PROVINCE

DISTRICT

VILLAGE/NAHIA

CONTROLLER AREA

CLUSTER NUMBER

TYPE OF LOCATION

STRUCTURE/BUILDING NUMBER/GATE NUMBER

HOUSEHOLD NUMBER

NAME OF HOUSEHOLD HEAD

HOUSEHOLD SELECTED FOR MALE SURVEY?

STATISTICAL CONFIDENTIALITY: BY THE TERMS GIVEN IN ARTICLE 11 OF THE LAW NO. 3/11, FROM THE 14TH OF JANUARY, LAW OF THE NATIONAL STATISTICS SYSTEM, ALL INDIVIDUAL DATA COLLECTED BY OFFICIAL STATISTICS ORGANIZATIONS, IN THIS CASE THE INE, ARE STRICTLY CONFIDENTIAL. COLLECTED DATA IS PROTECTED FROM ANY NON-STATISTICAL PURPOSES OR FROM ANY UNAUTHORIZED DISSEMINATION, ONLY TO BE USED FOR THE PRODUCTION OF OFFICIAL STATISTICS.

PLACE NAME/ADDRESS________
NAME OF HOUSEHOLD HEAD________
PROVINCE ____
MUNICIPALITY ____
COMMUNE ____
NEIGHBORHOOD/VILLAGE ____
CENSUS SECTION ____
HOUSEHOLD AREA ____

CLUSTER NUMBER (ID. IIMS) ____
HOUSEHOLD NUMBER ____
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR CHILDREN'S SURVEY?

IS HOUSEHOLD SELECTED FOR HUSBAND SURVEY?

IS HOUSEHOLD SELECTED FOR MEN'S SURVEY?

DIVISION____
DISTRICT____
UPAZILA____
UNION/WARD____
VILLAGE/MOHALLA/BLOCK____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
RURAL, MUNISIPALITY, OTHER URBAN, OR SMA:

HOUSEHOLD IN A SLUM?

NAME OF THE SLUM____
NAME OF THE HOUSEHOLD HEAD____
HOUSEHOLD SELECTED FOR MEN'S SURVEY?

PLACE NAME_____
CLUSTER NUMBER_____
PLOT NUMBER_____
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD_____
HOUSEHOLD NUMBER_____
REGION ____

URBAN/RURAL:

MILIEU:

HOUSEHOLD SELECTED FOR MEN'S SURVEY/ HIV TEST/ANEMIA TEST?

IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD

PROVINCE

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

IDENTIFICATION
REGION
DIVISION
SUB-DIVISION
LOCALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

LOCALITY NAME _____

NAME OF HOUSEHOLD HEAD _____

CLUSTER NUMBER _____

STRUCTURE NUMBER _____

HOUSEHOLD NUMBER _____

REGION _____

DISTRICT _____

URBAN/RURAL:

HOUSEHOLD SELECTED FOR MEN SURVEY:

Household selected for men's survey/tests/health spending?

DISTRICT _____________________ ___

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

HOUSEHOLD SELECTED FOR MALE SURVEY, DOMESTIC VIOLENCE MODULE,
ANTHROPOMETRY, AND BLOOD WORK?

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR MICRONUTRIENT'S STUDY?

Household selected for men's survey?

NAME OF HOUSEHOLD HEAD_________

PLACE NAME_________

PROVINCE_________

URBAN/RURAL

NAME AND NUMBER OF ENUMERATION AREA (DHS I.D.)_____

HOUSEHOLD NUMBER______

HOUSEHOLD SELECTED TO INTERVIEW MEN____

HOUSEHOLD SELECTED TO TEST CHILDREN___

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE___

IDENTIFICATION
NAME AND CODE OF REGION _________
NAME OF VILLAGE/TOWN/CITY __________
DHS CLUSTER NUMBER________
HOUSEHOLD NUMBER __________
NAME OF HOUSEHOLD HEAD _________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY

NAME AND CODE OF REGION* ______________
NAME OF VILLAGE/TOWN/CITY ________________
URBAN/RURAL

LARGE CITY/SMALL CITY/TOWN/RURAL

HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD _____________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY?

