DATA COLLECTED FROM THIS STUDY ARE CONFIDENTIAL AND WILL BE USED FOR SCIENTIFIC PURPOSES ONLY.

IDENTIFICATION

GOVERNORATE____________
PSU/SEGMENT NO. ____________
KISM/MARKAZ_______________
BUILDING NO.________________
SHIAKHA/VILLAGE_____________
HOUSING UNIT NO.______________

URBAN/RURAL

HOUSEHOLD NO. ___________

ANEMIA TESTING SUBSAMPLE:

NAME OF HOUSEHOLD HEAD______________
ADDRESS IN DETAIL____________________

TELEPHONE:

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS):
DATE___________
TEAM__________
INTERVIEWER_______________
SUPERVISOR______________
RESULT________________

RESULT

NEXT VISIT:
DATE_____________
TIME_________________

FINAL VISIT:
DAY______
MONTH_______
YEAR_________
TEAM_____
INT.NUMBER__________
SUP.NUMBER__________
RESULT______________

TOTAL NUMBER OF VISITS____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

FOR ALL HOUSEHOLDS:

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN AGE 15-49____
TOTAL ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT____

FOR HOUSEHOLDS IN ANEMIA TESTING SUBSAMPLE:

TOTAL ELIGIBLE FOR ANEMIA TESTING____

ADDRESS CHECKED BY: _____________________

REINTERVIEW:____________________

FIELD EDITOR
NAME______
DATE______
SIGNATURE_______

OFFICE EDITOR
NAME______
DATE_________
SIGNATURE________

CODER
NAME______
DATE________
SIGNATURE________

KEYER
NAME________
DATE___________
SIGNATURE_______

INTRODUCTION AND CONSENT

Hello. My name is______________

I am working with the Ministry of Health and Population.

We are conducting a survey about health all over Egypt. The information we collect will help the government plan health services.

Your household was selected for the survey.

I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team.

You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any questions you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER:__________________ DATE:____________________

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

001. LINE NO.

002. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, GO TO QUESTIONS 005-009 TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 010-039 FOR EACH PERSON.

003. RELATIONSHIP TO HOUSEHOLD HEAD: What is the relationship of (NAME) to the head of the household?

004. SEX: Is (NAME) male or female?

005. Just to make sure that I have a complete household listing: Are there any other persons such as small children or infants that we have not listed?

006. 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?

007. Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

008. TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED

009. RECORD TOTAL PERSONS

010. RESIDENCE: Does (NAME) usually live here?

011. Did (NAME) sleep here last night?

012. AGE: How old was (NAME) at his/her last birthday?
RECORD IN COMPLETED YEARS. IF 95 OR MORE, RECORD '95.'

013. MARITAL STATUS (IF AGE 15 OR OLDER): What is (NAME'S) current marital status?

014. ELIGIBILITY: CIRCLE LINE NUMBER OF EVER-MARRIED FEMALES

015. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MALES AGE 0-19

015A. ELIGIBILITY: CIRCLE LINE NUMBER OF NEVER-MARRIED FEMALES AGE 15-19

016. ELIGIBILITY: CIRCLE LINE NUMBER OF NEVER-MARRIED PERSONS AGE 1-17.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

017. Is (NAME)'s natural mother alive?
QUESTION REFERS TO CHILD'S BIOLOGICAL MOTHER.

018. Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
IF NO: RECORD '00.'

019. Is (NAME)'s natural father alive?
QUESTION REFERS TO CHILD'S BIOLOGICAL FATHER.

020. Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
IF NO: RECORD '00.'

021. CHECK 014 AND RECORD NUMBER ELIGIBLE FOR EVER-MARRIED WOMAN INTERVIEW.

022. CHECK 014, 015, AND 015A AND RECORD NUMBER ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT.

023. CHECK 014, 015, AND 015A AND RECORD NUMBER ELIGIBLE FOR ANEMIA TESTING.

024. CHECK 016 AND RECORD NUMBER ELIGIBLE FOR CHILD LABOR AND/OR DISCIPLINE MODULE.

EDUCATION:

025. (IF AGE 6 YEARS OR OLDER) EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

026. (IF AGE 6 YEARS OR OLDER) EVER ATTENDED SCHOOL:
What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

027. CURRENT/RECENT SCHOOL ATTENDANCE (IF AGE 6-24 YEARS)
Did (NAME) attend school at any time during the current school year, that is, the 2013/2014 school year?

028. CURRENT/RECENT SCHOOL ATTENDANCE (IF AGE 6-24 YEARS)
During this school year, what level and grade (is/was) (NAME) attending?

