PLACE NAME__
NAME OF HOUSEHOLD HEAD__
CLUSTER NUMBER___
HOUSEHOLD NUMBER______
REGION__

NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER ______
CONCESSION NUMBER ______
CLUSTER NUMBER ______
HEALTH DISTRICT ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) DETAILED ENVIRONMENT ______
NAME AND LINE NUMBER OF WOMAN ______
CLUSTER NUMBER IN DHS-IV 2005 ______
HOUSEHOLD SURVEYED IN DHS-IV 2005? (YES = 1, NO = 2) ______
HOUSEHOLD NUMBER IN DHS-IV 2005 ______
WOMAN SURVEYED IN DHS-IV 2005? (YES = 1, NO = 2) ______
WOMAN'S LINE NUNBER IN DHS-IV ______

REGION______
HEALTH DISTRICT ______
DISTRICT MUNICIPALITY/RURAL COMMUNITY ______
CLUSTER NUMBER ______
NAME OF HEAD OF CONCESSION ______
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER IN SAMPLE ______
NAME OF LOCALITY (DISTRICT MUNICIPALITY IN DAKAR, MUNICIPALITY, RURAL COMMUNITY) ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) DETAILED ENVIRONMENT ______
NAME AND LINE NUMBER OF WOMAN ______
HOUSEHOLD SAMPLE (OF THE 30 IN CLUSTER)? (YES = 1, NO = 2) ______
HOUSEHOLD CHOSEN FOR ANEMIA/MALARIA TEST? (YES = 1, NO = 2) ______

PLACE NAME_____
NAME OF HEAD OF HOUSEHOLD_____
HOUSEHOLD NUMBER_____
CONCESSION NUMBER _____
CLUSTER NUMBER _____
REGION _____
DEPARTMENT_____
SANITARY DISTRICT______

PLACE NAME ________________
NAME OF HEAD OF HOUSEHOLD ______________
PLOT NUMBER ___________
CLUSTER NUMBER ____________
REGION ___________

PLACE NAME _______
NAME OF HEAD OF HOUSEHOLD
HOUSEHOLD NUMBER ______
PLOT NUMBER _____
CLUSTER NUMBER ______
REGION ______

URBAN/RURAL

LOCATION

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

LOCATION (DETAIL) ______

WOMAN'S NAME AND LINE NUMBER _____

PLACE NAME _____

NAME OF HEAD OF HOUSEHOLD ______

HOUSEHOLD NUMBER ____

PLOT NUMBER ____

CLUSTER NUMBER _____

REGION ____

DEPARTMENT ____

SANITATION DISTRICT ____

URBAN/RURAL

MILIEU ____

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

WOMAN'S NAME AND LINE NUMBER _____

CHECK COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

IF HOUSEHOLD SELECTED FOR DV, CHECK WOMEN'S SELECTION TABLE (Q157A OF HOUSEHOLD QUESTIONNAIRE)

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

PLACE NAME _____

NAME OF HEAD OF HOUSEHOLD ______

HOUSEHOLD NUMBER ____

PLOT NUMBER ____

CLUSTER NUMBER _____

REGION ____

DEPARTMENT ____

SANITATION DISTRICT ____

URBAN/RURAL

MILIEU ____

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

WOMAN'S NAME AND LINE NUMBER _____

CHECK COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

IF HOUSEHOLD SELECTED FOR DV, CHECK WOMEN'S SELECTION TABLE (Q157A OF HOUSEHOLD QUESTIONNAIRE)

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

NAME OF REGION ______
NAME AND NUMBER OF HEAD OF HOUSEHOLD ______
CONCESSION NUMBER ______
CLUSTER NUMBER ______
REGION ______
DEPARTMENT ______
HEALTH DISTRICT ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4)______
NAME AND LINE NUMBER OF WOMAN ______