NAME AND CODE OF DISTRICT ______________

NAME AND CODE OF VILLAGE MUNICIPALITY __________________

WARD NUMBER _______

CLUSTER NUMBER _________

CITY/TOWN/COUNTRYSIDE

NAME OF HOUSEHOLD HEAD _______________

NAME OF RESPONDENT ______________

IS HOUSEHOLD SELECTED FOR MAN'S SURVEY

NAME AND CODE OF DISTRICT

WARD NUMBER

CLUSTER NUMBER

HOUSEHOLD NUMBER

CITY/TOWN RURAL

NAME OF HOUSEHOLD HEAD

NAME OF RESPONDENT

HOUSEHOLD SELECTED FOR MALE SURVEY

ALTITUDE

NAME AND CODE OF VILLAGE/MUNICIPALITY __________________

WARD NUMBER ______________

CLUSTER NUMBER _______________

HOUSEHOLD NUMBER _______________

NAME OF THE HOUSEHOLD HEAD _________________

NAME OF RESPONDENT _______________

HOUSEHOLD SELECTED FOR MALE SURVEY

ALTITUDE _____________

NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALITY

WARD NUMBER

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR MEN'S SURVEY:

HOUSEHOLD SELECTED FOR MEN'S SURVEY______

HEIGHT/WEIGHT MEASUREMENT, HEMOGLOBIN AND HIV TEST, SALT SAMPLE (LABORATORY)?

MEN'S SURVEY_____

IDENTIFICATION

STATE ____
LOCAL GOVT. AREA______
LOCALITY _____
ENUMERATION AREA_____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

PROVINCE/REGION

DISTRICT __

TEHSIL __

CLUSTER NUMBER __

HOUSEHOLD NUMBER __

HOUSEHOLD SELECTED FOR MEN INTERVIEW

PLACE NAME __

NAME OF HOUSEHOLD HEAD __

PROVINCE/REGION

DISTRICT ______

TEHSIL ________

NAME OF HOUSEHOLD HEAD _______

CLUSTER NUMBER _______

HOUSEHOLD NUMBER _______

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR DV?

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

URBAN/RURAL

LOCATION

LOCATION (detail) _______

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

PLACE NAME _____

NAME OF HEAD OF HOUSEHOLD _____

PLOT NUMBER ______

CLUSTER NUMBER ____

REGION ____

DEPARTMENT ____

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?

PLACE NAME _____

NAME AND NUMBER OF HEAD OF HOUSEHOLD _____

PLOT NUMBER ______

CLUSTER NUMBER ____

REGION ____

DEPARTMENT ____

HEALTH DISTRICT____

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?

*SMALL CITIES ARE: MWANZA, ARUSHA, MOROGORO, DODOMA, MOSHI, TANGA, IRINGA, MBEYA, AND TABORA. ALL OTHER URBAN AREAS ARE TOWN.

REGION _____

DISTRICT _____

WARD _____

LARGE CITY, MUNICIPALITY, SMALL TOWN, COUNTRISIDE (1)

NAME OF HOUSEHOLD HEAD _____

HOUSEHOLD NUMBER _____

HOUSEHOLD SELECTED FOR MAN'S SURVEY, SALT AND URINE TESTING?

(1) CITY: DSM, TANGA, MWANZA. MUNICIPALITY= DODOMA, KILIMANJARO, MOROGORO, PWANI, LINDI, MTWARA, SONGEA, IRINGA, SINGIDA, TABORA, RUKWA, SHINYANGA, KAGERA, MARA, MJIONI MAGHARIBI, WETE, CHAKE CHAKE, MKOANI. SMALL TOWN: ALL OTHER CITIES. RURAL: ALL OTHER AREAS.

HOUSEHOLD SELECTED FOR MALE SURVEY?