DEPARTMENT OF COMMUNITY MEDICINEVMCH&RI

II M.B.B.S., VILLAGE HEALTH SURVEY

Guidelines for Filling up the Proforma

Interview as far as possible the head of the family or wife of the head of

the family. If this is not possible interview a responsible adult member of the family

who will be able to furnish the details of the household members.

House No : Denotes building Number

Household No : Family/ies residing in the building

Name of the informant : Information provider ( to be an adult of the family)

Name : To start with the name of the head of the household

Head of the family : Eldest male earning member of the family. If not Possible take the opinion of the family.

Age : Record in completed years. Check the age with the. important events in their life.

Relationship to Head : Enter as head / son / daughter / father / mother / Sister / etc…

Marital Status : Follow the code

Literacy status : Record only for those who have attended formal Schooling.

Education : Follow the code

Income : Monthly income.Record for all the members. For those who are not Working enter as student / housewife / dependent

Occupation : Record for all the members. If not working Follow the code given below

If the occupation is agriculture use the following abbreviation:

L- Land Owner * A person who owns land, employ others to cultivate his land and he himself does not work in the field (or) A person who owns land and leases to a tenant to cultivate it.

CO – Cultivator Owner * A person who owns land and cultivates it himself; may also in addition hire other people to work in his land.

CT – Cultivator Tenant * He gets the land on lease basis from some one else and he cultivated it. He may also hire other people to work.

LAL – Landless Agricultural Labourer * A person who works for wages

(in cash or kind)

In case, a person can be classified in more than one classification, select the highest.

For other than agriculture record the name of the occupation, Occupation is to be filled for all persons. If not employed use abbreviation given below.

HW* - Housewife

RT - Retired

D - Disabled

O - Old age (aged 60 and above)

S - Student

UN - Unemployed

PS - Children under 5 years

HHW* - Housewife needs to be distinguished from an unmarried girl who does domestic work.

Type of house:

Hut : Thatched roof, mud / thatched wall and mud flooring.

Semi pucca : Thatched roof, cemented wall and cemented flooring.

Pucca : Tiled / concrete roof, cemented wall and cemented flooring.

Distance of sourceof drinking water : Enter in feet

Overcrowding : Convert the family members into consumption units.

Adult : 1 unit

Children (1-10 years) : Half unit

Infants : Not to be consideredOccupation:

Skilled : Specialised training, knowledge, ability and experience to acquire a high degree of proficiency. Ex: Teacher

Unskilled : Requires very little training, knowledge. Ex: manual Labourers

Skilled : Intermediate between skilled and unskilled. It requires moderate training, knowledge and ability. Ex: Drivers

Past History

Eligible Couple : Currently married couple wherein the female component is in the age group of 15 –49.

Whether to collect data on this page (i.e. Past history) can be checked with the first page.

If an EC gave birth to more than one child enter the data in all the columns for all the children one by one.

Registration : Registration means whether they have attended any health facility during pregnancy. Ex : PHC /Private/

RMMC&H /G.H.

For each pregnancy it has to be entered as Yes OR No

TT : Immunisation to mother Two doses

If pregnant with in five years of last immunization one dose

Present History

Trimester : Enter 1st,2nd or 3rd trimester OR months of pregnancy

IFA Recd : Whether received Iron and Folic Acid tablets. It has to be indicated as Yes or No

Prelacteal Feeding : What is given to the newborn before breastmilk. Ex: Sugar water

Time of initiation of Breastfeeding : When the child was breastfed. EX: Immediately / After One hour / Second day

How long Exclusively given : How many months the child is given only breast milk.

When stopped Completely : Complete stoppage of breast milk

Weaning : Gradual introduction of semisolid foods along with breast milk. It is not complete stoppage of breast milk.

Weaning Time Initiation : At what month started

Food started : Eg. Biscuit / Smashed vegetables

Immunisation :

Collected details for children who have completed one year but below 2 years.

Child Care:

Weight : Monthly / bimonthly / once in 3 months

Where ? : Balwadi / Sub Centre / Private Hospital / G.H.

Child Care:

Weight : Monthly / bimonthly / once in 3 months

Where ? : Balwadi / Sub Centre / Private Hospital / G.H.