DEMOGRAPHIC AND HEALTH SURVEY-BENIN 2001 - HOUSEHOLD QUESTIONNAIRE
DEPARTMENT
SUB-PREFECTURE/URBAN DISTRICT
URBAN 1
RURAL 2
RURAL 2
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
YES 1
NO 2
NO 2
YES 1
NO 2
NO 2
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____
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
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 ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___