IDENTIFICATION
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
REGION
URBAN/RURAL
URBAN 1
RURAL 2
MALARIA ENDEMIC REGION
Hyperendemic (Cabinda, Uige, K. Norte, Malange, L. Norte, L. Sul) 1
Mesoendemic Stable (Zaire, Luanda, Bengo, Benguela, K. Sul, Huambo, Bié) 2
Mesoendemic Unstable (Moxico, K. Kubango, Kunene, Huila, Namibe) 3
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT
HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
TOTAL NO. OF VISITS
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE