RF_COM_H_104_SUDHA.pdf
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RF_COM_H_104_SUDHA PART_1
COMMUNITY HEALTH CELL
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SOCIO DEMOGRAPHIC SURVEY
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Indicators: * RHH (Relationship to Head of Household ** Y & O (Year and Occupational)
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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SOCIO DEMOGRAPHIC SURVEY
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Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
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SOCIO DEMOGRAPHIC SURVEY
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Date:
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
1 a) Name of the slum:
residence in this slum
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
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Date:
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Date:
Let me assure you that any information you provide is strictly confidential
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Date:
Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
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Indicators : * RHH (Relationship to Head of Household ** Y & O (Year and Occupational)
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Indicators : * RHH (Relationship to Head of Household ** Y & O (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
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Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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1) high blood pressure (hypertension), diabetes . heart disease, coronary disease, hear, attack, back pain / disc problems migraine
(recurrent headaches), stroke (cerebral bleeding). , depression or anxiety’, sleep problems , hearing problems, vision problems .
gastntis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date :
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised
SOCIAL BACKGROUND
la) Name of the slum:
lb) No. of years of
di__
residence in this slum
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Own
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Yes/W
NAME OF SCHEME:
3 P.O
4 Any Others
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Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & O (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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IN ANY SAVING SCHEME:
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NAME OF SCHEME:
3 P.O
4 Any Others
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AGE
NAME
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator: S. p
Date :
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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NAME OF SCHEME:
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
23
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date :
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised 0 Not Recognised 0
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Indicators : * RHH (Relationship to Head of Household ** Y & O (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Date :
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
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Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and OccupationgJJ
2
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date :
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I.
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slum Recognised 0 Not Recognised O^
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NAME OF SCHEME:
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** ¥ & O (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of die slum:
residence in this slum
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slum Recognised 0 Not Recognised 0
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NAME OF SCHEME:
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AGE
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation®
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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AGE
NAME
RH H*
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURETY
Name of Investigator:
-5 .
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
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2 Commercial Bank
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NAME OF SCHEME:
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RH H*
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
o 2. .
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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Yes/No
NAME OF SCHEME:
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4 Any Others
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AGE
NAME
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator: TV)
Date:
Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
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7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
2
Yes/N
NAME OF SCHEME:
3 P.O
4 Any Others
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SI.
AGE
NAME
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SEX/
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
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Indicators : * RHH (Relationship to Head of Household ** Y &, 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
iA •
Date:
Let me assure you that any information you provide is strictly confidential
I.
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AU
1 a) Name of the slum:
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
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COMMUNITY HEALTH CELL
o5>
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Let me assure you that any information you provide is strictly confidential
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
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SOCIO DEMOGRAPHIC SURVEY
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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Indicators: * RHH (Relationship to Head of Household ** Y &. 0 (Year and Occupational
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
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2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator: $
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Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
•’
Date:
Let me assure you that any information you provide is strictly confidential
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SOCIAL BACKGROUND
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NAME OF SCHEME:
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Indicators: * RHH (Relationship to Head of Household ** Y &, 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
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SOCIAL BACKGROUND
1 a) Name of the slum:
4. RELIGION:
"
IN ANY SAVING SCHEME:
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
V) <Y
1
data of individual household members
Demographical
SI.
AGE
NAME
RH H*
No.
1
SEX
EDUCATION
Any Chronic disease i
(Y and O)**
I
o~< 'if
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1
L
I
2
J
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Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary' disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety’, sleep problems , hearing problems, rision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
2_ ? -
2
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
la) Name of the slum:....
/V
.yUk.-r
■
ii
residence
in
this
slum
.c.V.
/q)
2) House No
L
d • sf.
x
j
lb) No. of years of
Rented
Own
0
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 An}r Others
^^Xzr
1/
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
SEX
EDUCATION
Any Chronic disease
(Y and O)**
!
H-1
3/
I C1'
1^
Chronic disease
1) high blood pressure (hypertension), diabetes. heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
^7 -
/
-
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
residence in this slum
... lb) No. of years of
IS
2) House No
Rented
-
d'.'st
Ic)
O
/ dj
Li- .
