SURVEY QUESTIONARES

NAME :-

H.NO :-

TYPE OF DWELLING UNIT:- APARTMENT DUPLEX

C C
O
NUMBER OF PEOPLE LIVING IN RESIDENCE:- O

IS THIS RESIDENCE OWNED / RENTED ?

FAMILY ANNUAL INCOME

AREA/ SIZE OF RESIDENCE

A. 500 – 600 SQFT

B. 600 – 1000 SQFT
C. 1000 – 1500 SQFT
D. 1500 – 2000 SQFT
E. > THAN 2000 SQFT
F. < THAN 500 SQFT

AGE GROUP OF FAMILY MAMBERS

AGE GROUP NUMBER OF PEOPLE

1.0-10 YEARS

2.10-18 YEARS

3.18-24 YEARS

4.24-55 YEARS

5.>55 YEARS

QUESTIONS TO AGE GROUP 1

WHAT DO YOU DO (OCCUPATION) ? ___________________________________

WHERE IS IT _______________ HOW FAR ? __________________

HOW DO YOU TRAVEL WALK BYCYCLE 2 WHEELER 4 WHEELER BUS

WHEN DO YOU TRAVEL 8 AM 9 AM 10 AM 11 AM

WHEN DO YOU COME BACK 1 PM 2 PM 3PM 4 PM

WHEN TO YOU SLEEP AT NIGHT ? 8 PM 9 PM 10PM 11PM

WHEN DO YOU WAKE UP IN THE MORNING 5 AM 6 AM 7 AM 8 AM

HOW MUCH TIME DO YOU SPEND AT YOUR HOME ___________________________

WHAT IS YOUR DAILY SCHEDULE

WHAT ARE YOUR HOBBIES

WHERE WHEN HOW

WALKING

OUTDOOR SPORTS

DO YOU SPEND TIME WITH YOUR NEIGHBOURS ? _______________________________________

WHAT DO YOU DO ON A HOLIDAY ? __________________________________________________

QUESTIONS TO AGE GROUP 2

WHAT DO YOU DO (OCCUPATION) ? ___________________________________

WHERE IS IT _______________ HOW FAR ? __________________

HOW DO YOU TRAVEL WALK BYCYCLE 2 WHEELER 4 WHEELER BUS

WHEN DO YOU TRAVEL 8 AM 9 AM 10 AM 11 AM

WHEN DO YOU COME BACK 1 PM 2 PM 3PM 4 PM

WHEN TO YOU SLEEP AT NIGHT ? 8 PM 9 PM 10PM 11PM

WHEN DO YOU WAKE UP IN THE MORNING 5 AM 6 AM 7 AM 8 AM

HOW MUCH TIME DO YOU SPEND AT YOUR HOME ___________________________

WHAT IS YOUR DAILY SCHEDULE

WHAT ARE YOUR HOBBIES

WHERE WHEN HOW

WALKING

OUTDOOR SPORTS

DO YOU SPEND TIME WITH YOUR NEIGHBOURS ? _______________________________________

WHAT DO YOU DO ON A HOLIDAY ? __________________________________________________

QUESTIONS TO AGE GROUP 3

WHAT DO YOU DO (OCCUPATION) ? ___________________________________

WHERE IS IT _______________ HOW FAR ? __________________

HOW DO YOU TRAVEL WALK BYCYCLE 2 WHEELER 4 WHEELER BUS

WHEN DO YOU TRAVEL 8 AM 9 AM 10 AM 11 AM

WHEN DO YOU COME BACK 1 PM 2 PM 3PM 4 PM

WHEN TO YOU SLEEP AT NIGHT ? 8 PM 9 PM 10PM 11PM

WHEN DO YOU WAKE UP IN THE MORNING 5 AM 6 AM 7 AM 8 AM

HOW MUCH TIME DO YOU SPEND AT YOUR HOME ___________________________

WHAT IS YOUR DAILY SCHEDULE

WHAT ARE YOUR HOBBIES

WHERE WHEN HOW

WALKING

OUTDOOR SPORTS

DO YOU SPEND TIME WITH YOUR NEIGHBOURS ? _______________________________________

WHAT DO YOU DO ON A HOLIDAY ? __________________________________________________

QUESTIONS TO AGE GROUP 4

WHAT DO YOU DO (OCCUPATION) ? ___________________________________

WHERE IS IT _______________ HOW FAR ? __________________

HOW DO YOU TRAVEL WALK BYCYCLE 2 WHEELER 4 WHEELER BUS

WHEN DO YOU TRAVEL 8 AM 9 AM 10 AM 11 AM

WHEN DO YOU COME BACK 1 PM 2 PM 3PM 4 PM

WHEN TO YOU SLEEP AT NIGHT ? 8 PM 9 PM 10PM 11PM

WHEN DO YOU WAKE UP IN THE MORNING 5 AM 6 AM 7 AM 8 AM

HOW MUCH TIME DO YOU SPEND AT YOUR HOME ___________________________

WHAT IS YOUR DAILY SCHEDULE

WHAT ARE YOUR HOBBIES

WHERE WHEN HOW

WALKING

OUTDOOR SPORTS

DO YOU SPEND TIME WITH YOUR NEIGHBOURS ? _______________________________________

