PROVINCE
DISTRICT
VILLAGE/NAHIA
CONTROLLER AREA
CLUSTER NUMBER
TYPE OF LOCATION
STRUCTURE/BUILDING NUMBER/GATE NUMBER
HOUSEHOLD NUMBER
NAME OF HOUSEHOLD HEAD
NAME AND LINE NUMBER OF WOMAN
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
PLACE NAME ________
NAME OF HOUSEHOLD HEAD_______
PROVINCE_______
MUNICIPALITY_____
COMMUNITY_______
NEIGHBORHOOD/VILLAGE______
CENSUS SECTION______
AREAS OF RESIDENCE
CLUSTER NUMBER (ID. IIMS)______
HOUSEHOLD NUMBER_______
NAME AND LINE NUMBER OF WOMAN_______
THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
REGION ___
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
REGION ___
DIVISION:
DISTRICT:
THANA:
UNION OR WARD:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE?
NAME OF HOUSEHOLD HEAD:
NAME AND LINE NUMBER OF ELIGIBLE WOMAN:
DIVISION:
DISTRICT:
UPAZILA:
UNION OR WARD:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
RURAL OR MUNICIPALITY OR OTHER URBAN OR SMA?
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
NAME OF THE HOUSEHOLD HEAD____
NAME AND LINE NUMBER OF WOMAN____
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
CLUSTER NUMBER __________
HOUSEHOLD NUMBER __________
NAME OF THE HOUSEHOLD HEAD __________
NAME AND LINE NUMBER OF WOMAN __________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
NAME OF THE HOUSEHOLD HEAD _____
NAME AND LINE NUMBER OF ELIGIBLE WOMAN ________________
DEPARTMENT
SUB-PREFECTURE/URBAN DISTRICT
RURAL/URBAN MUNICIPALITY
VILLAGE/NEIGHBORHOOD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
DEPARTMENT
MUNICIPALITY
DISTRICT
TOWN/NEIGHBORHOOD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
PROVINCE _____
DEPARTMENT _____
COMMUNE/URBAN CENTER _____
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER_____
VILLAGE/SECTOR _____
PLACE NAME ______
NAME OF HOUSEHOLD HEAD _______
CLUSTER NUMBER ______
HOUSEHOLD UNIT NUMBER _______
REGION _______
VILLAGE _______
PLACE NAME ______
CLUSTER NUMBER _____
PLOT NUMBER _____
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
REGION _____
PLACE NAME/SUB-DISTRICT______
NAME OF HEAD OF HOUSEHOLD______
PROVINCE_______
MUNICIPALITY_______
DISTRICT NAME AND NUMBER_____
CLUSTER NUMBER______
HOUSEHOLD NUMBER______
IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PROVINCE
CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN
WOMAN SELECTED FOR MODULE ON VIOLENCE?
NAME OF HEAD OF HOUSEHOLD ___
HOUSEHOLD ___
WOMAN'S NAME ___
WOMAN'S LINE NUMBER ___
LOCALITY NAME: ___
NAME OF HEAD OF HOUSEHOLD: ___
REGION: ___
CLUSTER NUMBER: ___
STRUCTURE NUMBER: ___
HOUSEHOLD NUMBER: ___
NAME OF HEAD OF HOUSEHOLD AND HOUSEHOLD NUMBER: ___
NAME AND LINE NUMBER OF WOMAN: ___
IDENTIFICATION
NAME OF LOCALITY__________
NAME OF HEAD OF HOUSEHOLD___________
DEPARTMENT:___
SUBPREFECTURE: ___
MUNICIPALITY:___
CLUSTER NUMBER (EDST):___
STRUCTURE NUMBER:___
HOUSEHOLD NUMBER IN THE STRUCTURE: ___
SEQUENTIAL NUMBER OF SELECTED HOUSEHOLD (01-24 URBAN; 01-33 RURAL:___
Urban/rural
Residence
WOMAN'S NAME AND LINE NUMBER (FROM HOUSEHOLD QUESTIONNAIRE)_______
REGION NAME
LOCALITY NAME (NEIGHBORHOOD/VILLAGE)__________
NAME OF HEAD OF HOUSEHOLD____________
CLUSTER NUMBER
HOUSEHOLD NUMBER (URBAN=01 TO 25; RURAL=01 TO 30)
HOUSEHOLD NUMBER (SEQUENTIAL IN THE CLUSTER)
URBAN/RURAL (URBAN=1, RURAL=2)
N'DJAMENA-MOUNDOU/SARH/ABECHE-OTHER CITY-RURAL (N'DJAMENA=1, MOUNDOU/SARH/ABECHE=2, OTHER CITY=3, RURAL=4)
WOMAN'S NAME AND LINE NUMBER_________________
RESPONDENT POOL _________
NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) _________
NAME OF HOUSEHOLD HEAD ___________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER ______
PROVINCE _____
NAME OF HEAD OF HOUSEHOLD ____
CLUSTER NUMBER
HOUSEHOLD NUMBER
FORMER PROVINCE
NEW PROVINCE
DEPARTMENT NAME____
SUB-PREFECTURE NAME____
CENSUS DISTRICT___
CLUSTER NUMBER___
STRUCTURE NUMBER____
HOUSEHOLD NUMBER___
DEPARTMENT ___
SUB PREFECTURE ___
CENSUS DISTRICT ___
CLUSTER NUMBER ___
STRUCTURE NUMBER ___
HOUSEHOLD NUMBER ___
PLACE NAME_________
NAME OF HEAD OF HOUSEHOLD__________
CLUSTER NUMBER_____
STRUCTURE NUMBER________
HOUSEHOLD NUMBER________
REGION_______
PLACE NAME________
NAME OF HOUSEHOLD HEAD______
DHS CLUSTER NUMBER_____
PSU CODE____
HOUSEHOLD NUMBER_____
REGION ________________
ZONE __________________
WOREDA _______________
TOWN _________________
KEBELE _______________
ENUMERATION AREA ________________
CLUSTER NUMBER __________________
LOCALITY NAME ____________________
NAME OF HOUSEHOLD HEAD __________________________
CLUSTER NUMBER ___ ___ ___
HOUSEHOLD NUMBER ___ ___
REGION ___ ___
LOCALITY NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____
LOCALITY NAME:
NAME OF HOUSEHOLD HEAD:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
NAME AND LINE NUMBER OF WOMAN:
HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION AND DV?