Own
3) Head of the family
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
I
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
.1...Q.O.O
2
Yes/N
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
SEX
No.
EDUCATION
Any Chronic disease
(Y and O)**
I
k EH
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(
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(
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i
Chronic disease
1) high blood pressure (hypertension), diabetes , heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation§JJ
2
COMMUNITY HEALTH CELL
93
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of the slum:
.... lb) No. ofyearsof
Id)
residence in this slum ... J.. Zrr. - - / c )
2) House No
O
Rented
(3
3) Head of the family,
4. RELIGION:
. T’X'
Ov.n
l .
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
i
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
slum Recognised 0 Not Recognised 0
2 Commercial Bank
2
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
SEX
No.
EDUCATION
Any Chronic disease
(Y and O)**
M ■ H.
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Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or. ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
-SA .
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
O £
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
a:
1 a) Name of the slum:
lb) No. of years of
*-■
residence in this slum ...
2) House No
Rented
O
I d)
Ov.ii
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSEHOLD INCOME:-
Per Week Rs.
Per Month Rs.
i
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
2
/3?Z_
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
r
/V\/
(Y and O)**
EDUCATION
Any Chronic disease
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1) high blood pressure (hypertension), diabetes, heart disease, coronary' disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
3> •
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
I a) Name of the slum:
lb) No. of years of
residence in this slum ...y.DZL.... Ic)
2) House No
Rented
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d > st
&
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Q
3) Head of the family... ./'.’vn?
4. RELIGION:
...................................................
5. CASTE:
6. HOUSEHOLD INCOME:-
Per Week Rs.
Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/Nc/
NAME OF SCHEME:
\
3 P.O
4 Any Others
1
Demographical data of individual household members
s
SI.
—
AGE
NAME
RH H*
No.
SEX
EDUCATION
Any Chronic disease
(Yand O)**
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Chronic disease
1) high blood pressure (hypertension), diabetes. heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** ¥ & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
la) Name of die slum:
O
jL
-■...................... ................................................................................................................
I d)
d'.st
residence in this slum
2) House No
Ovm
Rented
lb) No. of years of
0
ZV -
<C,
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
i
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
2
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
Q
SI.
AGE
NAME
RH H*
SE?
No.
EDUCATION
Any Chronic disease
(Y and O)**
I
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Chronic disease
(j > 0
c
1
1
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems, hearing problems, vision problems,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and OccupationglJ
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
o S .
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
N
1 a) Name of the slum:
lb) No. of years of
/ (1) 'S
residence in this slum
2) House No
Rented
3) Head of the family.
O
Ovm
\J ' 1
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
I
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
-—.
2 Commercial Bank
2
V
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
SEX
p. H •
4.
a
s
Any Chronic disease
AT - N\
Xa)'
J
EDUCATION
b/V
(Y and O)**
i-r
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Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine,
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety7, sleep problems , hearing problems, ■vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator; ^7)
Date:
Let me assure you that any information you provide is strictly confidential
I.
o -X .
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
/A • / <s ) A/
residence in this slum
2) House No
v<
Rented
3) Head of die family...
I d)
diit. I
O
n"
■
Ov»Tl
4^
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
I
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
•A
2 Commercial Bank
2
O c> O •
^L\
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX\
EDUCATION
Any Chronic disease
(Y and O)**
■
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Chronic disease
4
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
L
o
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
4u
1 a) Name of the slum:
. ...
A/
,
residence m this slum J. K. ...... ] c
2) House No
Rented
lb) No. of years of
I d) vS
d' it - -
Own
O
3) Head of the family.
4. RELIGION:
...r.L
6. HOUSE HOLD INCOME:-
5. CASTE:
Per Week Rs.
Per Month Rs.
i
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
2
O O O
r^L
Yes/N
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
I
SEX
EDUCATION
Any Chronic disease
(Y and O)**
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i
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Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &. 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Dale:
Let me assure you that any information you provide is strictly confidential
I.
e
—• s •
- o 5 •
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
'Nr
I a) Name of the slum:
residence in this slum
it I G )
lb) No. of years of
.T:
Rented
2) House No
3) Head of the family...
