IDENTIFICATION
DISTRICT _____________
SUBCOUNTY/TOWN _____________
PARISH/WARD _____________
SUBPARISH/RC2 _____________
CLUSTER NUMBER
HOUSEHOLD NUMBER
FIRST VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE __________
TIME __________
SECOND VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
NEXT VISIT:
DATE __________
TIME __________
THIRD VISIT
DATE __________
INTERVIEWER'S NAME __________
RESULT __________
FINAL VISIT
MONTH
YEAR
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ___________
TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
DATE
OFFICE EDITED BY
DATE
KEYED BY
DATE
KEYED BY
Now we would like some information about the people who usually live in your household or who are staying with you now.
NUMBER
1)
2) Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.
3) Does (NAME) usually live here?
NO 2
4) Did (NAME) sleep here last night?
NO 2
5) Is (NAME) male or female?
FEMALE 2
6) How old is he/she?
FOSTERING (ONLY FOR CHILDREN UNDER 15 YEARS OLD)
7) Do any of his/her parents usually live in this household?
NO 2
8) CIRCLE LIN E NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
Just to make sure that I have a complete listing:
1. Are there any other persons such as small children or infants that we have not listed?
NO
2. In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO
TICK HERE IF CONTINUATION SHEET USED
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET [first sheet]
TOTAL NUMBER OF ELIGIBLE WOMEN ON THIS SHEET [second sheet]
TOTAL NUMBER OF ELIGIBLE WOMEN ON BOTH SHEETS