Participant consent form

Bachelor in social work

Texas International College, Tribhuvan University

Namaste:
I am …… of Social Work student studying in Bachelor level first year, in Texas International College,
Mitrapark, Chabahil affiliated to Tribhuvan University. This study is conducted in a partial fulfillment
of requirement for the filed visit and survey task.

Introduction:
The researcher is a student of Tribhuvan University. The study is being carried out as a partial
fulfillment of field visit and survey task. Researcher would appreciate your co-operation in answering
the question.

Direction:
The respondents are requested to mark (√) to choose right answer. The respondent can write their own
answer in other option and on blank spaces. Respondent can choose one or more answer in multiple
response question (MRQ). The respondents are requested to give their own opinion on the basis of
their knowledge.

The study consists of two parts:

Part I- Community profile

a. Socio-demographic profile
b. Caste and ethnic profile
c. Economic and occupational profile
d. Health profile
e. Education profile
f. Religious profile
g. Organization related profile

Part II- focus group discussion

Information related to
a. women,
b. health
c. education,
d. economic empowerment and
e. Livelihood.
Description of study

1. Project Title: Study on –“……….”

2. Student’s name: …………………. Bachelor in social work; mob- 9…….,
………..@gmail.com

3. Supervisor: …………………. Bachelor in social work; lecturer of Texas International

College, mob- 9…., ………..@gmail.com

4. Purpose(s) and Objective(s) of the report:

The purpose of this study is to develop an understanding of community profile and focus
group discussion related to women, health, education, economic empowerment, and livelihood
of Ghandruk Community.

5. Procedures:

 Participants in this study will be required to participate semi structured interview which will
be recorded and transcribed by the researcher with the participant’s permission
 Participants are free to ask questions regarding the procedures and goals of the study or your
role.

6. Funded by: No Funding

7. Potential Risks:

 There are no known or anticipated risks to you by participating in this study.

8. Potential Benefits:

 The results of these findings will be shared to the social work department of Texas College,
Tribhuvan University to further enhance the learning experience and to social work students
and faculties.
9. Compensation:

 There will be no compensation for this study.

10. Confidentiality:

 All information shared will be kept confidential and will only be used for the purposes of this
study
 Information will be stored digitally in password protected files and kept under the safe
keeping of the researcher

11. Storage of Data:

  Digitally recorded and transcribed files will be kept by the researcher. The information will be
discarded after completion of thesis.

12. Right to Withdraw:

 Your participation is voluntary and you can answer only those questions that you are
comfortable with. You may withdraw from the study project for any reason, at any time
without explanation or penalty of any sort.
 Your decision to participate or not in this study will have no effect on your position [e.g.
employment, social standing, access to services] or how you will be treated.
 Should you wish to withdraw due to illness and unavailability of time your information will
not be used for this study.

13. Follow up:

 A brief summary outlining study findings will be provided to participants. Names will be kept
anonymous so that there can be no clear linkage between participants in this study.

14. Questions or Concerns:

 Contact the researcher(s) using the information provided.

 This project has been approved on ethical grounds by bachelor program in social work, Texas
International College, Tribhuvan University. Any questions regarding your rights as a
participant may be addressed to the committee at (phone no- 980164456) and
(anantantv@gmail.com).

15. Continued or On-going Consent:

 Participants may be required to do a follow up interview only if it is necessary to clarify

information that was received during the initial interview process.

In this survey your personal experience and opinion is very important. We will keep the respondent’s
information anonymous. There is no right answer to the questions. Whatever answers you give is the right
answer for us. We believe that you will give us honest answers. Through random methods your ward and
your house were selected for the survey. This survey is about 40 minutes long. Respondent must be a Nepali
.The respondent must be living in the household for at least 6 months and should be member of the family
who eats in the same kitchen. In each ward 6 men and 6 women have to be interviewed.