4. RELIGION:
................. .........................................
6. HOUSE HOLD INCOME:-
Per Week Rs.
5. CASTE:
Per Month Rs.
2
7. involve:
1 Local SHG
IN ANY SAVING SCHEME:
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
SEX
Any Chronic disease
H• M
w
31
I'
(0
L
k
EDUCATION
(Y and O)**
Fh^-
=9-
iS
I
I
V
s
Chronic disease
1) high blood pressure (hypertension), diabetes , heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and OccupaUon^I
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator
-3 .
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
.... lb) No. of years of
d'si
residence in this slum
2) House No
Rented
O
id)
Ovm
3) Head of the family...
4. RELIGION:
......... ....................................................
6. HOUSE HOLD INCOME:-
Per Week Rs.
5. CASTE:
Per Month Rs
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
I
2 Commercial Bank
es/No,
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
SEX
No.
EDUCATION
Any Chronic disease
(Y and O)**
MgE
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Chronic di ase
Indicators
T
high blood pressure (hypertension), diabetes, heart dis ^ase coronary disease, hezt attack, back pain/ disc prob' ems , migraine
(recurrent headaches), stroke cerebral bleeding) , c epn ssion or anxiety, sleep problems , hearing problems, ■ dsion problems .
gastritis or ulcer, ob& any other (specify)
RHH (Relationship to Head of household ** Y & 0 dYeaJ and OccupationaJJ
1
15
I
!
7
/
I
2
e •
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator.
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
residence in this slum
lb) No. of years of
\0
fc)
Rented
2) House No
3) Head of the family.
o
I d)
Ovm
(£,V •'A
4. RELIGION:
5. CASTE:
6. HOUSEHOLD INCOME:-
Per Week Rs.
Per Month Rs. ...
i T7L
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
d'it
2 Commercial Bank
2
Yes/NcZ
NAME OF SCHEME:
3 P.O
4 Any Others
1
data of individual household members
Demographical
SI.
AGE
NAME
No.
(Y and O)**
I
H • H'
L
4
y>
SE>1
RH H*
4
l
EDUCATION
Any Chronic disease
1^
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h'Vfr/'Y.
<z 6^
q ,0
F,
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(\.F 7
b
\j^
F kj^
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2^
Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &, 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
■
°3
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
d • st
residence in this slum
Rented
2) House No
O
Ov.-n
3) Head of the family....
4. RELIGION:
......................
6. HOUSE HOLD INCOME:-
5. CASTE:
Per Week Rs.
Per Month Rs.
j 27L
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
A/....
2
Yes/N^'
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
I
z
SEX
EDUCATION
Any Chronic disease
(Y and O)**
-—kz
7^---- ;
7
v-> yy ■
yi .VA •
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S) ff'7m
Z& E-v’
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6
7
35|
1
y-yx/J •
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Chronic disease
1) high blood pressure (hypertension), diabetes, heart disease, coronary' disease, heart attack, back pain I disc problems , mipraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems
gastritis or ulcer, ob&g, an}' other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date :
Let me assure you that any information you provide is strictly confidential
I.
2^
Lj
IS .
OJ .
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of die slum:
lb) No. of years of
4.
/ ct) 3
residence in this slum
2) House No
Rented
O
Ovm
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
i
7. INVOL
1 Local SHG
IN ANY SAVING SCHEME:
2 Commercial Bank
2
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
Q
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
Any Chronic disease
(Y and O)**
H'H-
vJ
i- 0^
^3 ^•2?|
o'
\6
.—j
r&gv'.^.
£ 3>°- p
^Js,.p4
2
,v^
/v}|M i
Chronic disease
1) high blood pressure (hypertension), diabetes. heart disease, coronary' disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety’, sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
M - If - o S >
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
AJ
la)Name ofthe slum:
d> 5 i ■
I c)
residence in this slum
2) House No
Rented
lb) No. of years of
O
I d) 3
A/
Own
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
j 27L
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
.......
