indian emblem भारत सरकार | सामाजिक न्याय और अधिकारिता मंत्रालय
Ministry of Social Justice and Empowerment
Government of India
Need Assessment Survey
1. Village Level Data:
S. No. Particulars Name LGD Code
1. State*:
2. District*:
3. Block*:
4. Gram Panchayat*:
5. Village*:
6. Population of Village: (according to census, 2011):
7. SC Population of Village (according to census, 2011):
8. No. of Households as on Date*:
9. Current Total Population of Village/GP:
10. Current SC Population of Village/GP:
11. Period of Need Assessment/Household Survey*: From:
To:
2. GPS Data:
1. GPS Coordinates of Village: Latitude:
Longitude:
3. Details of Village PMAGY Convergence Committee (Minimum 5 members should be in Village Level Convergence Committee (VLCC)):
S. No. Name* Designation* Mobile Number* Email Address* Remarks
S. No. Particulars Name LGD Code
1. State*:
2. District*:
3. Block*:
4. Gram Panchayat*:
5. Village*:
1.Domain: Drinking water and Sanitation
  • 1.1 Monitorable Indicator: Whether there are adequate sustainable drinking water sources to cover the village available?
S. No. Particulars Status/No./Name
1. Whether adequate sustainable drinking water sources to cover the village are available?*
S. No. Details of action plan for providing additional drinking water sources for the village(Please provide Itemised list of works / initiatives identified)*
1
  • 1.2 Monitorable Indicator: % of households provided with clean drinking water
S. No. Particulars Status/No./Name
1. No. of households in the Village*
2. No. of households provided with clean drinking water*
3. No. of households not provided with clean drinking water*
S. No. Details of action plan for providing clean drinking water to all the households(Please provide Itemised list of works / initiatives identified)*
1
  • 1.4 Monitorable Indicator: Have toilets been provided in all Schools & Anganwadis in the village?
S. No. Particulars Status/No./Name
1. No. of Schools in Village*
2. No. of Anganwadis in Village*
3. No. of Schools having toilets*
4. No. of Anganwadis having toilets*
5. No. of Schools where toilets are to be constructed*
6. No. of Anganwadis where toilets are to be constructed*
7. Names of Schools where toilets are to be constructed*
8. Names of Anganwadis where toilets are to be constructed*
S. No. Details of action plan for construction of Toilets in Schools and Anganwadis(Please provide Itemised list of works / initiatives identified)*
1
  • 1.6 Monitorable Indicator: % of drains available along all internal roads
S. No. Particulars Status/No./Name
1. Total length (In Metres) of internal roads in the village*
2. Total length (In Metres) of drains already available along internal roads*
3. Total length (In Metres) of drains still to be constructed along internal roads*
S. No. Details of action plan for construction of drains along all internal roads(Please provide Itemised list of works / initiatives identified)*
1
  • 1.7 Monitorable Indicator: % of existing drains functioning
S. No. Particulars Status/No./Name
1. Total length (In Metres) of drains already available along internal roads*
2. Total length (In Metres) of drains functional*
3. Total length (In Metres) of drains to be made functional*
S. No. Details of action plan for making all the drains functional(Please provide Itemised list of works / initiatives identified)*
1
  • 1.8 Monitorable Indicator: % of solid and liquid waste being disposed effectively
S. No. Particulars Status/No./Name
1. Total volume of Solid waste (In Liters) generated during a month*
2. Total volume of Liquid waste (In Liters) generated during a month*
3. Volume of Solid waste (In Liters) disposed properly in a month*
4. Volume of Liquid waste (In Liters) disposed properly in a month*
5. Volume of Solid waste (In Liters) disposal capacity still to be added*
6. Volume of Liquid waste (In Liters) disposal capacity still to be added*
S. No. Details of action plan for 100% disposal of solid and liquid waste in the village(Please provide Itemised list of works / initiatives identified)*
1
3.Domain: Health and Nutrition
  • 3.2 Monitorable Indicator: Is an emergency Ambulance facility available on call?
S. No. Particulars Status/No./Name
1. Is an emergency Ambulance facility available on call?*
S. No. Details of action plan for making available emergency Ambulance Facility(Please provide Itemised list of works / initiatives identified)*
1
  • 3.11 Monitorable Indicator: Whether all Anganwadis are constructed?
