IDENTIFICATION

REGION

DISTRICT

WARD

ENUMERATION AREA

NAME OF HOUSEHOLD HEAD

TDHS NUMBER

HOUSEHOLD NUMBER

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE

LARGE CITIES ARE: DAR ES SALAAM, MWANZA, MBEYA AND TANGA. SMALL CITIES ARE: MOROGORO, DODOMA, MOSHI, IRINGA, SHINYANGA, SINGIDA, SONGEA, MTWARA, TABORA, MUSOMA, SUMBAWANGA, BUKOBA, KIGOMA NA MJINI MAGHARIBI. MIJI MINGINE NI MIJI MIDOGO

HOUSEHOLD SELECTED FOR MEN'S SURVEY AND SALT TESTING

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT*

RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE
TIME

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN 15-49

TOTAL ELIGIBLE MEN 15-49

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME

FIELD EDITOR
NAME

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is ______. I am working with National Bureau of Statistics. We are conducting a survey about health all over Tanzania. The information we collect will help the government to plan health services.
Your household was selected for the survey. The survey usually takes about 30 to 60 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 question 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.
Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: __________

DATE: ___________

HOUSEHOLD SCHEDULE

(1) LINE NO.

(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.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-19 FOR EACH PERSON.

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

(4) SEX: Is (NAME) male or female?

(5) RESIDENCE: Does (NAME) usually live here?

(6) RESIDENCE: Did (NAME) stay here last night?

(7) AGE: How old is (NAME)?
IF 95 OR MORE, WRITE '95'

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

(9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

(10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

(11) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 5

2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

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

(12) Is (NAME)'s natural mother alive?

(13) 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'.

(14) Is (NAME)'s natural father alive?

(15) 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'.

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

(16) Has (NAME) ever attended school?

(17) What is the highest level of school (NAME) has attended? SEE CODES BELOW.
What is the highest grade (NAME) completed at that level? SEE CODES BELOW.

(18) CURRENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: Is (NAME) currently attending school?

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

HOUSEHOLD CHARACTERISTICS

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

101A. Who is providing water at your main source?

101B. How long does it take you to go there, get water, and come back including waiting time?

101C. Do you do anything to the water to make it safer to drink?

101D. What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.

102. What kind of toilet facility do members of your household usually use?

103. Do you share this toilet facility with other households?

103A. How many households share this toilet facility?

104. Does your household have:

105. What type of fuel does your household mainly use for cooking?

106. What is the main source of energy for lighting in the household?

107. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION.
MARK ONLY ONE.

108. WALL MATERIAL
RECORD OBSERVATION.
MARK ONLY ONE.

109. ROOFING MATERIAL
RECORD OBSERVATION.
MARK ONLY ONE.

110. How many rooms in your household are used for sleeping?
(INCLUDING ROOMS OUTSIDE THE MAIN DWELLING)

111. Does any member of your household own:

112. How many acres of land for farming or grazing does this household own?
(PUT '0000.0' IF NONE AND 9999.8 IF DOESN'T KNOW)

113. Does the household use land for farming or grazing that it doesn't own?
IF YES: Is it rented, sharecropped, private land provided free, or open access/communal/other?

114. How many acres of land are used?
(PUT '0000.0' IF NONE AND 9999.8 IF DOESN'T KNOW)

115. How far is it to the nearest market place?
(WRITE '00' IF LESS THAN ONE KILOMETRE)

116. Now I would like to ask you about the food your household eats?
How many meals does your household usually have per day?

117. In the past week, on how many days did the household eat meat?

118. In the past week, on how many days did the household eat fish?

119. How often in the last year did you have problems in satisfying the food needs of the household?

120. How far is it to the nearest health facility?
(WRITE '00' IF LESS THAN ONE KILOMETRE)
IF MORE THAN 95 KM, WRITE 95.

121. If you were to go to (NAME OF HOSPITAL, HEALTH CENTRE, or HEALTH POST), how would you go there?

122. Did anyone in the household prepare ugali with maize flour in the past 7 days?

123. Where did you get the maize flour?

124. Where did you buy the maize flour?

125. What brand did you buy?

126. Did your household use oil to cook with in the past 7 days?

127. What kind of oil was it?

128. Where did you get the oil?

129. What brand did you buy?

130. Does your household have any mosquito nets that can be used while sleeping?

131. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

132. ASK RESPONDENT TO SHOW YOU THE NET(S).
IF MORE THAN 6 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

133. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, WRITE '00'.