2
Yes/Ni
NAME OF SCHEME:
3 P.O
4 Any Others
1
I
Demographical data of individual household members
SI.
AGE
NAME
RH H*
SEX
No.
1
EDUCATION
Any Chronic disease
(Y and O)**
'\j'i$
—
IK
i
i
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v/
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I
Chronic disease
/A
(<
4C-
aZZ 3
ycA
' y)
r
I
I) hish blood pressure (hypertension), diabetes, heart disease, coronary disease, heart attack, back pain / disc problems , migraine
(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety7, sleep problems, hearing problems, vision problems
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
&3>
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
Z7
- o 3
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
I d)
lc)
residence in this slum
Rented
2) House No
O
Ovm
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
I
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
2
Yes/No
. NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
>
EDUCATION
Any Chronic disease
i 4
)
L
SEX
(Y and O)A*
rr
^T) 7yy-^\
a
y' ir______
A? .
/)
i
i
Chronic disease
i
1) hish blood pressure (hypertension), diabetes. heart disease, coronary disease, heart attack, back pain / disc problems , misraine
(recurrent headaches) , stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, 'vision problems .
gastritis or ulcer, ob&g, any' other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
cT'st
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Rented
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4. RELIGION:
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data of individual household members
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Indicators: ♦ RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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2 Commercial Bank
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NAME OF SCHEME:
3 P.O
4 Any Others
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Demographical data of individual household members
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AGE
NAME
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No.
I
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Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation3J
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
JT-
A •
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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1 a) Name of die slum:
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2
7. INVOLVEMENT IN ANY SAVING SCHEME:
Yes/No
NAME OF SCHEME:
2 Commercial Bank
3 P.O
4 An)’ Others
1 Local SHG
1
Demographical data of individual household members
SI.
AGE
NAME
R H H*
No.
SEX
EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
/
S - d 3 4
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
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7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
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1
Demographical data of individual household members
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SI.
AGE
NAME
RH H*
No.
SEX
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
) -
Date:
Let me assure you that any information you provide is strictly confidential
I.
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5
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
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7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
71
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
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Rented
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3 P.O
4 Any Others
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Demographical data of individual household members
SI.
AGE
NAME
RH H*
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L
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
—
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of die slum:
lb) No. of years of
residence in this slum
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AGE
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation®
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Date:
Let me assure you that any information you provide is strictly confidential
I.
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Name of Investigator:
.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
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residence in this slum
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7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
2.
Yes/No
NAME OF SCHEME:
3 P.O
4 An)' Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** ¥ & 0 (Year and Occupation^
2
■^5
COMMUNITY HEALTH CELL
^3>
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
; -
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
la) Name of the slum:
lb) No. of years of
residence in this slum .
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2 Commercial Bank
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NAME OF SCHEME:
3 P.O
4 Anyr Others
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1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
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gastritis or ulcer, ob&g, am' other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
social
BACKGROUND
lb) No. of years of
residence in this slum ..3
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.
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2
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
Any Chronic disease
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
SEX
(Y and O)**
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^J
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
A•
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
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2 Commercial Bank
2.. cP
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2
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
i
SEX
EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupations^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
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slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
G
ci^i. . .
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2) House No
Id) 3-tu
0
3) Head of the family.
4. RELIGION:
5. CASTE:
6. HOUSE HOLD INCOME:-
Per Week Rs.
Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Ye
3 P.O
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NAME OF SCHEME:
4 Any Others
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Demographical data of individual household members
SI.
"71
AGE
NAME
No.
SEX S
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
'
Date:
Let me assure you that any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
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................
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O
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2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
2
1
Demographical data of individual household members
SI.
AGE
NAME
No.
I
SEX I <5
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y &. 0 (Year and OccupationSJ
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURETY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
o3 '
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
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4 Any Others
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data of individual household members
Demographical
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AGE
NAME
RH H*
No.
