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DEMOGRAPHIC AND HEALTH SURVEY-BENIN 2001 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

DEPARTMENT

SUB-PREFECTURE/URBAN DISTRICT

RURAL/URBAN MUNICIPALITY

URBAN 1
RURAL 2

TOWN/NEIGHBORHOOD

CLUSTER NUMBER

STRUCTURE NUMBER

HOUSEHOLD NUMBER

NAME OF HEAD OF HOUSEHOLD

MEN'S SURVEY:

YES 1
NO 2

ANEMIA SURVEY:

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER'S NAME____
RESULT ____

NEXT VISIT
DATE___
TIME____

FINAL VISIT
DAY____
MONTH____
YEAR 2001
NAME___
RESULT____

RESULT CODES:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_____ 9

TOTAL NUMBER OF VISITS__

TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN___

NAME AND LINE NUMBER OF RESPONDENT____

QUESTIONNAIRE USED: FRENCH 1