Your signature below indicates that you have read and understand the description provided; I have
had an opportunity to ask questions and my/our questions have been answered. I consent to
participate in the study project. A copy of this Consent Form has been given to me for my records.

…………………….. ……………………… …………………..

Name of participants researcher’s signature Date
 COMMUNITY BASELINE STUDY

Instruction for the interviewer

Conduct the interview in an informal, conversational manner, asking questions gently in a soft tone. Put
the respondent at ease. Do not proceed in an interrogative manner or intimidate the respondent in any
way. Give sufficient time to the respondent to reflect and answer the question without feeling rushed. If
the respondent does not understand the questions, repeat it slowly.

QUESTIONAIRE

WARD NO………………………….. TOLE…………………………………………………GROUP ………………………………………..

DATE ……………… INTERVIEWERS NAME……………………………….TIME STARTED…………..FINISHED………………

A. SOCIO-DEMOGRAPHIC INFORMATION
1.1 NAME OF HOUSEHOLD HEAD ……………………………………………………………………………………………
1.2 HOUSEHOLD NUMBER ………………………………………………………………………………………………………
1.3 ADDRESS
Present Previous
Province Province
District district
Rural/ urban Rural/ urban municipality
municipality
Ward no Ward no
Village/tole Village/tole

1.4 ETHNICITY/CASTE
a. _____Brahmin / ……………….
b. _____ chhetri/………………….
c. _____janajati /………………….
d. _____dalit /……………………...
e. _____ others
Please very specify in reply

Education qualification
Nursery / kG Class 9 Uttar madhyama
Class 1 Class 10 Sastri
Class 2 SLC/SEE Acharya
Class 3 Intermediate or 10 +2 TSLC CTEVT
Class 4 Bachelor degree Diploma CTEVT
Class 5 Master’s degree Non formal education
Class 6 Ph.D level Illiterate
Class 7 Prathamik Refused to say
Class 8 Purba Madhyama Other specify
Don’t know

Household member information

Male …………………………….. Female…………………… Total……………………

NO. Relation to Age Sex Ed. Level Main job Other job If children under
household head 15 is at school

1. Wife

2. Mother/father

3. Son/ daughter

4. Son/ daughter in
law

5. Other specify

a. Nuclear household…………………………….
b. Joint household
(Three generations / married son or daughter in the same house)
……………………………………..
Citizenship
Do you have citizenship?
a. yes
b. No
c. \Refused to say
d. Don’t know
Marital status
a. Married
b. Never married
c. Divorced/ separated/ widow

Do you suffer from any disability/ disorder (poor eyesight/ poor hearing/ limited mobility etc)?
Yes
No
Refused
If yes, specify the disability ………………………………………………………

Religion

Hindu Buddhist Christian Sikh Bon Muslim

Islam Kirat jain Bahai Prakriti Undefined

What is your main occupation?

Agriculture Private sector Unemployed Social protection Refused Own

job transfers business
Casual/ Private sector Household / Don’t know Selling goods Business/
informal job( agri) housewife tourism
labour ( agri)
Study/ Other specify Migration/ Rent Public sector/ Pension
students remittance civil service holder

B. LANDHOLDING

Does your family own land?

Yes, we own the land where our house is built, but the
land does not otherwise generate income (from
farming, renting etc.

Yes, we own land some of which generates income

(from farming, renting etc.)
 Yes, we own the land where our house is built and we
also own some land which generates income
No, we do not own any land
Refused
Don’t know

Landholding pattern

Owner cultivation
Tenant cultivation
Sharecropping( Mohiyani/ adhiya)

If the respondent is an owner cultivator, how much land do they own?

Less than 1 ropani 1 ropani 2 – 3 ropani Don’t know 4 ropani
Refused 5 ropani 6-10 10-20 More than 20
ropani

If the respondent is an own cultivator, do they rent out land?

a. Yes
b. no
If yes, how much…………………………………………………………………..
How much do you get every year for this ………………………………

For all respondent who farm. What are the main crops?
Paddy potato Vegetables Other specify
Wheat Bean corn Millet

Livestock
Do you own any animals? How many?
1. pig
2. chicken
3.goat
4. buffalo
5. cow
6. donkey
7. ducks
8. Other specify
Livelihood
Remoteness:
How much time does it take to reach rural municipality/municipality Office from your home?

