IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
CLUSTER NUMBER
HOUSEHOLD NUMBER
ADMINISTRATIVE REGION
NATURAL REGION
SANITATION DISTRICT NUMBER
LOCATION OF HOUSEHOLD

NAME AND LINE NUMBER OF WOMAN

IDENTIFICATION (1)

NAME OF LOCALITY: ______
NAME OF HEAD OF HOUSEHOLD: ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
NAME AND LINE NUMBER OF WOMAN ______
ADMINISTRATIVE REGION ______
NATURAL REGION ______
HEALTH DISTRICT NUMBER ______
AREA OF RESIDENCE (1 = CITY OF CONAKRY, 2 = OTHER CITY, 3 = RURAL)
______