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Appendix 2
Base Line Survey Form
Study Area: Bauniabad, Ward- 5, Thana- Mirpur, District- Dhaka
Survey period: November 2002
PRELIMINARY INFORMATION
Name of the Respondent: ______________________________________________Id No.: ___________
Name of Husband/Father of respondent: ________________________________________________
Sex: Male/Female
Block: ___________________________________________Lane: ______________________________
Name of the Interviewer______________________________
Date of Interview: _____________________________________
Start Time of Interview: _________________hr. ______________Minute___________________
End Time of Interview: __________________hr._______________Minute____________________
SOCIO ECONOMIC STATUS (SES)
Se-1: Family members’ description:
Se-2: How many members in your family are under or over the age of 5?
Se-2.1. Under 5 years old _________
Se_2.2. Over 5 years old__________
Se-3: What is the total/average income of the family? (Sum total of all members)_________________________
Se-4: Does your family possess the following items?
1. Almirah, 2. Table/chair/bench, 3. Wrist watch/wall clock, 4. Bed, 5. Bicycle/ricksha/boat,
6. Motor cycle/baby taxi, 7. Radio/cassette player, 8. TV, 9. Others___________
Se-5: Is the land where your house is built yours?
1. Yes, 2. Rented, 3. Not known, 4. Others_____________
COMMUNITY PARTICIPATORY ACTIVITIES
Se-6: Do you know how many committees/societies have been formed in your area? ______________
(e.g. Masjid committee, School committee, Environment committee, Water committee, Drainage/sanitation
committee, Biogas committee, Health committee, etc.)
Se-7: How many committees are you associated with?
Se-8: Are there many NGOs/GOs working in your area?
Yes=1, No=2
If yes, write the name and no. of NGOs/GOs.________________________________________________________
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