Less than half an hour 1

Between half an hour and 1 hour 2
More than one but less than 2 3
More than 2 4

In your view, what are the biggest problem facing in the community?

It is harder to find work/ making a living

Natural disaster( flood, landslide, etc)
Roads are bad
The economy is weaker
The price of goods has risen
Political parties don’t work for us
There is corruption for making work
Drinking water supply is inadequate
The government does not work for us
The climatic condition is worse than before
Electricity supply is worse and inadequate
Access to education is poor
Increase in taxation
Access to health service is poor
Poverty has increased
Access to media and internet is poor
Refuse
Other specify
Freedom of expression, domination and oppression
Caste based violence
Unemployment
Drugs abuse
Unemployed youth
Don’t know

Do you ever fear of being physically assaulted in your lives?

a. Yes
b. No
c. Refused
d. Don’t know
Do you ever have injustices in your lives?
e. Yes
f. No
g. Refused
h. Don’t know
If yes
how…………………………………………………………………………………………………….

Situation in the area where the respondent live

Now I would like you to think about the area where you live and work most of the time. Do you
think things in your area are improving, or do you think they are getting worse?

Improving
Electricity supply is improving
Overall everything is going positively
Drinking water supply is improving
The new rural/urban municipality has bring positive
changes
Access to education is improving
Local government and elected bodies bring changes
Climatic conditions are getting better
The situation of women is improving
The relation between caste/ ethnic groups/ religious groups
are improving
It is easier to find work/ make a living
There is no conflict in community
Business has improved
Other specify
Refused
Don’t know

Situation of household

Better The same Worse Refused to say Don’t know

Financial situation of your
household
Physical condition of your house /
dwelling
Health/ wellbeing of your family
members
Relation with other community
member
Relation with local government and
authorities
Access to food and drinking water
Situation of safety in community
In your opinion, what are the main threats to safety for most people in the area where you live and
work most of the time?

Major threats Reason behind

Natural disaster
Alcohol abuse
Crimes, thieves, gangs
Corruption, corrupt elites
Weak rule of law, poor governance ,
ineffective justice system
Gender based violence
Domestic violence, harmful practices
like witchcraft, sexual violence
Ethnic, religious or caste based tensions
Class based tensions
Poor infrastructure
Wild animals
Absence of police
No threats at all
Refused
Don’t know

Safety of the household

Now I would like to ask you about your feelings regarding your own safety and that of your family.
How safe would you say you and your family are? Would you say you are very safe, reasonably
safe, somewhat unsafe or very unsafe?
a. Very safe
b. Reasonable safe
c. Somewhat unsafe
d. Very unsafe
e. Refused
f. Don’t know

Household experience of violence, crime and justice

Have you or has anyone in your household been the victim of the following types of violence or
criminal act in the past year?

Ye No Refused Don’t know

s
Theft
Physical assault/ beating
Assault with weapon
Racketeering/ extortion
Burglary/ breaking and entering / looting
Property stolen/ livestock stolen
Kidnapping
Murder/ murder attempt
Sexual violence
Human trafficking
Physical exploitation faced in course of outside of home
Financial exploitation
Other specify

Thinking back over the past 12 months, how often have you or your household.