S. No. Particulars Status/No./Name
1. No. of Anganwadis in the village*
2. No. of Anganwadis with own building*
3. No. of Anganwadis which are to be constructed*
4. Location of Anganwadis which are to be constructed*
S. No. Details of action plan for construction of Anganwadis(Please provide Itemised list of works / initiatives identified)*
1
5.Domain: Rural Roads and Housing
  • 5.1 Monitorable Indicator: Is the village connected by all-weather road?
S. No. Particulars Status/No./Name
1. Is the village connected by all-weather road?*
S. No. Details of action plan for providing all weather road connectivity to village(Please provide Itemised list of works / initiatives identified)*
1
  • 5.2 Monitorable Indicator: % of internal roads that are CC/brick top/ Pakka/Tiled
S. No. Particulars Status/No./Name
1. Total length (In Metres) of internal roads in the village*
2. Length (In Metres) of internal roads (CC/brick top/Pakka/Tiled)*
3. Length (In Metres) of internal roads (CC/brick top/Pakka/Tiled) to be constructed*
S. No. Details of action plan for providing CC/brick top/Pakka/Tiled roads(Please provide Itemised list of works / initiatives identified)*
1
6.Domain: Electricity and Clean Fuel
  • 6.1 Monitorable Indicator: Whether the village has been electrified?
S. No. Particulars Status/No./Name
1. Whether the village has been electrified?*
S. No. Details of action plan for electrifying the Village(Please provide Itemised list of works / initiatives identified)*
1
  • 6.2 Monitorable Indicator: % of households having electricity connection
S. No. Particulars Status/No./Name
1. No. of households in the village*
2. No. of households having electricity connection*
3. No. of households not having electricity connection*
S. No. Details of action plan for providing electricity connection to all households(Please provide Itemised list of works / initiatives identified)*
1
  • 6.5 Monitorable Indicator: % of internal roads having street lights
S. No. Particulars Status/No./Name
1. Total length (In Metres) of internal roads*
2. Length (In Metres) of internal roads having street lights*
3. Length (In Metres) of internal roads not having street lights*
S. No. Details of action plan for 100% coverage of internal roads by street lighting(Please provide Itemised list of works / initiatives identified)*
1
9.Domain: Digitization
  • 9.1 Monitorable Indicator: Does the village have access to Internet connectivity?
S. No. Particulars Status/No./Name
1. Does the village have access to Internet connectivity?*
S. No. Details of action plan for providing Internet Connectivity to the village(Please provide Itemised list of works / initiatives identified)*
1
  • 9.2 Monitorable Indicator: Does the village have Common Service Centre or Cyber Cafe?
S. No. Particulars Status/No./Name
1. Does the village have Common Service Centre or Cyber Cafe?*
S. No. Details of action plan for providing Common Service Centre or Cyber Cafe in the village(Please provide Itemised list of works / initiatives identified)*
1
S. No. Particulars Name LGD Code
1. State*:
2. District*:
3. Block*:
4. Gram Panchayat*:
5. Village*:
6. Category (SC/ST/Others)*:
7. Have you entered details earlier*:
8. House Number/ Address*:
9. Name of the Head of the household*:
10. Number of persons in the household*:
11. Mobile Number (Optional):
1.Domain: Drinking water and Sanitation
  • 1.3 Monitorable Indicator: % of households having Individual Household Latrines (IHHLs)*
S. No. Particulars Status/No./Name
1. Does the household have Individual Household Latrine (IHHL)?
2. Is the household eligible for Individual Household Latrine (IHHL) under Swachh Bharat Mission - Gramin (SBM-G) / any other scheme(s)?
