QUESTIONNAIRE FOR AAJ TAK CARE AWARDS

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1 Serial No (To be filled at IMRB office) QUESTIONNAIRE FOR AAJ TAK CARE AWARDS INSTRUCTIONS 1. The findings of the survey will be shared with TV Today Network Ltd. 2. Please fill in this questionnaire only if your organization operates in India. 3. The questionnaire is available at the following link: 4. This questionnaire has 15 printed pages divided into 5 sections. 5. Please ensure that all sections are duly filled in. Do not leave any question blank. Incomplete questionnaires will not qualify for short listing. 6. If any question is not applicable for the company, clearly mention Not applicable or NA in the space provided. 7. Please attach all supporting documents along with the questionnaire for submission. 8. The completed questionnaire should be signed and stamped by the concerned authority in the organization. 9. Please send the completed questionnaires along with supporting documents latest by January 25, 2012 at atcareawards@imrbint.com or at the following address: Aaj Tak Care Awards C/O IMRB International Media & Panel Group SCO-47, 5th floor, Old Judicial Complex Sector 15, Gurgaon Ph: For more details, log onto 1

2 Defining CSR: Corporate Social Responsibility (CSR) refers to contributions made by a company to society through its core business activities, social investment and philanthropic programs as well as engagement in public policy. The goal of CSR is to assume responsibility for a company's actions and encourage a positive impact through its activities on the environment, consumers, employees, communities, stakeholders and all other members of the public sphere. Please do NOT write in ALL CAPITALS as it is difficult to read. Does your company engage in CSR activities? Please tick ( ) the relevant option Yes No SECTION 1: COMPANY CONTACT INFORMATION (only if the company engages in CSR activities) Name of Company Registered address City State Pin Telephone number (with area code) Fax Id Website (if any) Year of establishment Name of the CEO/Chairman SECTION 2: CSR HEAD CONTACT INFORMATION Name of Person Designation Address (if other than the registered office address) City State Pin Telephone number (with area code) Mobile Number Fax Id Link of CSR Website / Section (If no website, write 'None') 2

3 SECTION 3: COMPANY PROFILE Name of parent company (if none, write None ) Name of participating company Please tick ( ) the type of your company. PSU MNC - Multi National (from outside India but operating in India) Indian MNC- Indian Multi National Private Sector (operating in India only) Please tick ( ) the primary industry of your organization in the box adjacent to industry type Auto ancillaries Automobiles Banking Cement Construction Computers Diversified Electrical Electronics Engineering/Machinery Entertainment & Media Fertilizers Financial services FMCG & Consumer Durables Foods Healthcare Heavy Engineering Hotels Tick ( ) here Tick ( ) here Iron & Steel Logistics Metal Mining Oil & Gas Packaging Paint Paper Petroleum & Petrochemicals Polymer & Plastic Power Retail Shipping Software & ITES Telecommunication Textile Trading Others (please specify) 3

4 Which are the 3 main products/services of your organization? Please tick ( ) the figures relevant for your organization: Annual Revenue Rs cr Rs cr Rs cr Rs cr Rs cr Above Rs cr Rs cr CSR Budget (if any) Rs. (in crore) Please tick ( ) the average percent of your Annual Revenue which was allocated to CSR in last 3 years? % 5-7% 0.5-1% More than 7% 1-2% Depends on board s decision (not fixed) 2-3% Doesn t have any relation with the annual revenue 3-4% No specific budget 4-5% SECTION 4: CSR ACTIVITIES Does your organization have a CSR Policy/trust/foundation? Yes No In the process Please specify the year in which your organization formulated a CSR policy? (e.g.2002). Please skip this question if your organization does not have a CSR policy. 4

5 Who is responsible for compliance/implementation of CSR policy in your company? You can tick ( ) more than one option, if applicable. CEO CSR Director/Manager Administration Finance department Tick ( ) here HR Department Corporate Communication Not fixed, but decided annually in Annual General Meeting Any other, please specify N.B.: Questions hereafter are mandatory Please select ( ) the most appropriate CSR category under which your entry is applicable. To submit more than one entry, please fill separate application form(s). Education Healthcare Livelihood Environment Empowerment Tick ( ) here Please provide more details about the coverage and scope of your CSR initiatives. (e.g. 5) Number of state(s) covered Number of district(s) covered Number of village(s) covered Number of towns(s) covered Any other, please specify 5

6 Please write about your CSR activities in detail on the aforementioned category in maximum 500 words for each parameter. Please touch upon the following points in the write up. Please use additional sheets, if required. Significance of issues addressed (Maximum 500 words) 6

7 Scale (Maximum 500 words) 7

8 Replicability (Maximum 500 words) 8

9 Sustainability (Maximum 500 words) 9

10 Finances (Maximum 500 words) 10

11 People Participation (Maximum 500 words) 11

12 Innovativeness (Maximum 500 words) 12

13 Promotion of Equity (Maximum 500 words) 13

14 Explain in 200 words how do you see your CSR initiative/effort? Please use inputs from the previous parameters and provide a synopsis to support your CSR initiative/effort. Please use additional sheets, if required. 14

15 SECTION 5: CONTACT DETAILS Please provide the contact details of the contact person (official filling up this survey form) G1. Name* G2. Designation G3. Name of Company G4. Registered address City State Pin G5. Telephone number (with area code) G6. Mobile Number G7. Alternate Mobile Number G8. id 1 G9. id 2 G10. Company website Declaration: Must be signed by the CSR Representative/ Concerned Authority I hereby confirm that the information provided in this form are true and correct to the best of my knowledge at the time of submitting this form. Signature: Seal/Stamp Name: Designation: Date: Place: THANK YOU FOR TAKING OUT TIME TO RESPOND TO OUR QUESTIONS. The results of this survey will be shared with TV Today Network Ltd. Caveat/Fineprint If shortlisted, you may be contacted for further information* The information provided above is open to scrutiny at any point, before, during and after the AT Care Awards If shortlisted, the company/employee providing inputs may be contacted for further information* If shortlisted for felicitation, the company s representatives would be required to travel to Delhi to attend a formal Awards Ceremony, the date of which will be notified and shared in advance. The travel expenses for the same will be borne by the participating company. 15

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