Alway Often Sometimes Never Not Refused Don’t

s applicable know
Skipped a meal
because you didn’t
have money to buy
food
Gone without medical
treatment or medicine
because did not have
money
Not been able to send
children to school
because of lack of
money for transport
or uniform or other
school costs

If your household were involved in a dispute over domestic violence (gharelu hinsha), from whom
would you ask for help to resolve it? (IF ASKED: by domestic violence we mean a behavior which
involves violence or other abuse by one person against another in a domestic setting, such as in
marriage or cohabitation).
 Dispute Dispute over dept. Domestic Victims of crimes
over violence
land
Mayor/ rural municipality chair
Village municipality assembly
Ward chairperson/ member
Member of provincial assembly
Member of federal parliament
Civil servants
Member of district coordination
committee
Provincial ministers
Army
Police
Lawyer
Judicial committee
Teacher
District court
Traditional justice (community leaders,
elders/headmen, unofficial panchayat,
religious entity etc.)
Dialogue group
Social worker / social mobilizer
Women’s group
Religious/caste/ethnic leader
Local business person
Friends and family
I can rely on myself and solve it myself

In the past twelve months, have you taken any of the following precautions for fear of being
physically hurt or sexually assaulted?

Never Sometimes Often All the time Never Refused Don’t know
Avoided going out of
your house on your own
Avoided taking certain
streets/roads or going to
certain areas
Avoided being around
 certain people you are
afraid might hurt or
sexually assault you
Are you afraid for your
safety inside your own
home?
Taken safety measures
inside your own home

IDENTITY
I would now like to ask some questions about identity.

a. Mother tongue, identity and access to services

1. Is Nepali your mother tongue? (IF ASKED: by mother tongue, we mean the first
language you learned while growing up)

i. Yes
ii. No
iii. Refused
iv. Don’t know

Do you feel disadvantaged because you cannot use your mother tongue, instead of Nepali, in the
following situations?

No Total Little Problem Don’t

problem problem problem but has no know
advantage
When interacting with other people at
work/ clients
When you go to public offices to report
problem( police office etc)
When you go to government office to
obtain some public services such as
citizenship, marriage/birth/death
certificates
When you go in banks for deposits
When going to the health posts
When studying in school/ college etc

Overall, do you think relations between people from different ethnicity, religion or caste are
improving, getting worse or remain more or less the same in Nepal?
a. Improving
 b. Getting worse
c. The same
d. Refused
e. Don’t know
If you think improving, reason why you think relations are improving?

People pay less attention to caste/ethnic/religious differences these days, they are less
important for them

There is greater recognition/protection of the rights of all ethnicities, religions and

castes by authorities

There is greater representation of all ethnicities, religions and castes in the parliament
and government

People know their place better. They do not try to question or change the traditional
social order as much as they did

If you think getting worse, reason why you think relations are getting worse?

People pay more attention to caste/ethnic/religious differences these days.

There is too much attention to the rights of minorities and lower castes.
There is still not enough attention to the rights of minorities and lower castes.
There is not much representation of minorities and lower castes in the parliament and
government.
Political parties/leaders are playing up caste, ethnic and religious divisions
Caste/ethnicity-based parties were defeated in local elections.
People don’t know their place in society anymore.
They question the traditional order too much.
The authorities still do not pay enough attention to fulfill the obligations toward
constitutional recognition/protection of the rights of all ethnicities, religions and castes
Other specify

Would you accept that your son or daughter marry someone from a different caste?

a. Yes
b. No
 Women and Gender related attitudes

Now I am going to read statements about women and men and their position in society. Would you
please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with
these statements?

Strongly Somewhat Somewhat Strongl Refused Don’t

agree agree disagree y know
disagree
It is more important for a family to have a
son than a daughter
A higher education is more important for a
boy than for a girl
Women should be encouraged to work
outside the home
It is not suitable for women to engage in
politics
Women should have no control over her
income, movement and decisions
A woman has the right to decide how many
children she should bear.
It is okay for a wife to seek community
mediation if she has problems in the house.
If a wife does not obey her husband, he has
the right to punish her
To be a man, you need to be tough

The participation of the father is important

in raising children
When job opportunities are limited, men
should have more right to a job
It is a man’s responsibility to fulfil financial
needs for his family.

