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Urban Homeless Survey 2025 (Pilot Drive)

Longitude

Latitude

FORM NO(Required)

NAME OF ULB(Required)

WARD NO(Required)

LOCATION(Required)

Address Line 1 Address Line 2 & Landmark City State ZIP / Postal Code Country

FULL NAME OF THE RESPONDENT(Required)

FATHER/HUSBAND'S NAME

FULL NAME OF CO-RESPONDENT

RELATIONSHIP WITH PRIMARY RESPONDENT

AGE OF RESPONDENT(Required)

SEX OF RESPONDENT(Required)

Male

Female

Other

Experience of staying in a SUH shelter before

Yes

No

WILLING TO AVAIL OF GOVT. ARRANGED SHELTER?(Required)

Yes

Other

Awareness about SUH(Required)

Yes

No

PRESENT LIVING STATUS(Required)

Street

Station

Footpath

Religious Places

River Banks

Under Flyover

Subway

Field

Bus Stand

Other

Duration of staying at this spot

*m – month | *y – year

<1 m

1–6 m

6m – 1y

1y – 1.5y

1.5y – 2y

>2y

WHETHER LIVING IN STATIC LOCATION

Static

Dynamic

PHYSICALLY CHALLENGED

Yes

No

MENTALLY CHALLENGED

Yes

No

ANY CHRONIC ILLNESS

Yes

No

ANY ADDICTION

Yes

No

EDUCATIONAL QUALIFICATION

No Education

Till Class 5

Till Class 10

Till Class 11

Till Class 12

>Class 12

Other

OCCUPATION(Required)

Beggar

Rag Picker

Daily Laborer

Works in shop

Rickshaw Puller

Van Puller

Security Guard

Domestic Help

No Occupation

Other

LOCATION OF WORK

0-5 km

5- 10 km

10-15 km

15- 20km

> 20km

MONTHLY INCOME

0-1000

1000-5000

5000- 10,000

>10,000

Whether Receiving GOVT Benefits

Yes

No

If YES, then type of benefit received

Ration

Health Card

Pension

Laxmi Bhandar

Others

Any ID Proof(Required)

Yes

No

Type of ID Proof(Required)

Aadhar

Voter

PAN

Bank Account

Ration Card

Others

Staying alone or with Family/Community

Alone

With Community

With Family

Other

Access to Toilets/Water Nearby

Yes

No

Access to Food

Beg for food

Given by others

Buy food

Donated by NGO

MAA Canteen

Self Cooked

Others

PHOTO(Required)

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