
At household
Other
27B Other specify
28.1 Distance between residence and domestic usage water collection point before JJM
28.2 Distance between residence and domestic usage water collection point after JJM-FHTC
29.1 Mode of transportation used to collect domestic water before JJM
By walking
Bicycle
Motorized vehicle
Others
29.2 Mode of transportation used to collect domestic water after JJM-FHTC
By walking
Bicycle
Motorized vehicle
Others
At household
30.1 Is domestic water free or paid before JJM?
Free
Amount to be paid
30.2 Is domestic water free or paid after JJM-FHTC?
Free
Amount to be paid
31.1 Amount to be paid for domestic water before JJM
31.2 Amount to be paid for domestic water after JJM-FHTC
32.1 Male family members collecting domestic water before JJM
32.2 Female family members collecting domestic water before JJM
32.3 Boys collecting domestic water before JJM
32.4 Girls collecting domestic water before JJM
32.5 Male family members collecting domestic water after JJM-FHTC
32.6 Female family members collecting domestic water after JJM-FHTC
32.7 Boys collecting domestic water after JJM-FHTC
32.8 Girls collecting domestic water after JJM-FHTC
33.1 Time taken to collect domestic water before JJM (minutes)
33.2 Time taken to collect domestic water after JJM-FHTC (minutes)
34. If JJM water is not suitable for drinking, specify the reason
Previous
Next
35.1 Before JJM - drinking water sources
Irrigation borewell
Open well
Hand pump
Other
35.1 Other specify
35.2 After JJM-FHTC - drinking water sources
Irrigation borewell
Open well
Hand pump
Other
35.2 Other specify
36.1 Distance to drinking water collection point before JJM
36.2 Distance to drinking water collection point after JJM-FHTC
37.1 Mode of transportation for drinking water before JJM
By walking
Bicycle
Motorized vehicle
Others
37.2 Mode of transportation for drinking water after JJM-FHTC
By walking
Bicycle
Motorized vehicle
Others
38.1 Is drinking water free or paid before JJM?
Free
Amount to be paid
38.2 Is drinking water free or paid after JJM-FHTC?
Free
Amount to be paid
39.1 Amount to be paid for drinking water before JJM
39.2 Amount to be paid for drinking water after JJM-FHTC
40.1 Male family members collecting drinking water before JJM
40.2 Female family members collecting drinking water before JJM
40.3 Boys collecting drinking water before JJM
40.4 Girls collecting drinking water before JJM
40.5 Male family members collecting drinking water after JJM-FHTC
40.6 Female family members collecting drinking water after JJM-FHTC
40.7 Boys collecting drinking water after JJM-FHTC
40.8 Girls collecting drinking water after JJM-FHTC
41.1 Time taken to collect drinking water before JJM (minutes)
41.2 Time taken to collect drinking water after JJM-FHTC (minutes)
Previous
Next
42.1 Before JJM: In a week, how many days is water supplied?
All days of the week (7 days)
Alternative days
Others
42.1 After JJM-FHTC: In a week, how many days is water supplied?
All days of the week (7 days)
