[NAME OF COUNTRY]
[NAME OF ORGANIZATION]
PLACE NAME____
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ___
REGION___
RURAL 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME_____
RESULT____
HOUSEHOLD PRESENT BUT NO COMPETENT RESPONDENT AT HOME 2
HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)__________9
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME___
FINAL VISIT
MONTH____
YEAR____
INTERVIEWER'S NAME____
RESULT____
TOTAL IN HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN____
FIELD EDITED BY
NAME______
DATE______
OFFICE EDITED BY
NAME_____
DATE_____
KEYED BY
NAME______
DATE______
Now we would like some information about the people who usually live in your household or who are staying with you now.
2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.
3. RESIDENCE: Does (NAME) usually live here?
NO 2
4. RESIDENCE: Did (NAME) sleep here last night?
NO 2
5. SEX: Is (NAME) male or female?
FEMALE 2
FOSTERING FOR CHILDREN UNDER 15 YEARS OLD:
7. Do either of his/her parents usually live in this household?
NO 2
8. ELIGIBILITY: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW
TOTAL NUMBER OF ELIGIBLE WOMEN___
TICK HERE IF CONTINUATION SHEET USED____
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO
2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
3. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO