REGN NO: E29814
CSR NO: CSR00019712
NITI AAYOG NO: MH/2020/0271494
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Survey Form
1. Personal & Family Information
Personal Information
Full Name
*
Mobile Number
*
Email Address
WhatsApp Number
Date of Birth
*
Education
*
Age
Gender
Select Gender
Male
Female
Other
Marital Status
Select Status
Single
Married
Widow
Divorced
Photograph
Address Information
Village
*
District
Address
Family Details
Total Family Members
Adults
Children
2. Income & Employment
Income Details
Monthly Income
Select Monthly Income
Below ₹5,000
₹5,000–₹10,000
₹10,000–₹20,000
Above ₹20,000
Income Source
Select Income Source
Salary
Business
Labour
Agriculture
None
Employment Status
Employment Status
Select Employment Status
Student
Unemployed
Self-employed
Private Job
Government Job
Daily Wage
Homemaker
Employment / Job Details
Occupation
*
Currently Working
Yes
No
Interested Job Role
*
Select Role
Domestic Worker
Housekeeping
Baby Sitter
Patient Care
Working Hours
*
Nothing Is Selected
2 Hours
4 Hours
6 Hours
8 Hours
10 Hours
12 Hours
24 Hours
3. Skills & Support
Disability Information
Any Disability?
Select
Yes
No
Type of Disability
Disability Percentage
Disability Certificate
Government Scheme
Do you receive any Government Benefits?
Select
Yes
No
Which Scheme?
Skills
Select Skills
Computer
Tailoring
Housekeeping
Electrician
Beauty
Cooking
Driving
Data Entry
Other
Training Required
Which training are you interested in?
Housekeeping
Elderly care
Culinary Arts
Child Care
Baby sitting
Data Entry
4. Documents & Banking
Documents Available
Select Available Documents
Aadhaar
PAN
Ration Card
Bank Passbook
Disability Certificate
Income Certificate
Caste Certificate
Bank Details (Optional)
Bank Name
Account Number
IFSC Code
5. Contact & Survey Information
Emergency Contact
Emergency Contact Name
Relationship
Mobile Number
Referral Source
How did you know about us?
Select Source
Facebook
Instagram
Friend
Volunteer
School
Hospital
CSR Company
Website
GPS Location
Latitude
Longitude
Capture Current Location
Survey Details
Form Filled By
Self
Other
Executive Name
Aadhaar Number
*
Interest Status
*
Interested
Not Interested
Survey Date
6. Consent & Submission
Consent
I agree that Child Vision Foundation may use this information for welfare programmes.
*
Signature
Beneficiary Signature
Surveyor Signature
Suggestions / Remarks
Submit Survey
