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APPENDIX VII
I. SUB-SAMPLE SURVEY PROFORMA
Sub-Centre :
Village :
Serial Number :
Name of the person :
Name of the spouse :
Address :
PART A
1. Which is the nearest Govt. Service Unit for the Health Service.
Service Unit Name Distance in Kms.
(a) P.H.C.  
(b) Sub-Centre  
(c) Others  
   
2. Is there any public transport facility to attend.
(i) P.H.C. Yes No
(ii) Sub-Centre Yes No
   
3. Do you take treatment for any of your ailments at PHC/ Sub-Centre?
(1) Yes  
(2) No  
If no, specify reasons (put a tick mark)
(i) Staff not kind  
(ii) Doctor does not give enough attention  
(iii) Long distance  
(iv) Conveyance problem  
(v) Wait for a long time  
(vi) Inadequate drugs  
(vii) Demand money  
(viii) Non ambulatory status  
(ix) Utilizing other facilities  
(x) Others (specify)  
   
4. What type of service do you utilise for the following ailments?
  PHC Sub-Centre Others
(a) for minor physical ailments  
(b) for major physical ailments  
(c) for all psychiatric ailments  
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