029. EARLY CHILDHOOD EDUCATION PROGRAM ATTENDANCE (IF AGE 3-5 YEARS)
Is (NAME) currently attending kindergarten, a private nursery school, or other program to prepare him/her for primary school?

IF NO: Has (NAME) ever attended any type of program to prepare him/her for school?

030. EARLY CHILDHOOD EDUCATION PROGRAM ATTENDANCE (IF AGE 3-5 YEARS)
Within the last seven days, how many hours did (NAME) attend kindergarten, a private nursery school, or any other program.

IF DID NOT ATTEND IN LAST SEVEN DAYS, RECORD '00'

031. BIRTH REGISTRATION (IF AGE 0-4 YEARS): Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

032. CHILDCARE (IF AGE 0-4 YEARS): Sometimes adults taking care of children have to leave the house to go shopping, wash clothes, or for other reasons and have to leave young children. On how many days in the past week, was (NAME) left alone for more than one hour?

IF NEVER LEFT ALONE, RECORD '0.'

033. On how many days in the past week, was (NAME) left in the care of another child, that is, someone less than 10 years old, for more than one hour?

IF NEVER LEFT IN THE CARE OF ANOTHER CHILD, RECORD '0.'

034. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS): Has (NAME) ever been injured or involved in an accident at home?

035. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS): What type of injury(ies) or accident(s) did (NAME) have?
CIRCLE CODE FOR EACH TYPE OF INJURY OR ACCIDENT MENTIONED

036. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS)
Did the injury or accident (NAME) had at home require medical?

037. DISABILITY (IF AGE 0-9 YEARS): Does (NAME) have any physical, mental or other condition(s) or disability(ies) that make(s) it difficult for (him/her) to carry out daily activities in the same manner as other people (his/her)age?

038. DISABILITY (IF AGE 0-9 YEARS): What type of disability(ies) does (NAME) have?
CIRCLE CODE FOR EACH TYPE OF DISABILITY MENTIONED

039. DISABILITY (IF AGE 0-9 YEARS): How old was (NAME) when he first showed signs of a disability?
RECORD AGE WHEN DISABILITY STARTED. IF CHILD WAS BORN WITH A DISABILITY RECORD '94.' IF CHILD WAS LESS THAN ONE YEAR OLD WHEN A DISABILITY FIRST OCCURRED, RECORD '00.'

HOUSEHOLD ENVIRONMENT AND POSSESSIONS

101. What type of dwelling does your household live in?

102. Is your dwelling owned or rented by your household?
IF OWNED: Is it owned solely by your household or jointly with someone else?

103. What kind of toilet facility do members of your household usually use?
IF FLUSH OR POUR FLUSH, PROBE: Where does it flush to?

104. Do you share this facility with other households?

105. How many households use this toilet?

106. What is the main source of drinking water for members of your household?

107. Where is (SOURCE IN 106) located?

108. How long does it take to go there, get water, and come back?

109. Do you treat your water in any way to make it safer to drink?

110. What do you usually do to the water to make it safer to drink?
PROBE: Anything else?
RECORD ALL MENTIONED

111. Does your household have:

112. Does your household own a satellite dish?
IF NO: In your home, are you connected to satellite from elsewhere?

113. How does your household mainly dispose of kitchen waste and trash?
RECORD MAIN METHOD OF DISPOSAL ONLY. IF TWO OR MORE METHODS ARE USED EQUALLY, RECORD THE METHOD HIGHEST ON THE LIST.

114. Does your household have:

115. How many rooms does your household use for sleeping?

116. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION

117. Does any member of this household own:

118. Does any member of your household have an account in a bank or any saving institution?

119. Does any member of this household own any land that can be used for agriculture?

120. How many feddans or kirates of agricultural land do members of this household own?
IF MORE THAN 95 FEDDAN, ENTER '99.95'.

121. Does your household own any livestock, herds, or farm animals?

122. How many of the following does your household own?
IF NONE, ENTER '00'.
IF MORE THAN 95, ENTER '95'.
IF UNKNOWN, ENTER '98'.

Cattle (buffalo, calf)?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?

123. Does your household own any poultry or birds?

124. How many of the following does your household have?
IF NONE, ENTER '00'
IF MORE THAN 95, ENTER '95.'
IF UNKNOWN, ENTER '98'.

Chickens?
Geese?
Ducks?
Pigeons?
Quail?
Turkey?
Ornamental/song birds?
Any other birds?

125. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

126. Please show me where members of your household most often was their hands?

127. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

128. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

129. CHECK IDENTIFICATION PAGE:

130. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TESTING SALT FOR IODINE.