PLACE NAME___
NAME OF HOUSEHOLD HEAD___
CLUSTER NUMBER___
HOUSEHOLD NUMBER___
NAME AND LINE NUMBER OF WOMAN___
PLACE NAME _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER ______
LINE NUMBER OF WOMAN _____
NAME OF WOMAN ______
LOCALITY NAME _____
NAME OF HOUSEHOLD HEAD ____
CLUSTER NUMBER _____
STRUCTURE NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____
DISTRICT _____
URBAN/RURAL
NAME AND LINE NUMBER OF WOMAN:
MINISTRY OF HEALTH
GHANA STATISTICAL SERVICES
IDENTIFICATION
LOCALITY NAME __________________
NAME OF HOUSEHOLD HEAD _____________________
REGION ________
DISTRICT ___________
CLUSTER NUMBER __________
HOUSEHOLD NUMBER ___________
NAME AND LINE NUMBER OF WOMAN ____________________
PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION CODE _____
PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____
URBAN/RURAL:
NAME OF PLACE__________
NAME OF HEAD OF HOUSEHOLD____________
CLUSTER NUMBER___________
HOUSEHOLD NUMBER____________
ADMINISTRATIVE REGION_____________
NAME AND LINE NUMBER OF WOMAN
PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____
1. GOVERNORATE
2. DISTRICT
3. SUBDISTRICT
4. LOCALITY
5. STRATUM NUMBER
6. CENSUS BLOCK NUMBER
7. JPFHS-II CLUSTER NUMBER
8. HOUSEHOLD NUMBER
9. URBAN/RURAL
10. AMMAN/LARGE CITY/MEDIUM CITY/TOWN/COUNTRYSIDE
AMMAN ALMOST 1,000,000
MEDIUM CITY (ZARQA, RUSSAIFA, IRBID, SALT, MADABA) 50,000 - 500,000
SMALL CITY 20,000 - 49,999
TOWN 5,000 - 19,999
COUNTRYSIDE LESS THAN 5,000
11. NAME OF HOUSEHOLD HEAD
12. NAME AND LINE NUMBER OF WOMAN
GROUP NO:__
QUESTIONNAIRE NO:___
GOVERNORATE:____
DISTRICT:____
SUBDISTRICT:____
LOCALITY:____
STRATUM:____
URBAN/RURAL:
BLOCK NO:_____
BUILDING NO:_____
HOUSING UNIT NO:_____
CLUSTER NO:_____
HOUSEHOLD NO:____
TELEPHONE NO (IF AVAILABLE):____________
NAME AND LINE NUMBER OF WOMAN: _______________
GOVERNORATE ____
DISTRICT______
SUB-DISTRICT _____
LOCALITY ______
AREA ____
SUB-AREA ______
STRATUM ______
URBAN/ RURAL
QUESTIONNAIRE NUMBER______
BLOCK NUMBER ______
BUILDING NUMBER _____
HOUSING UNIT NUMBER ________
CLUSTER NUMBER ________
HOUSEHOLD NUMBER _______
TELEPHONE/ MOBILE NUMBER (if available) __________
QUESTIONNAIRE NO.: _____
GOVERNORATE: __________
DISTRICT: _________
SUB-DISTRICT: ________
LOCALITY: ________
AREA: ________
SUB-AREA: ________
STRATUM: ________
URBAN/RURAL
BLOCK NO.: ___
BUILDING NO.: ___________
HOUSING UNIT NO.: __________
CLUSTER NO: __________
HOUSEHOLD NO.: ____________
TELEPHONE/MOBILE NO. (if available)
____________________
NAME AND LINE NUMBER OF WOMAN: ______________________ ____
QUESTIONNAIRE NUMBER _____
GOVERNORATE ____
DISTRICT _____
SUB-DISTRICT _____
LOCALITY ____
AREA _____
SUB-AREA _____
STRATUM _____
URBAN/RURAL
BLOCK NUMBER _____
BUILDING NUMBER _____
HOUSING UNIT NUMBER _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
TELEPHONE/MOBILE NUMBER (if available) _______________
CLUSTER NUMBER ___________
HOUSEHOLD NUMBER __
