9. EMPLOYMENT AND INCOME OF ALL MEMBERS OF THE HOUSEHOLD 9.1 CURRENT EMPLOYMENT AND INCOME No. Name Primary source of income (such as employment, pension, scrap collection, selling used goods) If official employment - name of employer and type of work Monthly income from the primary occupation Other sources of income (specify - scrap collection, seasonal work, social welfare, disability payment, remittances, and so on) Estimated monthly income from other sources Total estimated monthly income 1 2 3 4 5 6 7 8 9 10 MONTHLY INCOME OF THE HOUSEHOLD
11. AFFECTED OBJECTS 11.1 All objects which the household uses:  11.1.1 Housing unit (house) 11.1.1.1 Number of rooms: 11.1.1.2 Type of construction material:  Brick or concrete  Wood  Cardboard and other scrap 11.1.1.3 Size (in square metres):  11.1.2 objects (specify):  Shed  Workshop  Other (specify): 11.1.2.1 Number of rooms: 11.1.2.2 Type of construction material:  Brick or concrete  Wood  Cardboard and other scrap 11.1.2.2 Size (in square metres): 11.2 Are you the owner or the user of the housing unit?  11.2.1 Owner  11.2.2 User 11.2.2.1 If you are the user, do you pay rent?  Yes (go to 11.2.2.2)  No 11.2.2.2 Specify how much:
11.7 Does the household have access to electricity?  11.7.1 Yes 11.7.1.1 Is the connection legal or illegal?  Legal connection  Illegal connection  11.7.2 No 11.8 How do you rate your current living (housing) conditions?  Good  Average  Poor 11.8.1 Main reason why: 11.9 Please indicate what you change to improve your living conditions. 11.9.1 Specify: 12. XXX PROJECT 12.1 Are you aware of the XXX that will be built in this area?  12.1.1 Yes 12.1.1.1 How did you first find out about the project?  From people in the settlement  From city officials  From the  Other (specify)  12.1.2 No 12.2 Did you attend the public meeting held by the city?  Yes  No
XXX PROJECT IN XXX (RURAL SETTING) Development of the RAP/ LRP - socio-economic baseline survey CENSUS / SURVEY / ASSET INVENTORY FORM 1. GENERAL INFORMATION 1.1 Survey form number: 1.1.1 Connected survey form numbers (for other affected plots): 1.2 Location of the affected plot: 1.2.1 District: 1.2.2 Town / village: 1.3 Cadastral number of the affected plot: 1.4 Size of the affected plot (in Ha): 1.5 Name of surveyors: 1.5.1 Signature: 1.5.2 Signature: 1.6 Date of survey: 1.7 Name of survey supervisor: Signature: 2. INFORMATION ABOUT THE OWNER(S)/USER OF THE AFFECTED LAND PLOT Note: the person using the land plot is who should be surveyed (be it the owner or person using the land plot under some formal or informal arrangement) 2.1 Name of the owner(s) of the affected land plot: 2.2 Resident address(es) and contact phone number(s) of the owner(s): 2.3 Name of the user (if different than the owner) of the affected land plot: 2.4 Resident address and contact phone number of the user: 2.5 Status of the user:  2.5.1 Plot is owned by family or relative (with no formal usage agreement)  2.5.2 Tenant (formal user of land with agreement from the owner)  2.5.3 Informal user (user of land without knowledge or agreement from the owner)  2.5.9 Other (specify)
12. WORK FORCE ASSOCIATED WITH AFFECTED LAND PLOT 12.1 Who is engaged in agriculture/animal husbandry associated with the affected land plot?  12.1.1 Members of the household (please specify how many individuals):  12.1.2 Hired help (please specify how many individuals): Note: hired help includes persons engaged temporarily or permanently, formally or informally, for some kind of compensation such as a salary or goods. 13. USE OF NATURAL RESOURCES IN THE AREA BY THE RESPONDENT’S HOUSEHOLD 13.1 Is there a publically owned forest, stream, river, lake or other natural resource near the affected land that the respondent or any member of the household is using in connection to the household’s livelihood?  13.1.1 Yes (proceed to 13.2)  13.1.2 No (proceed to 14) 13.2 Specify the main use of the natural resource and the season of activity:  13.2.1 Fishing Season:  13.2.2 Feeding livestock Season:  13.2.3 Hunting Season:  13.2.4 Collecting spices Season:  13.2.5 Collecting herbs Season:  13.2.6 Collecting mushrooms Season:  13.2.7 Logging Season:  13.2.9 Other (specify) Season: