PLACE NAME/SUB-DISTRICT______

NAME OF HEAD OF HOUSEHOLD______

PROVINCE_______

MUNICIPALITY_______

DISTRICT NAME AND NUMBER_____

CLUSTER NUMBER______

HOUSEHOLD NUMBER______

NAME OF LOCALITY/SUB-HILL (COLLINE) ______
NAME OF HEAD OF HOUSEHOLD ______
PROVINCE ______
COMMUNE ______
NAME AND NUMBER OF HILL (COLLINE) ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
URBAN-RURAL AREA (1 = URBAN, 2 = RURAL) ______
WOMAN'S NAME AND LINE NUMBER ______