Format-3 (Consolidation of Household Data for Beneficiary oriented initiatives and Action Plan for fulfilling needs)

Domain: Drinking Water and Sanitation
Monitorable Indicator: % of households having Individual Household Latrines (IHHLs)
Sl. No. Particulars Status/No.
1 No. of households not having individual household latrine (IHLL)
2 No. of households not having IHLL but eligible under Swachh Bharat Mission-Gramin(SBM-G)

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: Whether people are still defecating in the open in the village
Domain: Education
Sl. No. Particulars Status/No.
1 No. of ST children in the village (6-10 years), both boys and girls
2 No. of ST children in the village (6-10 years), both boys and girls, attending primary school
3 No. of ST children in the village (6-10 years), both boys and girls, not attending primary school

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of children (11-13 years), attending middleschool
Sl. No. Particulars Status/No.
1 No. of ST children in the village (11-13 years), both boys and girls
2 No. of ST children in the village (11-13 years), both boys and girls, attending middle school
3 No. of ST children in the village (11-13 years), both boys and girls, not attending middle school

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of children (14-15 years),attendingsecondary school
Sl. No. Particulars Status/No.
1 No. of children in the village (14-15 years), both boys and girls
2 No. of children in the village (14-15 years), both boys and girls, attending secondary school
3 No. of children in the village (14-15 years), both boys and girls, not attending secondary school

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of children (16-17 years)attending higher secondaryschool
Sl. No. Particulars Status/No.
1 No. of children in the village (16-17 years), both boys and girls
2 No. of children in the village (16-17 years), both boys and girls, attending higher secondary school
3 No. of children in the village (16-17 years), both boys and girls, not attending higher secondary school

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of children (18-23 years) attendingpost higher secondary education
Sl. No. Particulars Status/No.
1 No. of children in the village (18-23 years), both boys and girls
2 No. of children in the village (18-23 years), both boys and girls, attending post higher secondary education
3 No. of children in the village (18-23 years), both boys and girls, not attending post higher secondary education

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of ST children (out of those attending school & eligible) receiving prematric scholarship
Sl. No. Particulars Status/No.
1 No. of ST children in the village eligible for getting the Prematric Scholarship for ST Students
2 No. of children (out of 1 above) receiving Pre-matric Scholarship for ST students
3 No. of children (out of 1 above) not receiving Pre-matric Scholarship for ST students

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: %of ST children (out of those pursuing post-matric education and eligible) receiving post-matric scholarship
Sl. No. Particulars Status/No.
1 No. of ST children in the village eligible for getting the Postmatric Scholarship for ST Students
2 No. of children (out of 1 above) receiving Post-matric Scholarship for ST students
3 No. of children (out of 1 above) not receiving Post-matric Scholarship for ST students

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Housing
Monitorable Indicator: % of eligible households having Pucca House
Sl. No. Particulars Status/No.
1 % of eligible households having Pucca House

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Livelihood
Monitorable Indicator:% of total households having at least one member employment / self employment / engaged in remunerative sustainable agricultural practices / Minor Forest Produce (MFP) collection or other activities
Sl. No. Particulars Status/No.
1 % of total households having at least one member employment / self-employment
2 % of total households engaged in remunerative sustainable agricultural /livelihood practices
3 % of total households engaged in MFP collection or other activities

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Health and Nutrition
Monitorable Indicator: % of eligible householdscovered under any Health Protection Scheme
Sl. No. Particulars Status/No.
1 No. of eligible households still to be covered under any Health Protection Scheme?

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of pregnant women who are severelyanemic
Sl. No. Particulars Status/No.
1 No. of ST women in the village who are pregnant
2 No. of ST pregnant women who are severely anemic

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of low birth weight children born during the last oneyear
Sl. No. Particulars Status/No.
1 No. of ST children born during the last one year in the village
2 No. of ST children born during the last one year having low birth weight

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of full immunization of children (< 1year)
Sl. No. Particulars Status/No.
1 No. of ST Children below one year of age in the village
2 No. of ST Children in the village below 1 year of age not immunized

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of underweight children (0-5 years) in the village
Sl. No. Particulars Status/No.
1 No. of ST children of 0-5 years in the village
2 No. of ST children of 0-5 years in the village who are underweight

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: How many pregnant women died during the last oneyear?
Sl. No. Particulars Status/No.
1 No. of ST women in the village who were pregnant during the last one year
2 No. of ST pregnant women in the village who died during the last one year

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: How many children (< 1 year) died during the last oneyear?
Sl. No. Particulars Status/No.
1 How many ST children in the village were in age group of <1 year
2 How many ST children (< 1 year) died during the last one year

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Social Security
Monitorable Indicator: % of eligible women provided with WidowPension
Sl. No. Particulars Status/No.
1 No. of eligible ST women of the village already provided with Widow Pension
2 No. of eligible ST women of the village not provided with Widow Pension

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of eligible persons provided with Old Age Pension
Sl. No. Particulars Status/No.
1 No. of ST persons in the village who are eligible for Old Age Pension
2 No. of eligible ST persons in the village already provided with Old Age Pension
3 No. of eligible ST persons in the village not provided with Old Age Pension

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of eligible persons provided with Disability Pension
Sl. No. Particulars Status/No.
1 No. of ST persons of the village eligible for Disability Pension
2 No. of eligible ST persons in the village already provided with Disability Pension
3 No. of eligible ST persons in the village not provided with Disability Pension

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Road Connectivity
Monitorable Indicator: % of households living in Kachcha/unsafe houses
Sl. No. Particulars Status/No.
1 No. of ST households living in the Kachcha/unsafe houses
2 No. of ST households living in the Kachcha/unsafe houses who are eligible to get a house under Pradhan Mantri AwasYojana(PMAYG)/any other scheme(s)

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Domain: Electricity and LPG Supply
Monitorable Indicator: % of households having electricity connection
Sl. No. Particulars Status/No.
1 Total No. of ST households in the village
2 No. of ST households not having an Electricity connection
3 No. of eligible ST households to be provided an Electricity connection under SAUBHAGYA Scheme/ any other scheme(s)

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of households using at least one LED bulb
Sl. No. Particulars Status/No.
1 Total No. of ST households in the village
2 No. of ST households who have an Electricity connection in their homes
3 No. of ST households who have an Electricity connection in their homes and are using at least one LED Bulb
4 No. of ST households to be provided with the LED bulb under UJALA Scheme/ any other scheme(s)

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Monitorable Indicator: % of households having Gasconnection
Sl. No. Particulars Status/No.
1 No. of ST households in the village
2 No. of ST households who are using clean fuel in their homes
3 No. of ST households eligible under UJJAWALA Yojana/ any other scheme(s) but not have Gas connection

Household/Beneficiaries identified and initiatives planned:

Sl. No. Details of beneficiaries Details of Initiatives
Category of beneficiary House No./Address Name of head of the Household Name of Beneficiary Aadhaar Number
1
2
Format-3 List