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DEMOGRAPHIC AND HEALTH SURVEY IN MALI (EDSM-V, 2012), MEN'S QUESTIONNAIRE

COMMITTEE OF PLANNING AND STATISTICS/MINISTRY OF HEALTH
NATIONAL OFFICE OF STATISTICS AND INFORMATION
REPUBLIC OF MALI

IDENTIFICATION

PLACE NAME________
CLUSTER_________
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD_____________
PLOT NUMBER ________
HOUSEHOLD NUMBER__________
ADMINISTRATIVE REGION_________

URBAN/RURAL/ MILIEU

URBAN 1
RURAL 2

BAMAKO, OTHER CITIES, OTHER TOWNS, RURAL/MILIEU (DETAILED)

BAMAKO 1
OTHER CITIES 2
OTHER TOWNS 3
RURAL 4

MAN'S FIRST AND LAST NAME AND LINE NUMBER

NAME_________
LINE NUMBER________

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE___________

INTERVIEWER'S NAME________
RESULT*__________

NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE_______
TIME________

FINAL VISIT
DAY_____
MONTH______
YEAR 2012
INTERVIEWER'S NAME_______
RESULT________

TOTAL NUMBER OF VISITS_________

*RESULTS CODES


COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER________ (SPECIFY) 7