131. CHECK THE NUMBER OF HOUSEHOLD MEMBERS AGE 1-17 YEARS RECORDED IN 016.

CHILD LABOR AND DISCIPLINE MODULE

201. FOLLOW INSTRUCTIONS AND COMPLETE COLUMNS 1-5 IN TABLE 1

(a) Check Q. 016 in the household listing then list each of the never-married children aged 1-17 years below in the order they appear in the Household Listing Form. Do not include other household members outside the age range 1-17 years.

(b) Record the line number, name, sex and age for each child.

(c) Then record the total number of children aged 1-17 in Q202; if more than 9 children, record 9.

CHILDREN AGED 1-17 YEARS ELIGIBLE FOR CHILD LABOR AND DISCIPLINE QUESTIONS

1. RANK NUMBER

2. LINE NUMBER

3. NAME

4. SEX

5. AGE

202. RECORD THE TOTAL NUMBER OF CHILDREN IN TABLE 1

203. FOLLOW INSTRUCTIONS AND COMPLETE TABLE 2 IN ORDER TO IDENTIFY THE CHILD FOR WHOM THE CHILD LABOR AND DISCIPLINE MODULE WILL BE ADMINISTERED.

(b) Check the last digit of the household questionnaire serial number of the cover page. This is the number of the row you should go to in the table below.

(c) Check the total number of eligible children age 1-17 in Question 202 above. This is the number of the column you should go to.

(d) Find the box where the row and the column meet and circle the number that appears in the box. This is the rank number of the child (see Column 1 in Table 1) about whom the questions on child labor and/or child discipline may be asked, depending on the child's age.

TABLE 2: SELECTION OF RANDOM CHILD FOR CHILD LABOR AND DISCIPLINE QUESTIONS:

CHILD LABOR MODULE:

204. CHECK AGE Q012:

205. CHECK TABLE 2 AND RECORD THE RANK NUMBER SELECTED FOR THE MODULE. THEN CHECK TABLE 1 AND RECORD THE NAME OF THE CHILD CORRESPONDING TO THE RANK NUMBER. ASK QUESTIONS 206 TO 229 AS APPROPRIATE FOR THIS CHILD.

Now I would like to ask about any work children in the household may do. Since last (DAY OF THE WEEK), did (NAME) do any of the following activities, even for only one hour?

206. Did (NAME) do any work or help on his/her own or the household's plot/farm/food garden or look after animals? For example, growing farm produce, harvesting or feeding, grazing, or milking animals?

207. Did (NAME) help in family business or relative's business with or without pay, or run his/her business?

208. Did (NAME) produce or sell articles, handicrafts, clothes, food or agricultural products?

209. Since last (DAY OF THE WEEK), did (NAME) engage in any other activity in return for income in cash or in kind, even for only one hour?
IF NO: Please include any activity (NAME) performed as a regular or casual employee, self-employed, or employer, or as an unpaid family worker helping in household business or farm.

210. CHECK 206-209.

211. Since last (DAY OF THE WEEK), about how many hours did (NAME) engage in this activity (these activities), in total?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

212. Does this activity (Do these activities) require carrying heavy loads?

213. Does this activity (Do these activities) require working with dangerous tools (knives, etc.) or operating heavy equipment?

How would you describe the work environment of (NAME)?

214. Is (NAME) exposed to dust, fumes, or gas?

215. Is (NAME) exposed to extreme cold, heat, or humidity?

216. Is (NAME) exposed to loud noise or vibration?

217. Is (NAME) require to work at heights?

218. Is (NAME) required to work with chemicals (pesticides, glues, etc. ) or explosives?

219. Is (NAME) exposed to other things, processes or conditions bad for (NAME's) health or safety?

220. Since last (DAY OF THE WEEK), did (NAME) fetch water or collect firewood for the household?

221. In total, how many hour, did (NAME) spend on fetching water or collecting firewood for household use, since last (DAY OF THE WEEK)?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

Since last (DAY OF THE WEEK), did (NAME) do any of the following for the household:

222. Shopping for the household?

223. Repair any household equipment?

224. Cooking or cleaning utensils for the household?

225. Washing clothes?

226. Caring for children?

227. Caring for the old or sick?

228. Other household tasks?

228A. CHECK Q222-Q228:

229. Since last (DAY OF THE WEEK), how many hours, did (NAME) engage in this activity (these activities), in total?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

230. CHECK AGE Q012:

231. CHECK TABLE 2 AND RECORD THE RANK NUMBER SELECTED FOR THE MODULE. THEN CHECK TABLE 1 AND RECORD THE NAME OF THE CHILD CORRESPONDING TO THE RANK NUMBER.