Alternative days
Others
42.2 Before JJM: If answer is other than all days, were you satisfied?
Yes
No
42.2 After JJM-FHTC: If answer is other than all days, are you satisfied?
Yes
No
42.3 Before JJM: If No, what is your expectation?
7 days weekly
Others
42.3 After JJM-FHTC: If No, what is your expectation?
7 days weekly
Others
42.4 Before JJM: Is quantity of water supply sufficient?
Yes
No
42.4 After JJM-FHTC: Is quantity of water supply sufficient?
Yes
No
42.5 Before JJM: Are you satisfied with the quantity of water supplied?
Yes
No
42.5 After JJM-FHTC: Are you satisfied with the quantity of water supplied?
Yes
No
42.6 Before JJM: Morning supply time
42.6 Before JJM: Evening supply time
42.6 Before JJM: Total duration of water supply per day (minutes)
42.6 After JJM-FHTC: Morning supply time
42.6 After JJM-FHTC: Evening supply time
42.6 After JJM-FHTC: Total duration of water supply per day (minutes)
42.7 After JJM-FHTC: Are you satisfied with the current schedule and water supply duration?
Yes
No
42.8 If No, what changes should be made?
Change in supply time
Extending supply duration
Distribution pressure to be increased
Others
42.8 Other specify
42.9 Before JJM: Are you satisfied with water quality?
Yes
No
42.9 After JJM-FHTC: Are you satisfied with water quality?
Yes
No
42.10 If No, what are the issues?
Turbid
Salinity
Other
42.10 Other specify
43. Storage facilities at home
Sump
Overhead Tank
Barrels
Domestic items only (pots & buckets)
43A. Sump approximate capacity
43B. Overhead tank approximate capacity
43C. Barrels number and capacity
43D. Pots & buckets numbers
44. Are you satisfied with storage facilities available with you?
Yes
No
45. How many liters of water are you able to collect per supply?
46. Is water quantity sufficient?
Yes
No
46B. If No, how much additional water do you want?
47A. Do you require additional equipment such as electric motors to access water from the tap?
Yes
No
47B. Is the water supply sufficient without such support?
Yes
No
48. What alternative arrangements have you made to meet shortages of potable/drinking water?
49. Alternative potable water sources
Purchasing packaged drinking water
Using an RO plant
Collecting water from a neighboring village
Using an irrigation borewell
Other
49 Other specify
50. Distance between home and alternative potable/drinking water source
51A. Time required to collect potable/drinking water from alternative source (minutes)
51B. At what time do you visit the alternative source?
51C. If payment needs to be made, what is the amount?