WHAT DO YOU DO ON A HOLIDAY ? __________________________________________________

QUESTIONS TO AGE GROUP 5

WHAT DO YOU DO (OCCUPATION) ? ___________________________________

WHERE IS IT _______________ HOW FAR ? __________________

HOW DO YOU TRAVEL WALK BYCYCLE 2 WHEELER 4 WHEELER BUS

WHEN DO YOU TRAVEL 8 AM 9 AM 10 AM 11 AM

WHEN DO YOU COME BACK 1 PM 2 PM 3PM 4 PM

WHEN TO YOU SLEEP AT NIGHT ? 8 PM 9 PM 10PM 11PM

WHEN DO YOU WAKE UP IN THE MORNING 5 AM 6 AM 7 AM 8 AM

HOW MUCH TIME DO YOU SPEND AT YOUR HOME ___________________________

WHAT IS YOUR DAILY SCHEDULE

WHAT ARE YOUR HOBBIES

WHERE WHEN HOW

WALKING

OUTDOOR SPORTS

DO YOU SPEND TIME WITH YOUR NEIGHBOURS ? _______________________________________

WHAT DO YOU DO ON A HOLIDAY ? __________________________________________________

COMMON QUESTIONS TO FAMILY MEMBERS

HOW MUCH TIME DO YOU SPEND WITH YOUR FAMILY MEMBERS EVERY DAY ?

LESS TIME VERY LESS TIME MOST OF THE TIME

HOW OFTEN YOU HAVE A MEAL TOGETHER ?

SOMETIMES VERY RARE ONCE IN A DAY TWICE IN A DAY EVERY TIME

HOW MUCH WOULD YOU RATE FOR THE VENTILATION AT YOUR HOME ?

1___________________________________________________________________10

HOW MUCH WOULD YOU RATE FOR THE DAY LIGHT AT YOUR HOME ?

1___________________________________________________________________10

HOW MUCH WOULD YOU RATE FOR THE CIRCULATION AT YOUR HOME ?

1___________________________________________________________________10

HOW MUCH WOULD YOU RATE FOR THE COMFORTLEVEL IN YOUR NEIGHBOURHOOD?
1___________________________________________________________________10

DO YOU INTERACT WITH YOUR NEIGHBOURS ? YES/NO

DO YOUR CHILDERN INTERACT WITH YOUR NEIGHBOURS ?

HOW MANY PEOPLE ARE YOU AWARE OF IN YOUR NEIGHBOUR HOOD ?

A VERY FEW A FEW MANY EVERYONE

HOW OFTEN YOU TAKE HELP FROM YOUR NEIGHBOURS ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW OFTEN DO YOU CELEBRATE WITH YOUR NEIGHBOURS ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

DO YOU HAVE A PARK IN YOUR NEIGHBOURHOOD? YES/NO

HOW OFTEN YOU USE IT ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

DO YOU HAVE A PLAYGROUND IN YOUR NEIGHBOURHOOD? YES/NO

HOW OFTEN YOU USE IT ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW FAR IS A GROCERY STORE FROM YOUR HOME ?

< 200M < 500M < 1KM < 3KM < 5KM > 5KM

HOW OFTEN YOU GO TO GROCERY STORE ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER (ORDER ONLINE)

HOW FAR IS A HEALTH CARE CENTER FROM YOUR HOME ?

< 200M < 500M < 1KM < 3KM < 5KM > 5KM

HOW OFTEN YOU GO TO HEALTH CARE CENTER ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW FAR IS A BANK FROM YOUR HOME ?

< 200M < 500M < 1KM < 3KM < 5KM > 5KM

HOW OFTEN YOU GO TO HEALTH BANK ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW FAR IS AN ATM FROM YOUR HOME ?

< 200M < 500M < 1KM < 3KM < 5KM > 5KM

HOW OFTEN YOU GO TO AN ATM ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW FAR IS A RESTAURANT FROM YOUR HOME ?

< 200M < 500M < 1KM < 3KM < 5KM > 5KM

HOW OFTEN YOU GO TO AN RESTAURANT ?

OFTEN VERY OFTEN ONCE IN A WHILE NEVER

HOW FAR IS A SHOPPING MALL FROM YOUR HOME ?

< 1KM < 3KM < 5KM < 10KM > 10 KM

HOW OFTEN YOU GO TO A SHOPPING MALL ?

OFTEN VERY OFTEN ONCE IN A WHILE