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Kohram Helpline Foundation
Foundation For Social Change
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Kannada
Malayalam
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DONATE
Home
About Us
Who We Are
Our Journey
Our Team
What Drives Us
Activity & Events
Campaign
Crowdfunding
List of Donors
Join Us
Member
Volunteer
ID Card
Media
Documents
Survey Form
Contact
Login
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Kohram Helpline Foundation
(Public Survey Form for Social Welfare and Assistance)
Survey Details
Date
Surveyor Name
Area / Ward / Village
1. General & Personal Details
Head / Respondent Name
Father / Husband Name
Gender
Male
Female
Other
Age (Years)
Mobile Number
Full Address
Total Family Members
Adults
Children
2. Social & Economic Status
Occupation / Source of Income
Daily Wager
Self-employed
Private Job
Unemployed
Other
Monthly Family Income
Less than ₹5,000
₹5,000–₹10,000
₹10,000–₹20,000
More than ₹20,000
House Type
Kutcha
Pucca
Rented
Other
Ration Card
BPL
APL
Antyodaya
None
3. Basic Needs & Problems
Priority (1 = High, 3 = Normal)
Education
School Admission / Books / Fee Assistance / Women Literacy
1
2
3
Health
Regular Treatment / Medicine Cost / Distance to Govt Hospital
1
2
3
Relief Material
Ration / Seasonal Assistance (Blankets, Clothes, etc.)
1
2
3
Employment / Skills
Tailoring, Technical or other Skill Development Training
1
2
3
Government Scheme
Pension / Ayushman Card / Housing Scheme Benefits
1
2
3
4. Status of Government Schemes
Is the family benefiting from any government scheme?
Yes
No
Are Aadhar card / necessary documents available?
All have
Some pending
None
5. Surveyor's Special Remarks
Immediate need of the family
Possibility of assistance by the organization
Signature / Thumb (Respondent Name)
Signature (Surveyor Name)
Submit Survey
