COMMITTEE OF PLANNING AND STATISTICS/MINISTRY OF HEALTH
NATIONAL OFFICE OF STATISTICS AND INFORMATION
REPUBLIC OF MALI
PLACE NAME________
CLUSTER_________
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD_____________
PLOT NUMBER ________
HOUSEHOLD NUMBER__________
ADMINISTRATIVE REGION_________
RURAL 2
BAMAKO, OTHER CITIES, OTHER TOWNS, RURAL/MILIEU (DETAILED)
OTHER CITIES 2
OTHER TOWNS 3
RURAL 4
MAN'S FIRST AND LAST NAME AND LINE NUMBER
LINE NUMBER________
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_________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER________ (SPECIFY) 7