3. Name of household member to whom IHHL to be provided under SBM-G / any other scheme(s)
  • 1.5 Monitorable Indicator: Whether people are still defecating in the open in the village*
S. No. Particulars Status/No./Name
1. Whether people in the household are still defecating in the open?
2.Domain: Education
  • 2.1 Monitorable Indicator: % of children (6-10 years), both boys and girls, attending primary schools*
S. No. Particulars Status/No./Name
1. Total no. of children in the household (6-10 years), both boys and girls
2. No. of children in the household (6-10 years), both boys and girls attending primary school
3. No. of children in the household (6-10 years), both boys and girls not attending primary school
4. Name(s) of children in the household (6-10 years), both boys and girls not attending primary school
  • 2.2 Monitorable Indicator: % of children (11-13 years), both boys and girls, attending middle school*
S. No. Particulars Status/No./Name
1. No. of children in the household (11-13 years), both boys and girls
2. No. of children in the household (11-13 years), both boys and girls attending middle school
3. No. of children in the household (11-13 years), both boys and girls not attending middle school
4. Name(s) of children in the household (11-13 years), both boys and girls not attending middle school
  • 2.3 Monitorable Indicator: % of children (14-15 years), both boys and girls, attending secondary school*
S. No. Particulars Status/No./Name
1. No. of children in the household (14-15 years), both boys and girls
2. No. of children in the household (14-15 years), both boys and girls attending secondary school
3. No. of children in the household (14-15 years), both boys and girls not attending secondary school
4. Name(s) of children in the household (14-15 years), both boys and girls not attending secondary school
  • 2.4 Monitorable Indicator: % of children (16-17 years), both boys and girls, attending higher secondary school*
S. No. Particulars Status/No./Name
1. No. of children in the household (16-17 years), both boys and girls
2. No. of children in the household (16-17 years), both boys and girls attending higher secondary school
3. No. of children in the household (16-17 years), both boys and girls not attending higher secondary school
4. Name(s) of children in the household (16-17 years), both boys and girls not attending higher secondary school
  • 2.5 Monitorable Indicator: % of children (18-23 years), both boys and girls, attending post higher secondary education*
S. No. Particulars Status/No./Name
1. No. of children in the household (18-23 years), both boys and girls
2. No. of children in the household (18-23 years), both boys and girls attending post higher secondary education
3. No. of children in the household (18-23 years), both boys and girls not attending post higher secondary education
4. Name(s) of children in the household (18-23 years), both boys and girls not attending post higher secondary education
  • 2.6 Monitorable Indicator: % of SC children (out of those attending school & eligible) receiving pre-matric scholarship*
S. No. Particulars Status/No./Name
1. No. of children eligible for getting the Pre-matric Scholarship for SC Students
2. No. of children (out of 1 above) receiving Pre-matric Scholarship for SC students
3. No. of children (out of 1 above) not receiving Pre-matric Scholarship for SC students
4. Name(s) of children (out of 1 above) not receiving Pre-matric Scholarship for SC students
  • 2.7 Monitorable Indicator: % of SC children (out of those pursuing post matric education and eligible) receiving post-matric scholarship*
S. No. Particulars Status/No./Name
1. No. of children eligible for getting the Post-matric Scholarship for SC Students
2. No. of children (out of 1 above) receiving Post-matric Scholarship for SC students
3. No. of children (out of 1 above) not receiving Post-matric Scholarship for SC students
4. Name(s) of children (out of 1 above) not receiving Post-matric Scholarship for SC students
3.Domain: Health and Nutrition
  • 3.1 Monitorable Indicator: % of eligible households covered under any Health Protection Scheme*
S. No. Particulars Status/No./Name
1. Is the household covered under any Health Protection Scheme(s)?
2. Is the household eligible to be covered under any Health Protection Scheme(s)?
3. Name of household member to be covered under any Health Protection Scheme(s)?
  • 3.3 Monitorable Indicator: % of pregnant women who are severely anaemic*
S. No. Particulars Status/No./Name
1. No. of women in the household who are pregnant
2. No. of pregnant women in the household who are severely anaemic
3. Name(s) of pregnant women in the household who are severely anaemic
  • 3.4 Monitorable Indicator: % of institutional deliveries in the village during the last one year*
S. No. Particulars Status/No./Name
1. No. of deliveries in the household during the last one year
2. No. of Non institutional deliveries in the household during the last one year
3. Name(s) of pregnant women who had non-institutional delivery and reasons thereof
  • 3.5 Monitorable Indicator: % of low birth weight children born during the last one year*
S. No. Particulars Status/No./Name
1. No. of children born during the last one year in the household
2. No. of low birth weight children born during the last one year in the household
3. Name(s) of low birth weight children born and reasons thereof
  • 3.6 Monitorable Indicator: % of full immunization of children (< 1 year)*
S. No. Particulars Status/No./Name
1. No. of children below one year in household
2. No. of children (< 1 year) not immunized
3. Name(s) of children (< 1 year) not immunized
  • 3.7 Monitorable Indicator: % of underweight children (0-5 years) in the village*
S. No. Particulars Status/No./Name
1. No. of children (0-5 years) in the household
2. No. of underweight children (0-5 years)
3. Name(s) of underweight children (0-5 years)
  • 3.8 Monitorable Indicator: How many pregnant women died during the last one year?*