If you were to be born again, would you want to be born as?

a. Woman
b. Man
c. Others
d. No difference
e. Refused

In your opinion, in our country, society generally favors...

 Men, women and others equally
Men over women and others
Women and others over men

Respondent’s experience of public services / organization related

Are you aware of services provided by your local government?
a. Yes
b. No
c. Refused
d. Don’t know

If yes, Name major services

Educatio Road Drinking Employmen Electricity healt Managemen Solid waste Drainage
n water t h t of public managemen
spaces t
Irrigation Agricultur Managemen Disaster Environmen Other Refused Don’t know Market
e / t of elderly managemen t protection managemen
livestock t t
services

During the past one year, what services have you received through the municipality office,
including ward office?

An identity document (such as Birth/death/marriage/migration certificate

Recommendation for citizenship
Other recommendations
Social Security Allowances (Single women, senior citizen, )
Employment-related services
None
Divorce
Services support from judicial committee
Land related services
Others
Now I would like to ask you about your experience in accessing certain public services in your
municipality/rural municipality. Based on your experience, how easy or difficult is it to obtain the
following services?

Very Easy Difficul Very Never Refuse Don’t

easy t difficult tried d know
An identity document (such as
citizenship card, birth certificate
A place in primary public school
 for a child
Medical treatment at the local
health post or hospital
Help from police when you need
it
Access to social security benefits
Services support from the
Judicial Committee

Why do you think that it is “difficult” or “very difficult” to access public services in your
municipality/rural municipality?

Delay in providing services

Municipality officials’ non-responsible attitude
/bureaucratic hurdles
Bribery
There is political influence in the services
provided
Incapacity of municipality officials
Complicated process (e.g.lengthy forms)
Discriminatory behavior
Others
Refused
Don’t know/ can’t say

ECONOMIC OUTLOOK AND OPPORTUNITIES

Views on economic outlook
Do you think economic conditions in your community are improving?
1. Yes, economic conditions are improving
2. Economic conditions are staying the same
3. No, economic conditions are getting worse

If economic conditions improving, why do you think that economic conditions are improving in
your community?

Better infrastructure
Overall there is progress
More investment
Easier to find work
Water supply is improving
Better government support services
 It is easier for women to work
Easier to access market to sell products
Better roads
Less corruption/ bribes
More opportunities for labor migration
Better access to training
More ngos and ingos for welfare
Work pays more
Remittance are increasing
Homestay business is improving
Easier to get loan, find capital
Other specify
Refused
Don’t know/ can’t say

If economic conditions are getting worse, in your view, why are economic conditions in your getting
worse in your community?

More corruptions/ bribes

Harder to find work
Overall there is little progress
Less opportunities for labor migration
Infrastructure getting worse
Less investment
Work pay less
Government support services are getting worse
Harder to access market to sell products
Poor roads
Less access to training
The water supply is getting worse
It is worse for women to get work
Prices of goods are getting high
Prices for what I sell are getting down
Other specify
Don’t know
Refused

Migration
Is anyone in your family currently in a foreign country for work?
a. Yes
b. No
If yes, how many: _____
No one in my family is currently living abroad ____
Refused
Don’t know
Remittances

Have you or family members ever received remittance from inside or outside the country?
a. Yes, from inside Nepal only
b. Yes, from outside Nepal only
c. Yes, from both inside and outside Nepal.
d. Refused
e. Skip to section
f. Don’t know

Are there any social organizations or program in this community?

Literacy programme
Women’s group
Youth group
Boy scouts
Clubs
Cooperatives
Guthi or gosthi
Farmer’s organisations
None
Other specify
Don’t know
Refused

Have you or anyone in your family, ever participated in any community activity?