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V ‘e
I
SEX
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &. 0 (Year and OccupationgJ
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of the slum:
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residence in this slum
C
6. HOUSE HOLD INCOME:-
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2 Commercial Bank
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5. CASTE:
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slum Recognised O Not Recognised 0
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NAME OF SCHEME:
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4 Any Others
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1
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SI.
AGE
NAME
RHH*
No.
X
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data of individual household members
SEX
EDUCATION
Any Chronic disease
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^’
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
02
Name of Investigator:
Date ;
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
N
1 a) Name of the slum:
lb) No. of years of
-p. AJ-
residence in this slum
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Rented
Ov.n
3) Head of the family.
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........
6. HOUSE HOLD INCOME:-
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Per Month Rs.
z
i
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/Nk
NAME OF SCHEME:
3 P.O
4 Any Others
-2
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
Any Chronic disease
(Y and O)**
L
3
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TL
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &. 0 (Year and Occupation§IJ
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name o f Investigato r:
Date:
Let me assure you that any information you provide is strictly confidential
I.
I:
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
I
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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NAME OF SCHEME:
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2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator.
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SOCIAL BACKGROUND
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
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Indicators : * RHH (Relationship to Head of Household ** Y&O (Year and Occupatior^g
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation®
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
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COMMUNITY HEALTH CELL
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
^5
Date:
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator: <j)c
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SOCIO DEMOGRAPHIC SURVEY
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
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gastritis or ulcer, ob&g, any other (specify)
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COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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SOCIO DEMOGRAPHIC SURVEY
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
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SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
residence in this slum
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Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
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Demographical
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No.
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
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NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
p■
1
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EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
IL
la) Name of the slum:
residence in this slum
lb) No. of years of
is
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7. INVOLVEMENT IN ANY SAVING SCHEME:
Vfocal SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
9
Demographical data of individual household members
SI.
AGE
NAME
No.
RHH*
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I
KM
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SEX
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation§J
2
COMMUNITY HEALTH CELL
/W\
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you lzs: any information you provide is strictly confideraial
I.
SOCIAL BACKGROUND
slum Recognised 0 Not Recognised 0
/v
1 a) Name of ±e slum:
residence in this slum
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2 Commercial Bank
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NAME OF SCHEME:
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SI.
AGE
NAME
No.
RH H*
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gastritis or ulcer, ob&g, any other (specify)
Lndicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you tha: any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of me slum:
lb) No. of years of
residence in this slum
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7. INVOLVEMENT IN ANY SAVING SCHEME:
Local SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
No.
/
RH H*
SEX
EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household *’ Y & 0 (Year and Occupation^!
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you tkai any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of me slum:
lb) No. of years of
residence in this slum
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I
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Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
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(Y and O)**
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gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y &. 0 (Year and Occupations^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you tkai any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of the slum:
residence in this slum
4. RELIGION:
slum Recognised O Not Recosmsed 0
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zs
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7. INVOLVEMENT IN ANY SAVING SCHEME:
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2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Am* Others
1
Demographical data of individual household members
SI.
AGE
NAME
No.
I
RH H*
SEX
EDUCATION
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &, 0 (Year and Occupations
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
residence in this slum
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NAME OF SCHEME:
3 P.O
4 Any Others
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Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
i
SEX
EDUCATION
Any Chronic disease
(Y and O)**
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
5
Name of Investigator:
Date:
Let me assure you iLai any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
1 a) Name of me slum:
lb) No. of years of
residence in this slum
I C- )
2) House No
3) Head of me family..C/'T'
.3
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6. HOUSE HOLD INCOME:-
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slum Recognised 0 Not Recognised 0
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Demographical data of individual household members
SI.
AGE
NAME
RH H*
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gastritis or ulcer, ob&g, any other (specify)
Indicators : ‘ RHH (Relationship to Head of Household
----------1 ** Y & 0 (Year and Occupational
2
COMMUNITY HEALTH CELL
e
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
/ (f
Date :
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
la) Name of the slum:
S.
........
h.
residence in this slum
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lb) No. of years of
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Per Month Rs.
