CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE FOR ANEMIA TEST
RECORD '00' IF NOT LISTED
(RECORD 00 IF NONE LISTED)
RECORD 00 IF NOT LISTED
STATE/REGION______
DISTRICT_____
TOWNSHIP_____
WARD/VILLAGE TRACT____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
LINE NUMBER OF WOMAN___
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
(RECORD '00' IF NOT LISTED)
WOMAN 1
WOMAN 2
WOMAN 3
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
IF NO: RECORD '00'.