S. No. Particulars Status/No./Name
1. No. of women of the household who were pregnant during the last one year?
2. No. of pregnant women of the household who died during the last one year?
3. Name(s) of pregnant women of the household who died during the last one year and reasons thereof
  • 3.9 Monitorable Indicator: How many children (< 1 year) died during the last one year?*
S. No. Particulars Status/No./Name
1. No. of children (< 1 year) in the household
2. How many children (< 1 year) of the household died during the last one year?
3. Name(s) of children (< 1 year) of the household who died during the last one year and reasons thereof
  • 3.10 Monitorable Indicator: % of persons with communicable diseases getting treatment as per protocol*
S. No. Particulars Status/No./Name
1. No. of household members suffering from communicable diseases
2. No. of household members suffering from communicable diseases and getting treatment as per protocol
3. No. of household members suffering from communicable diseases and not getting treatment as per protocol
4. Name(s) household members suffering from communicable diseases and not getting treatment as per protocol
4.Domain: Social Security
  • 4.1 Monitorable Indicator: % of eligible women provided with Widow Pension*
S. No. Particulars Status/No./Name
1. No. of women in the household eligible for Widow Pension
2. No. of eligible women in the household already provided with Widow Pension
3. No. of eligible women in the household not provided with Widow Pension
4. Name(s) of eligible women in the household not provided with Widow Pension
  • 4.2 Monitorable Indicator: % of eligible persons provided with Old Age Pension*
S. No. Particulars Status/No./Name
1. No. of persons in the household who are eligible for Old Age Pension
2. No. of eligible persons already provided with Old Age Pension
3. No. of eligible persons not provided with Old Age Pension
4. Name(s) of eligible persons not provided with Old Age Pension
  • 4.3 Monitorable Indicator: % of eligible persons provided with Disability Pension*
S. No. Particulars Status/No./Name
1. No. of persons in the household eligible for Disability Pension
2. No. of eligible persons already provided with Disability Pension
3. No. of eligible persons not provided with Disability Pension
4. Name(s) of eligible persons not provided with Disability Pension
5.Domain: Rural Roads and Housing
  • 5.3 Monitorable Indicator: % of households living in Kachcha/unsafe houses*
S. No. Particulars Status/No./Name
1. Does the household live in Kachcha/unsafe house?
2. Is the household eligible for a house under Pradhan Mantri Awas Yojana - Gramin (PMAY-G) / any other scheme(s)
3. Name of household member is to be provided house under PMAY-G / any other scheme(s)
6.Domain: Electricity and Clean Fuel
  • 6.2 Monitorable Indicator: % of households having electricity connection*
S. No. Particulars Status/No./Name
1. Does the house have electricity connection?
2. Is the household eligible for an Electricity connection under the SAUBHAGYA Scheme / any other scheme(s)
3. Name of household member to whom Electricity connection is to be provided under the SAUBHAGYA Scheme / any other scheme(s)
  • 6.3 Monitorable Indicator: % of households using at least one LED bulb*
S. No. Particulars Status/No./Name
1. Does the house have electricity connection?
2. Is the house using at least one LED bulb?
3. The name of household member to whom LED bulb is to be provided under the UJALA Scheme / any other scheme(s)
  • 6.4 Monitorable Indicator: % of households having Gas connection*
S. No. Particulars Status/No./Name
1. Does the house use clean fuel?
2. Is the house eligible for gas connection under UJJAWALA Yojana / any other scheme(s)?
3. Name of the household member to whom Gas connection is to be provided under UJJAWALA scheme / any other scheme(s)
7.Domain: Agricultural Practices etc.