7. INVOLVEMENT
ATT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/No—"
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
SEX
EDUCATION
Any Chronic disease
(Y and O)**
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gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
2) House No
3) Head of the family...
4. RELIGION:
Rented
O
Ov.ii
A
...................... ..........................................
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5. CASTE:
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2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
/
Demographical data of individual household members
SI.
AGE
NAME
No.
RH H*
SEX
EDUCATION
Any Chronic disease
(Y and O)**
z
C^'
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5
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupationgg
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator.
Date:
Let me assure you thai any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
11.
1 a) Name of die slum:
residence in this slum
6
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2 /l^L
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Ye
NAME OF SCHEME:
3 P.O
4 Any Others
1
Demographical data of individual household members
SI.
AGE
NAME
No.
RH H*
SEXj
(Y and O)**
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y &. 0 (Year and Occupaticr^J
2
COMMUNITY HEALTH CELL
,3
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator: 32)^
Date:
Let me assure you that any information you provide is strictly confidential
I.
A Jff3
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
la) Name of the slum: ...
lb) No. of years of
M 3>-1’’:
residence in this slum ... ^4
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3 ?L
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
NAME OF SCHEME:...
3 P.O
4_Aity Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
SEX
No.
(Y and O)**
Any Chronic dis' se
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems ,
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational)
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised O Not Recognised 0
SOCIAL BACKGROUND
la) Name of the slum:
residence in this slum
lb) No. of years of
U
2) House No
d-
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Rented
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A.
O
3) Head of the family...—
4. RELIGION:
...............................
6. HOUSEHOLD INCOME:-
5. CASTE:
Per Week Rs.
Per Month Rs.
2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
Commercial Bank
a
NAME OF SCHEME:
3 P.O
4 Am' Others
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
I
i
EDUCATION
Any Chronic disease
s
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety', sleep problems , hearing problems, vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupation^
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you ilza: any information you provide is strictly confidential
I.
slum Recognised 0 Not Recogmsed 0
S0CL4L BACKGROUND
1 a) Name of the slum:
lb) No. of years of
residence in this slum
2) House No
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d • sZ
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3) Head of the family..
4. RELIGION:
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Per Month Rs.
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2 n^L
/\J s>
Yes/No
NAME OF SCHEME:
3 P.O
4 Any Others
•
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'
7
1
Demographical data of individual household members
SI.
AGE
NAME
RH H*
No.
z
5
SEX
EDUCATION
(Y and O)**
H- H
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety, sleep problems , hearing problems, vision problems.
gastritis or ulcer, ob&g, any other (specify)
Indicators : * RHH (Relationship to Head of Household ** Y & 0 (Year and Occupational
2
>
I
COMMUNITY HEALTH CELL
X-:L‘
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator
Date:
Let me assure you Lzai any information you provide is strictly confidential
I.
SOCIAL BACKGROUND
la) Name of me slum:...
lb) No. of years of
residence in this slum
I c) A; <1 "N <
2) House No
3) Head of the family
4. RELIGION:
slum Recognised 0 Not Recognised 0
Rented
6. HOUSE HOLD INCOME:-
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/ d) xS’iuli,
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5. CASTE:
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2
7. INVOLVEMENT IN ANY SAVING SCHEME:
1 Local SHG
2 Commercial Bank
Ye
NAME OF SCHEME:
3 P.O
4 Am' Others
1
Demographical data of individual household members
SI.
AGE
NAME
RHH*
No.
z
SEX
EDUCATION
Any Chronic disease
(Y and O)**
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(recurrent headaches), stroke (cerebral bleeding) , depression or anxiety*, sleep problems , hearing problems, 'vision problems .
gastritis or ulcer, ob&g, any other (specify)
Indicators: * RHH (Relationship to Head of Household ** Y&O (Year and Occupational
2
COMMUNITY HEALTH CELL
SOCIO DEMOGRAPHIC SURVEY
Name of Investigator:
Date:
Let me assure you that any information you provide is strictly confidential
I.
slum Recognised 0 Not Recognised 0
SOCIAL BACKGROUND
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1 a) Name of the slum:
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residen; in this slum
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