1120) Where is that?
IF SOURCE IS HOSPITAL, HEALTH UNIT, OR CLINIC, WRITE THE NAME OF THE PLACE.
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
Any other place?
RECORD ALL SOURCES MENTIONED.
(NAME OF PLACE) _______________________
GOVERNMENT
GOVERNMENT HOSPITAL A
GOVT. HEALTH UNIT B
VCT CENTER C
FAMILY PLANNING CLINIC D
MOBILE CLINIC E
OTHER GOVT (SPECIFY) __________ F
NON GOVERNMENTAL (SPECIFY) ___________ G
PRIVATE MEDICAL
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR H
PHARMACY I
OTHER PRIVATE MEDICAL (SPECIFY) _________ J
OTHER NON-MEDICAL (SPECIFY) __________ X