134. OBSERVE BRAND OR TYPE OF MOSQUITO NET.
FEEL TEXTURE OF NET IF STIFF/ROUGH CIRCLE 'OLYSET'

135. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

136. Who treated the net?

137. How many months ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

138. Did anyone sleep under this mosquito net last night?

139. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

140. GO BACK TO 132 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 141.

141. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

142. CHECK COVER OF HOUSEHOLD QUESTIONNAIRE. IF HOUSEHOLD SELECTED FOR ADDITIONAL SALT TESTING ASK FOR ADDITIONAL FULL TABLESPOON OF SALT. PLACE SALT IN CONTAINER.
PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S CONTAINER OF SALT AND THE 3RD ON THE TRANSMITTAL FORM.

SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

200. ONLY ONE WOMAN PER HOUSEHOLD SHOULD BE SELECTED FOR DV MODULE. USE THE TABLE BELOW TO SELECT ONE WOMAN TO BE INTERVIEWED WITH DV MODULE IN THIS HH.

NAME OF SELECTED WOMAN____________________________________
HH LINE NUMBER _______

GO TO COL. 9 IN THE HH SCHEDULE AND WRITE 'DV' NEXT TO THE LINE NUMBER OF THE WOMAN SELECTED.

HOW TO USE THE TABLE FOR SELECTION OF RESPONDENTS FOR DV

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 FEMALES (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN YOU SHOULD GO TO.
THE CELL WHERE THE ROW AND THE COLUMN MEET IS THE NUMBER OF THE SELECTED WOMAN FOR THE DOMESTIC VIOLENCE MODULE IN THE HOUSEHOLD SCHEDULE.
FOR EXAMPLE, THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 (LINE NUMBERS 02, 04, AND 05). IF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '216', THE LAST DIGIT IS "6", THEREFORE GO TO ROW '6'. THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD, THEREFORE GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER WHERE THE ROW AND COLUMN MEET ('2') AND CIRCLE THE BOX. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER "04" IN OUR EXAMPLE). WRITE HER LINE NUMBER ABOVE IN THE BOXES INDICATED.
TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE
LAST DIGIT OF THE HOUSEHOLD Q-RE SERIAL NUMBER
TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 IN THE HOUSEHOLD

WEIGHT, HEIGHT, HEMOGLOBIN, VITAMIN A AND IRON FOR CHILDREN 0-5 YEARS

501. CHECK COLUMN 11. RECORD THE LINE NUMBER, NAME AND AGE FOR ALL ELIGIBLE CHILDREN LESS THAN 5 YEARS OF AGE IN QUESTIONS 502-503. IF THERE ARE MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 513 AND FOR THE VITAMIN A TEST PROCEDURE IN 517 FOR EACH ELIGIBLE CHILD.
IF NO ELIGIBLE CHILDREN, TICK HERE AND SKIP TO Q. 601

502. LINE NUMBER (COLUMN 11)
NAME (COLUMN 2)

503. What is (NAME'S) birth date?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HIST ORY AND ASK DAY OF BIRTH; IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH AND YEAR OF BIRTH

504. CHECK 503:
CHILD BORN IN JANUARY 2005 OR LATER?

505. WEIGHT IN KILOGRAMS

506. HEIGHT IN CENTIMETERS

507. MEASURED LYING DOWN OR STANDING UP?

509. CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

510. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONS IBLE FOR CHILD (COLUMN 1 HH SCHEDULE). RECORD '00' IF NOT LISTED.

510A. READ ALL CONSENT STATEMENTS. PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT WAS GIVEN.

CONSENT STATEMENT FOR ANEMIA TEST FOR CHILDREN
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 request that all children born in 2005 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger.
The equipment used in taking 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 told to you right away. The result will be kept 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 allow (NAME(S) OF CHILD(REN)) to participate in the anemia test?

