IDENTIFICATION (1)

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
HOUSEHOLD SELECTED FOR MAN'S SURVEY (1=YES, 2=NO)

INTERVIEWER VISITS

FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __

TOTAL NUMBER OF VISITS: __

*RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES

SUPERVISOR
NAME ______
NUMBER __ __ __ __

FIELD EDITOR
NAME ______
NUMBER __ __ __ __

OFFICE EDITOR
NUMBER __ __

KEYED BY
NUMBER __ __

Note: Brackets [] indicate items that should be adapted on a country-specific basis.

SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS (PAPER OPTION) (1)

DVH00) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR DV MODULE?

YES
NO (GO TO 101)

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 01, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE)/ WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

DVH01)

(1) If the survey will be conducted using paper questionnaires, retain "SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS." If the survey will be conducted using CAPI, delete the "SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS", because the selection will be done automatically.