Rural Energy Needs Baseline Survey Sheet

1. Household Information

Survey Date Village/Location Head of Household Name Contact Number Family Size Number of Children under 18

2. Household Energy Sources

Energy Source	Used? (Yes/No)	Main Purpose	Monthly Expenditure
Electricity (Grid)
Solar
Generator
Firewood
Charcoal
Other (specify)

3. Appliances in Use

Appliance	Quantity	Usage Hours/Day
Lighting Bulbs
Radio
TV
Fan
Refrigerator
Other (specify)

4. Cooking & Water Heating

Main Cooking Fuel Secondary Cooking Fuel Fuel collection/purchase frequency (per week) Main Water Heating Method

5. Household's Challenges & Needs

What are your main challenges with energy supply? What would improve your household's energy situation?