NCRD Servey Form (New General) Data Form

Data of NCRD Survey for BPL

1. Nearest Masjid/Temple/
HOUSE HOLD SUR VEY FORM
Cross Street / Main Road Ward No. Mobile No.Door No.
Taluk City/Town Mohalla / Area / LocalityDist
Church/Gurudwara
State ____________
RATION CARD: IF YES : IF BPL CARD HOLDER RECEIVING :
BPL APL AAY Free RationFree LPG Yes NoYes No
AUSHMAN BHARA TH AROGYA HEALTH SCHEME
Names of the
Family Members
Age
Relationship
to the head
of the Family
Whether
Receiving
Widow /
Old Age
Disabled
Pension
Level of
Education
1. Employed/
Unemployed
2. Profession/
Occupation
Specific
Details
Monthly
income
In Case of
Widows,
Husband‘s
Death
Certificate
Available
In Case of
Physically
Handicapped
Whether
Medical
Certificate
Available
Whether
attending
MADRASA
or
MAKTAB
Yes / No Voter ID Y / N
Aadhar
Y / N
Any Chronic
Diseases Like
Heart, Kidney,
Health Status
Suffering from
Cancer, Sugar,
Asthama,
T.B. Etc
Sl.
No
Voter List SL. No.
3 4 5 6 7 8 9 10 12 131411 15 1716
1
2
3
4
5
6
7
8
1 2 18 19
whether
going to
School
Yes / No
SC/ST/ OBC
Muslim/Hindu/
& Others
Christian
Constituency _________________________________ Booth No. __________
Accomodation: House / Hut Own / Rented Home-Less Site-Less
E Shram Card
20
Y / N
School / College/ Graduate
Whether
Orphan (O)
Widow (W)
Deserted by Husband (DH)
Disabled (D)
If Disabled
Kind of Disability
Blind/Deaf/Dumb
One Leg/Both Legs
One Hand/Both Hands
Polio, Etc.,
Divorcee