Full Name (required) Phone (Enter number with Country code) (required) When did you receive it? (required) Have you received tricycle for first time? (required) Yes No Age (required) How many members are there in your family? (required) How many members are earning in your family? (required) What is average monthly income of your family? (required) Below Rs. 5,000 Between Rs. 5,000 to Rs. 10,000 Between Rs. 10,000 to Rs. 20,000 More than Rs. 20,000 Where do you go with Tricycle? (required) School Work place Park, Temple etc. Other Is it functioning properly? (required) Yes No In which ways has tricycle helped you? (required) What is the best thing you could do after receiving tricycle? (required) Does it help you earn more money with more mobility? (required) Yes No How much do you earn in a month after getting tricycle? (required) How have you been helpful to others? (required) General Feedback (required) I confirm that information submitted is accurate.
