Census Data Collection Form
(One form to be used for one family only)

 

  1. Name of the head of the family _________________________________________________
  2. Address ___________________________________________________________________

_____________________________________________________________________

  1. Details of the Family:

S/No

Name

Relation with the Head of the Family

Age (in Years)

Sex (M/F)

Marital Status (M/ UM)

Education Qualification

Occupation (Source of Income)

Income (Per Month)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  1. Type Of Family – Joint/ Nuclear/ Extended- _______________________
  2. Per capita income – Rs. ___________________________per month
  3. Total Number of dependent (non earning) members in the family   -_______________________
  4. If education incomplete – list the reasons for each of the members with incomplete education-
    1.  
    2.  
    3.  
    4.  
    5.  

 

  1. Details of Occupation
S. No.

Please mention the place of work

                     i.            Local (in the village, local town)

                   ii.            Distant (other state or city)

Type of work

     
     
     
  1. Fertility details

 

1st woman

2nd woman

3rd woman

4th woman

Age at marriage

 

 

 

 

Age at 1st childbirth

 

 

 

 

Total no. of pregnancies of the woman

 

 

 

 

Total no. of children ever born alive

 

 

 

 

No. of children alive at present

 

 

 

 

Age of the youngest child

 

 

 

 

Age of the eldest child

 

 

 

 

(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
           
           
           
           
           

11. Details of the Immunization status of the children in the family (use ü for immunization received and ű for immunization not received.)

Immunisation

Receiving age

Child’s name

Child’s name

Child’s name

Child’s name

Child’s name

Child’s name

BCG, zero dose OPV (optional)

At birth or at 6weeks

 

 

 

 

 

 

OPV/DPT 1

6 weeks

 

 

 

 

 

 

OPV/DPT 2

10 weeks

 

 

 

 

 

 

OPV/DPT 3

14 weeks

 

 

 

 

 

 

Measles

9 months

 

 

 

 

 

 

OPV/DPT 4

18-24 months

 

 

 

 

 

 

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

Whether registered in the health centre

YES / NO

Whether going for regular health check ups

YES / NO

Whether receiving Iron and folic acid tablets

YES / NO

Whether TT Immunization received

YES / NO

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

TRIBALZONE is a place for all Chotanagpur tribals , regardless of blood quantum, to "gather" and to heal, and share their unique cultures, artistic talents and rich heritage.