52. How much time do you save, and what are you doing with the time being saved?
Previous
Next
53.1 Before JJM: Women of working age can engage in paid employment
Yes
No
53.1 After JJM: Women of working age can engage in paid employment
Yes
No
53.2 Before JJM: Women in good health can participate in family occupations
Yes
No
53.2 After JJM: Women in good health can participate in family occupations
Yes
No
53.3 Before JJM: Able to participate in social group meetings
Yes
No
53.3 After JJM: Able to participate in social group meetings
Yes
No
53.4 Before JJM: Able to support children's education
Yes
No
53.4 After JJM: Able to support children's education
Yes
No
53.5 Before JJM: Children can attend school
Yes
No
53.5 After JJM: Children can attend school
Yes
No
53.6 Before JJM: Children can spend more time on their studies
Yes
No
53.6 After JJM: Children can spend more time on their studies
Yes
No
53.7 Before JJM: More time is saved in water collection and storage
Yes
No
53.7 After JJM: More time is saved in water collection and storage
Yes
No
53.8 Before JJM: Health and hygiene have improved
Yes
No
53.8 After JJM: Health and hygiene have improved
Yes
No
53.9 Before JJM: Water is available for toilet use and handwashing
Yes
No
53.9 After JJM: Water is available for toilet use and handwashing
Yes
No
53.10 Before JJM: Water-borne diseases have been reduced
Yes
No
53.10 After JJM: Water-borne diseases have been reduced
Yes
No
53.11 Other benefits before vs after JJM
54.1 Before JJM: Maintaining kitchen garden and meeting family vegetable needs
Yes
No
54.1 After JJM-FHTC: Maintaining kitchen garden and meeting family vegetable needs
Yes
No
54.2 Before JJM: Maintaining milch animals and meeting family dairy needs
Yes
No
54.2 After JJM-FHTC: Maintaining milch animals and meeting family dairy needs
Yes
No
54.3 Before JJM: Maintaining milch animals and selling surplus dairy
Yes
No
54.3 After JJM-FHTC: Maintaining milch animals and selling surplus dairy
Yes
No
55.1 Before JJM: Constructed during
Yes
No
55.1 After JJM-FHTC: Constructed during
Yes
No
55.2 Before JJM: Having sufficient water supply
Yes
No
55.2 After JJM-FHTC: Having sufficient water supply
Yes
No
55.3 Before JJM: Used by senior citizens / women / girls for toilet and bathing
Yes
No
55.3 After JJM-FHTC: Used by senior citizens / women / girls for toilet and bathing
Yes
No
55.4 Before JJM: All family members are using toilet / bathing
Yes
No
55.4 After JJM-FHTC: All family members are using toilet / bathing
Yes
No
56 Episode 1 Before JJM: Do any members of your family suffer from water-borne diseases?
Yes
No
56 Episode 1 Before details (Relation with HoH, Sex, Year, Age at time of disease, Diagnosed disease)
56 Episode 1 Before frequency of water-borne disease
56 Episode 1 Before treatment cost
56 Episode 1 After JJM-FHTC: Do any members of your family suffer from water-borne diseases?
Yes
No
56 Episode 1 After details (Relation with HoH, Sex, Year, Age at time of disease, Diagnosed disease, leading to death)
56 Episode 1 After frequency of water-borne disease
56 Episode 1 After treatment cost
56.4 Is the expenditure on treatment reduced now?
Yes
No
57. Is there any mortality?
Yes
No
57 Before JJM mortality details
57 After JJM-FHTC mortality details
58.1 Before JJM: Are you able to feel chlorine/presence in water?
Yes
No
58.2 After JJM-FHTC: Are you able to feel chlorine/presence in water?
Yes
No
59. Have you observed any improvement in overall health conditions after the implementation of JJM?
Yes
No
60. Are you aware of Jal Jeevan Mission?
Yes
No
61. Overall, are you satisfied with JJM services compared to earlier supply system?
Yes
No
62. If aware of JJM, how did you come to know?
63. Did they consult with you?
Yes
No
64. Are you aware of the source of water?
Yes
No
64B. If Yes, specify source of water
65. Have you been provided with a water testing kit?
Yes
No
66. If yes, how frequently is it used?
Weekly
Fortnightly
Monthly
Quarterly
Other
67. Village level / multi-village project?
Village level project
Multi-village project
68. How frequently do they clean OHT?
Once in a month
Once in a quarter
Others
68B. If Others, specify OHT cleaning frequency
69. Did you/anyone in the house migrate to different places?
Yes
No
70. If yes, did they migrate for employment?
Yes
No
71. Is their migration due to shortage/non-availability of water?
Yes
No
72. If yes, after the implementation of JJM, did they come back to the village?
Yes
No
73. If Yes, mention their type of employment
74. If you have additional pipeline for domestic purpose water apart from JJM-FHTC, how many days in a week is it supplied?
7 weekly days
Alternative days
Others
Not applicable
75. If answer is other than daily, are you satisfied?
Yes
No
76. If No, what is your expectation?
7 weekly days
Others
77A. Morning time of supply for domestic purpose water
77B. Evening time of supply for domestic purpose water
77C. Duration of domestic purpose water supply (minutes)
78. Are you satisfied with the above schedule and water supply duration?
Yes
No
79. If No, what changes are needed?
Change in supply time
Extending supply duration
Distribution pressure to be increased
Others
80. Storage facilities for domestic purpose water
Sump / Overhead Tank
Barrels
Domestic items only
81. How many liters of domestic purpose water can you collect in one supply?
82. Are you satisfied with the quality/quantity of domestic purpose water collected?
Yes
No
83. If No, how much additional quantity are you expecting?
84. Alternative sources for domestic purpose water
Hand pump
Hand pump with washing clothes on spot
Neighbor village piped supply
Irrigation borewell with washing clothes on spot
Other
84B. Other specify
85. Distance between home and alternative source for domestic purpose water
86. Time required to collect domestic purpose water from alternative source (minutes)
86B. At what time do you visit the alternative source?
87. Are you satisfied with the quality of domestic purpose water?
Yes
No
88. If No, what are the issues?
Turbid
Salinity
Other
Enumerator remarks / respondent additional comments
Previous
Website
Submit Survey