DISTRICT NAME AND NUMBER
VILLAGE/MUNICIPALITY NAME AND NUMBER
NAME OF HOUSEHOLD
NAME OF RESPONDENT
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
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___________ 9
Now we would like some information about the people who usually live in your household or who are staying with you now.
1. LINE NUMBER
2. 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.
8. Has (NAME) ever been to school?
11. Has (NAME) ever been married?
12. Has (NAME) started living with his/her spouse?
PUBLIC TAP 12
PUBLIC WELL 22
STONE TAP (DHARA) 44
ON PREMISES 996
VENILATED IMPROVED PIT 22
NO FACILITY/BUSH/FIELD 41
OTHER (SPECIFY) 96 ___
OTHER (SPECIFY) ___ 96
MARBLE CHIPS 34
NOT IODIZED 12
LOOSE SALT 22