512. READ ANEMIATEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD.
CIRCLE CODE AND SIGN.

513. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

515. READ VITAMIN A AND IRON CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

CONSENT STATEMENT FOR VITAMIN A, IRON DEFICIENCY AND INFECTION TEST FOR CHILDREN
As part of the survey we also are asking people all over the country to take a test for vitamin A and iron deficiency and infection. Vitamin A and iron deficiency are health problems that can result from poor nutrition.
Low Vitamin A can lead to blindness and low resistence to infection and low iron can slow how well children grow and develop.
This survey will help the government to develop programs to prevent and treat iron and Viatmin A deficiency.
For these tests, we need a few (more) drops of blood from a finger.
No names will be attached so we will not be able to tell you the test results. No one else will be able to know the test results are for your child.
The test will be done at the Tanzanian Food and Nutrition Center Laboratory.
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 allow (NAME(S) OF CHILD(REN)) to take the vitamin A deficiency test?

516. BAR CODE LABEL
VITAMIN A AND IRON
PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

517. OUTCOME OF BLOOD VITAMIN A AND IRON TEST PROCEDURE

518. GO BACK TO 502 IN NEXT COLUMN IN THIS QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 601.

TICK HERE IF CONTINUED IN ANOTHER QUESTIONNAIRE.

WEIGHT, HEIGHT, HEMOGLOBIN, VITAMIN A. IRON AND URINARY IODINE FOR WOMEN AGE 15-49

601. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 602. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 610 AND FOR THE VITAMIN A TEST PROCEDURE IN 616 FOR EACH ELIGIBLE WOMAN.

IF NO ELIGIBLE WOMEN, TICK HERE

602. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

603. WEIGHT IN KILOGRAMS

604. HEIGHT IN CENTIMETERS

606. AGE:
CHECK COLUMN 7.

607. MARITAL STATUS:
CHECK COLUMN 8.

608. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONS IBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

608A. READ CONSENT STATEMENTS AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED.

609. READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPOND ENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 609 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE Q.608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 609 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of this survey, we are asking people all over the country to give blood for 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 in taking 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 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 (allow NAME OF ADOLESCENT to) take the anemia test?

610. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

613. PREGNANCY STATUS:
CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

614. READ THE VITAMIN A AND IRON CONSENT STATEMENT.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR VITAMIN A AND IRON DEFICIENCY TESTS
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 614 IF RESPONDENT CONSENTS TO THE VITAMIN A AND IRON TESTS AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 614 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of the survey we also are asking people all over the country to give blood for a vitamin A and iron deficiency test. Low Iron and vitamin A are health problems that can result from poor nutrition. Low Vitamin A can lead to blindess and lower resistence to infections and low iron cause low energy and tiredness in women.
This survey will help the government to develop programs to prevent and treat vitamin A and iron deficiency.
For the tests, we need a few more drops of blood from a finger after the blood for anemia has been collected.
Again the equipment used in taking the blood is clean and completely safe.
It has never been used before and will be thrown away after each test.
The test will be done at the Tanzanian Food and Nutrition Center Laboratory.
No names will be attached so we will not be able to tell you the test results. No one else will be able to know the test results are for you/(NAME OF ADOLESCENT).
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 (allow NAME OF ADOLESCENT to) take the test?

615. BAR CODE LABEL
VITAMIN A
AND IRON
PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

616. OUTCOME OF VITAMIN A AND IRON TESTS PROCEDURE

617. READ THE URINARY IODINE CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR URINARY IODINE TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 617 IF RESPONDENT CONSENTS TO THE URINARY IODINE TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 617 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of the survey we also are asking women all over the country to take a test for iodine deficiency. Iodine deficiency is a health proble that can result poor nutrition.
This survey will help the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of your urine. The urine will be tested at the Tanzanian Food and Nutrition Laboratory
No names will be attached so we will not be able to tell you the test results. No one else will be able to know the test results are for you/(NAME OF ADOLESCENT).
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 (allow NAME OF ADOLESCENT to) take the iodine deficiency test?

618. BAR CODE
URINARY IODINE

PUT THE 1ST BAR CODE LABEL
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S COLLECTION CUP AND THE THIRD LABEL ON THE COLLECTION TUBE AND THE FOURTH LABEL ON THE TRANSMITTAL FORM.

619. OUTCOME OF URINARY IODINE TEST PROCEDURE

620. GO BACK TO 603 IN THE NEXT COLUMN IN THE QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, END INTERVIEW.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
______________________________________

COMMENTS ON SPECIFIC QUESTIONS:
______________________________________

ANY OTHER COMMENTS:
______________________________________

SUPERVISOR'S OBSERVATIONS
______________________________________

NAME OF THE SUPERVISOR: __________
DATE: __________