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)?