IDENTIFICATION

NAME OF LOCALITY__________
NAME OF HEAD OF HOUSEHOLD___________

DEPARTMENT:___
SUBPREFECTURE: ___
MUNICIPALITY:___
CLUSTER NUMBER (EDST):___
STRUCTURE NUMBER:___
HOUSEHOLD NUMBER IN THE STRUCTURE: ___
SEQUENTIAL NUMBER OF SELECTED HOUSEHOLD (01-24 URBAN; 01-33 RURAL:___
Urban/rural

Residence

WOMAN'S NAME AND LINE NUMBER (FROM HOUSEHOLD QUESTIONNAIRE)_______

REGION NAME

LOCALITY NAME (NEIGHBORHOOD/VILLAGE)__________

NAME OF HEAD OF HOUSEHOLD____________

CLUSTER NUMBER

HOUSEHOLD NUMBER (URBAN=01 TO 25; RURAL=01 TO 30)

HOUSEHOLD NUMBER (SEQUENTIAL IN THE CLUSTER)

URBAN/RURAL (URBAN=1, RURAL=2)

N'DJAMENA-MOUNDOU/SARH/ABECHE-OTHER CITY-RURAL (N'DJAMENA=1, MOUNDOU/SARH/ABECHE=2, OTHER CITY=3, RURAL=4)

WOMAN'S NAME AND LINE NUMBER_________________