  • 7.1 Monitorable Indicator: % of eligible farmers provided with Soil Health Card*
S. No. Particulars Status/No./Name
1. Is the household involved in farming
2. Is the household eligible for Soil Health Card?
3. Whether the household already having Soil Health Card?
4. Name of household member to whom Soil Health Card is to be provided
  • 7.2 Monitorable Indicator: Extent (in %) of organic farming practices adopted*
S. No. Particulars Status/No./Name
1. Is the household involved in farming?
2. Has the household adopted organic farming practices?
3. Is the household ready to adopt organic farming practices?
4. Name of household member who desires to adopt organic farming practices
  • 7.3 Monitorable Indicator: Extent (in %) of watershed management practices adopted*
S. No. Particulars Status/No./Name
1. Is the household involved in farming?
2. Has the household adopted watershed management practices?
3. Does the household want to adopt watershed management practices?
4. Name of household member who wants to adopt watershed management practices
8.Domain: Financial Inclusion
  • 8.1 Monitorable Indicator: % of village population (> 5 years) having Aadhaar identification*
S. No. Particulars Status/No./Name
1. No. of persons (> 5 years) in the household
2. No. of household members (> 5 years) who already have Aadhaar
3. No. of household members (> 5 years) who don’t have Aadhaar
4. Name(s) of household members (> 5 years) who don’t have Aadhaar
  • 8.2 Monitorable Indicator: % of households having account in Banks/Post Office*
S. No. Particulars Status/No./Name
1. No. of members (above 18 years) in the household who are eligible for opening an account in Banks/Post Office
2. No. of eligible household members who have an account in Banks/Post Office
3. No. of eligible household members who do not have an account in Banks/Post Office
4. Name(s) of eligible household members who do not have an account in Banks/Post Office
  • 8.3 Monitorable Indicator: % of eligible persons covered under Pradhan Mantri Suraksha Bima Yojana (PMSBY)*
S. No. Particulars Status/No./Name
1. No. of persons (18-70 years) in the household who are eligible for coverage under Pradhan Mantri Suraksha Bima Yojana / any other scheme(s)
2. No. of eligible household members not covered under Pradhan Mantri Suraksha Bima Yojana / any other scheme(s)
3. Name(s) of eligible household members not covered under Pradhan Mantri Suraksha Bima Yojana / any other scheme(s)
  • 8.4 Monitorable Indicator: % of eligible persons covered under Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY)*
S. No. Particulars Status/No./Name
1. No. of household members (18-50 years) eligible for coverage under Pradhan Mantri Jeevan Jyoti Bima Yojana / any other scheme(s)
2. No. of eligible household members not covered under Pradhan Mantri Jeevan Jyoti Bima Yojana / any other scheme(s)
3. Name(s) of eligible household members not covered under Pradhan Mantri Jeevan Jyoti Bima Yojana / any other scheme(s)
9.Domain: Digitization
  • 9.3 Monitorable Indicator: % of eligible persons who are digitally literate*
S. No. Particulars Status/No./Name
1. No. of household members (14-60 years) who are eligible for getting training under Pradhan Mantri Gramin Digital Saksharta Abhiyan (PMGDISHA) / any other scheme(s)
2. No. of eligible household members who are digitally literate
3. No. of eligible household members who are to be given the training under PMGDISHA / any other scheme(s)
4. Name(s) of eligible household members who are to be given the training under PMGDISHA / any other scheme(s)
10.Domain: Livelihood and Skill Development
  • 10.1 Monitorable Indicator: % of eligible youth undergoing skill development*
S. No. Particulars Status/No./Name
1. No. of youth in the household who are eligible to get skill development training
2. No. of eligible youth in the household to whom skill development training already given
3. No. of eligible youth in the household to whom skill development training to be given
4. Name(s) of eligible youth in the household to whom skill development training to be given
  • 10.2 Monitorable Indicator: % of eligible youth who have been able to avail bank linked loans*
S. No. Particulars Status/No./Name
1. No. of youth in the household eligible for availing bank linked loans
2. No. of eligible youth in the household who have been able to avail bank linked loans
3. No. of eligible youth in the household who have not been able to avail bank linked loans however wish to avail now
4. Name(s) of eligible youth in the household who wish to avail bank linked loans
  • 10.3 Monitorable Indicator: % of households which have at least one member as a member of any SHG*
S. No. Particulars Status/No./Name
1. Is any member of the household a member of any self-help group (SHG) ?
2. No. of members who wish to become member of a SHG
3. Name(s) of such members