1. Name of the head of family:

2. Age:

3. Residential Address :

4. Martial Status: Married ☐ Unmarried ☐

5. No. of members of family (dependent)

6. Occupation: Service ☐ Self employed ☐

7. Average monthly income (in Rs.)

• Up to Rs. 1000 ☐
• Between Rs. 1000 to Rs. 2000 ☐
• Between Rs. 2000 to Rs. 5000 ☐
• Between Rs. 5000 to Rs. 10,000 ☐
• More than Rs. 10,000 ☐

8. Which type of fuel do you use

• Wood coal
• Kerosene
• Oil Gas

9. Do you use gas yes ☐ No ☐

10. Do you use only gas Yes ☐ No ☐

11. If you do not use gas, what is the main reason? 

• Not getting the gas connection. ☐
• Insufficient money to get connection ☐
• Use of gas is unsafe ☐

12. If you use other fuel goods along with the use of gas, what is the main reason?

• Non – availability of sufficient gas. ☐
• Limited use of gas due to high price of gas ☐
• For the point of view of health, use of gas for all activities is not right ☐

13. If you use gas, why?

• Cheap than other types of fuel ☐
• Use of gas is conveninent ☐
• Any other reason ☐

14. How far is gas distribution agency from residence?

• up to 1 km ☐
• Between 1 km and 5 km. ☐
• More than 5 km. ☐