VILLAGE CHARACTERISTCS

NAME AND AFFILIATION OF FORM FILLER, AND DATE

1. IDENTIFICATION
1.1 District name;
1.2 Tehsil name;
1.3 Village name;
1. LAND USE; (Source of information from MRO or VRO)
1.1 Geographic area of village
1.2 Cultivated (area)
1.3 Uncultivated permanent fallow
1.4 Uncultivated current fallow
1.5 Wasteland
1.6 Area under forest
1.7 Available for lease on average per year
1.8 Irrigated (percentage or area)
1.9 Is there a canal, river in the village?
1.10 How many tube wells or other irrigation wells are in village (specify type and number)
2. LAND DISTRIBUTION BY SIZE CLASS
2.1 landless hhs
2.2 >0 to 0.25 acre
2.3 >0.25 acre to 0.50 acre
2.4 >0.50 acre to 1.00 acre
2.5 > 1 acre to 1.25 acre and so on
3. VILLAGE HOUSEHOLDS; (Source of information from NGO workers and VRO)
3.1 Total village population
3.1 No. of village households by major caste group: SC, ST, OBC, General
3.2 How many households are on electronic land data base?
4. LOCATION OF VILLAGE
4.1 Distance of village from main road
4.2 Distance of village from market
4.3 Distance from Mandal headquarters
5. PUBLIC FACILITIES IN VILLAGE
5.1 School: level: primary, secondary, intermediate, college. Specify which ones are present
5.2 Health: PHC, SHC, hospital, other
5.3 Drinking water wells
5.4 Percent (or number) of HHs with piped drinking water
5.5 Percent (or number) of HHs with toilet access
5.6 Percent (or number) of HHs with electricity in homes
5.7 Percent (or number) of HHs with TV
6. PANCHAYAT DETAILS
6.1 Panchayat Pradhan: male or female?
6.2 How active is the panchayat? Very active, medium active, less active, inactive
A. Medium Active
6.3 Does it provide support to farmers?
7. GENERAL POINTS
7.1 What are the health problem faced by polluted water?
7.2 What do you see as the main problems facing the village today?
7.3 How can these problems be solved?
 QUESTIONNAIRE FOR SURVEY
1. Name of the respondent:
2. Age:
3. Sex
4. Educational qualification:
5. Occupation
[ ] Government [ ] Private [ ] Unemployed [ ] Others
6. Family details

Members Sex Age Occupation Income/ month

7. Annual Income
8. Expenditures
9. Address:
10. Phone:
11. Email (if any):
12. Housing typology
[ ] Apartment [ ] Individual [ ] Others
13. When did you construct/ buy this house?
14. Area of the plot ( Sq ft)
15. Built Area of the house( Sq ft)
16. How many years have you lived in this area
17. Why did you shift to this area?
18. How many times you have experienced floods?
[ ] Every year [ ] More than times a year
19. How long was this area flooded by river water? (in each flood) Days Hours
20. What was the cause of River water pollution?
/Heavy rains/Poor Drainage/ Canal embankment breaching [ ] others (specify)
13. What was the extent of flood and River
water?
[ ] Inside of the house

[ ] Garage/ Shed

[ ] Open land

[ ] Foot path

[ ] Garden

[ ] Others (specify)
14. What was the depth of River water?

[ ] Less than one feet [ ] one to two feet

[ ] three to four feet [ ] four to five feet

15. What were the outflows of River water?

[ ] Storm water drains [ ] Tanks/ lakes/ ponds/ streams/ canal

16. Have you experienced damage to your property from flood and River water pollution?
17. What are your suggestions to minimize the effects of River water pollution?
18. Give your suggestions to improve the quality of life
19. List the problems prevailing in your area

Encroachment [ ]

Congestion [ ]

Ground water quality [ ]

Traffic [ ]

Drainage [ ]

River water pollution [ ]

Transportation [ ]

Metro water supply [ ]

Pollution [ ]

A. Public Work Department officials questions

a) How long you have been working as an engineer in this river?

b) What was the condition of river before five, ten and twenty years, etc.?
c) Are you aware of sewage disposal in the river?
d) If yes, what actions have you taken to stop the sewage disposal?
e) Whether all the encroachments have been removed?
f) Whether there is any obstruction of flow due to sewage and waste particles?
g) How often do you measure discharge data? (Monsoon/non monsoon)
h) What are future plans to improve the river?