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Questions marked with a * are required Exit Survey
 
 
* Name of the Investigator:
   
 
 
 
* Date:
DayMonthYear
  
 
 
 
* Questionnaire No.:
   
 
 
 
* ID No. (Village/Category/No.):
   
 
 
 
* Name of the Village:
   
 
 
 
* Name of the Panchayat:
   
 
 
 
* District:
   
 
 
 
* Name of the Respondent::
   
 
 
 
* Relationship with the titleholder/Head of the affected household:
   
 
 
 
* Religion