Street cleaning
Shared farm labour
Free labour for construction
Free labour for agriculture( parma/ mela)
None
Other specify
Don’t know

ACCESS TO INFORMATION
Now I would like to finish with a few questions about information and the media. How many of the
following types of mobile phones do you own?
a. Simple mobile phone ________________________
b. Smart phone (Android, iPhone etc.) _____________
c. Refused
 d. Don’t know

Do you ever use internet (social media/ Facebook/ twitter etc.)

a. Yes
b. No
c. Refused
d. Don’t know
If YES: How often do you use internet:
a. several hours a day,
b. about half an hour to one hour a day,
c. at least once a day,
d. at least once a week,
e. at least once a month,
f. a few times a year, hardly ever or never

How do you normally get information about what is happening in the country or in the area where
you live? Is there any other way you get information about what is happening in the country?

Television
Radio Nepal
Community radio/ FM radio
National newspaper
Local news paper
Internet
Social media
SMS on mobile
Local community leader
Government official
Ward office
Community-based group (women’s group,
savings and credit etc.)

Political parties
Friends and family and neighbors
Market
Leaflets, posters
Civil society/ NGOs
Other specify
Don’t know
Refused

ECONOMIC PROFILE
3.1 What is your main source of income?
1. Government job, specify …………………………………………
2. Business, specify …………………………………………
3. Other waged job, specify …………………………………………
4. Farming …………………………………………
5. Irregular (works less than half year) …………………………………………
6. Manual labor/ construction work …………………………………………
7. Service abroad …………………………………………
8. Tourism …………………………………………
9. Shopkeeper …………………………………………
10. Remittance ………………………………………..
10. Other specify
…………………………………………

3.2 PER MONTH EARNING

1. Less than 1000
2. 1000- 5000
3. 5000- 10000
4. 10000- 15000
5. 15000- 20000
6. More than 20000, specify……………………………………………………………
3.3 Is this all about the same all year around
1. Yes 2. No

3.3.2 Who decides what money is spent on( major items such as land, festivals, education etc.)
1. Wife
2. Father
3. Mother
4. Self and wife
5. Brother
6. Sister
7. Uncle
8. Son
9. Daughter
10. Other specify
3.6 Who keeps money for day to day expenses?
1. Wife
2. Father
3. Mother
4. Self and wife
5. Brother
6. Sister
7. Uncle
8. Son
9. Daughter
10. Other specify

3.7 Does anyone else in the household earn? Who?

1. No one
2. Father
3. Wife
4. Father
5. Mother
6. Self and wife
7. Brother
8. Sister
9. Uncle
10. Son
11. Daughter
12. Other specify
Accept up to four answers if there is more than one wage earner

3.8 On what five main items do you spend your money every month?
1. Food
2. Fests and festivals
3. Transport
4. Education
5. Alcohol and tobacco
6. Clothing
7. Farming and manual work
8. Medicine
9. Electricity
10. Other specify

3.9 do you owe anyone money (over Rs 5000)

a. yes b. no
3.9.2 If yes, who to
1. Family member
2. Neighbor / friend
3. Bank
4. Money lender
5. other, specify ……………………..

3.9.1 What did you borrow the money for?

1. Household expenses
2. Business purpose
3. House building
4. Social expenses (wedding etc.)
5. Medical expenses
6. Other specify……………………….

4. Physical infrastructure
4.1 main material of house
1. Fired brick
2. Breeze block
3. Natural material (mud, bamboo etc.)
4. Cemented
5. Cement and wood
7. Stone and mud
6. Other specify

4.2 roofing
1. Tile
2. Thatch
3. Zinc and iron
4. Other specify

4.3 No of storey
1. Ground floor only
2. Ground and 1st
3. Ground 1st and 2nd
4. More specify
4.4 electricity supply to the house
a. Yes b. no
4.4 is there a sullage pipe for waste water (kitchen waste, bathroom waste etc.). Where does it
drain to?
a. yes – it drains to………………………………………………………………….
b. no

4.5 what fuel do you use for cooking

a. wood
b. kerosene
c. electricity
d. dung
e. agricultural by product ( gobar gas)
f. LP gas
g. other specify……………………………..