ASK QUESTIONS 232 AND 233 FOR THIS CHILD.

232. Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are used. Please tell me if you are anyone else in your household has used this method with (NAME) in the past month.

233. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

300. CHECK IF HOUSEHOLD IS IN THE ANEMIA SUBSAMPLE ON THE IDENTIFICATION SHEET

TABLE FOR SELECTION OF THE ELIGIBLE WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

IF THERE IS NO ELIGIBLE WOMAN, RECORD '00' IN BOXES ASSIGNED FOR RECORDING LINE NUMBER OF ELIGIBLE WOMAN. THEN GO TO QUESTION 301.

IF ONLY ONE ELIGIBLE WOMAN WRITE THE NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

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 014) IN THE HOUSEHOLD SCHEDULE. CIRCLE THIS NUMBER AT THE TOP OF THE TABLE TO DETERMINE THE COLUMN NUMBER YOU SHOULD USE.

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 THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER FO THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

WEIGHT AND HEIGHT MEASUREMENT

301. CHECK COLUMNS 014, 015, AND 015A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL PERSONS ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT. BEGIN WITH EVER-MARRIED WOMEN AGE 15-49 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 014 CONTINUE WITH ALL MALES AGE 0-19 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015. THEN RECORD INFORMATION FOR ALL NEVER MARRIED FEMALES AGE 0-19 YEARS WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015A. IF MORE THAN NINE PERSONS, USE AN ADDITIONAL QUESTIONNAIRE.

302. LINE NUMBER FROM COLUMN 014-015 OR 015A
NAME FROM COLUMN 002

303. What is (NAME)'s birth date?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY. IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

304. CHECK 303 MONTH AND YEAR OF BIRTH:
IS THE YEAR OF BIRTH 1994 OR LATER?

305. WEIGHT IN KILOGRAMS

306. HEIGHT IN CENTIMETERS

307. MEASURED LYING DOWN OR STANDING UP?

308. GO BACK TO 302A IN NEXT COLUMN OF THIS PAGE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE ELIGIBLE PERSONS, GO TO 309.

309. NAME OF MEASURER

NAME OF ASSISTANT

HEMOGLOBIN MEASUREMENT

400. CHECK: IF HOUSEHOLD IN THE ANEMIA SUBSAMPLE

401. CHECK COLUMNS 014 , 015 AND 015A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL PERSONS ELIGIBLE FOR ANEMIA TESTING. BEGIN WITH EVER-MARRIED WOMEN AGE 15-49 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 014 CONTINUE WITH ALL MALES AGE 0-19 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015. THEN RECORD INFORMATION FOR ALL NEVER-MARRIED FEMALES AGE 0-19 YEARS WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015A. IF MORE THAN NINE PERSONS, USE AN ADDITIONAL QUESTIONNAIRE.

402. CHECK 302: RECORD NAME AND LINE NUMBER.

403. FROM 302 RECORD AGE

404. RECORD FROM QUESTION 303 DATE OF BIRTH.

405. CHECK 404: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

406. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD IN HOUSEHOLD SCHEDULE.

407. ASK FOR CONSENT FOR ANEMIA TEST FOR ELIGIBLE CHILD OR ADOLESCENT FROM ADULT IDENTIFIED IN 406 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 1994 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.

408. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

409. CHECK COLUMN 012 AND RECORD AGE.

410. ASK FOR CONSENT FOR ANEMIA TEST FOR ELIGIBLE ADULT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you (and your parent/guardian) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?

411. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

412. CHECK COLUMN 013 MARITAL STATUS

413. PREGNANCY STATUS: CHECK 226 IN EVER-MARRIED WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

414. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

415. GO BACK TO 402 IN NEXT COLUMN OF THIS PAGE OR IN THE FIST COLUMN OF THE NEXT PAGE; IF NO MORE ELIGIBLE PERSON, GO TO 416.

416. NAME OF TECHNICIAN

NAME OF ASSISTANT

INTERVIEWER OBSERVATIONS:

TO BE FILLED IN AFTER COMPLETING INTERVIEW

501. COMMENTS ABOUT RESPONDENT:
_________________________________________________________________________
_________________________________________________________________________
______________________________

502. COMMENTS ON SPECIFIC QUESTIONS:
_________________________________________________________________________
_________________________________________________________________________
_____________________________

503. ANY OTHER COMMENTS:
_________________________________________________________________________
_________________________________________________________________________
_____________________________

504. TECHNICIAN'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF TECHNICIAN: ______________________
DATE:___________________________

505. SUPERVISOR'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF SUPERVISOR_________________
DATE______________________

506. EDITOR'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF EDITOR____________
DATE________________