NAME OF HOUSEHOLD HEAD ____________________
NAME AND LINE NUMBER OF WOMAN __________________________ ___
TELEPHONE/MOBLIE NUMBER (IF AVAILABLE) _______________________
PROVINCE __________
DISTRICT __________
LOCATION/TOWN __________
SUBLOCATION/WARD __________
CLUSTER NUMBER
HOUSEHOLD NUMBER
STRUCTURE NUMBER
PROVINCE __________
DISTRICT __________
LOCATION/TOWN __________
SUBLOCATION/WARD __________
NASSEP CLUSTER NUMBER__
KDHS CLUSTER NUMBER__
PROVINCE __________
DISTRICT __________
LOCATION/TOWN __________
SUBLOCATION/WARD __________
NASSEP CLUSTER NUMBER
KDHS CLUSTER NUMBER
COUNTRY ____________
DISTRICT ____________
LOCATION/TOWN ____________
SUBLOCATION ____________
NASSEP CLUSTER NUMBER ____________
KDHS CLUSTER NUMBER ____________
HOUSEHOLD NUMBER ____________
NAME OF HOUSEHOLD HEAD ____________
NAME AND LINE NUMBER OF WOMAN ____________
CHECK IN 101A IN HOUSEHOLD QUESTIONNAIRE: IS WOMAN SELECTED FOR SECTION 14?
PLACE NAME __________________
NAME OF HOUSEHOLD HEAD ____________________
EA NUMBER ___ ___ ___
HOUSEHOLD NUMBER ___ ___ ___
FARITANY (REGION) NAME ______
FIVONDRONAMPOKOTANY (DISTRICT) NAME ______
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER _____
PLACE NAME ____
NAME OF HOUSEHOLD HEAD ____
CLUSTER NUMBER ____
HOUSEHOLD UNIT NUMBER ____
REGION (FARITANY) ____
PLACE NAME _______
NAME OF HOUSEHOLD HEAD _______
CLUSTER NUMBER _______
HOUSEHOLD UNIT NUMBER _______
REGION (FARITANY) ______
VILLAGE ______
PLACE NAME ______
NAME OF HOUSEHOLD HEAD _______
CLUSTER NUMBER _______
SEQUENTIAL NUMBER OF THE HOUSEHOLD WITHIN THE CLUSTER _______
BUILDING NUMBER _______
HOUSEHOLD UNIT NUMBER _______
REGION ______
VILLAGE ______
ANTANANARIVO/OTHER CITY/RURAL AREA?
TA/STA/TOWN______
ENUMERATION AREA _______
VILLAGE OR PLACE_______
MDHS CLUSTER NUMBER _______
HOUSEHOLD NUMBER ________
NAME OF HOUSEHOLD HEAD_____
MDHS CLUSTER NUMBER _____
HOUSEHOLD NUMBER ______
URBAN/RURAL _____
NAME OF HOUSEHOLD HEAD __________________
DISTRICT _____________________ ___
CLUSTER NUMBER __
HOUSEHOLD NUMBER ___
URBAN/RURAL __
NX__
OF__
NUMBER OF HOUSEHOLD QUESTIONNAIRE__
REGION__
CLUSTER__
ARRONDISSEMENT/COMMUNE__
VILLAGE CODE__
VILLAGE NEIGHBORHOOD__
NAME OF HEAD OF COMPOUND__
NAME OF HEAD OF HOUSEHOLD__
PLACE NAME__
NAME OF HEAD OF HOUSEHOLD__
CLUSTER NUMBER___
COMPOUND__
HOUSEHOLD NUMBER______
REGION__
CIRCLE__
PLACE NAME____
CLUSTER NUMBER_____
CONCESSION NUMBER _____
PLACE NAME__
FULL NAME OF HEAD OF THE HOUSEHOLD ____
COMMUNE__
CLUSTER NUMBER___
HOUSEHOLD NUMBER______
ADMINISTRATIVE REGION ____
NAME OF PLACE____________
CLUSTER NUMBER_______
LAST NAME AND FIRST NAME OF HEAD OF HOUSEHOLD_______________
PLOT NUMBER_______
HOUSEHOLD NUMBER__________
REGION____________
WOMAN'S QUESTIONNAIRE
IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN
REGION _____
PROVINCE OR PREFECTURE ___
CIRCLE ___
MUNICIPALITY/RURAL MUNICIPALITY ____
OTHER CENTER ___
SURVEY DISTRICT _
RABAT-CASA/LARGER CITY/SMALL CITY/RURAL
CLUSTER NUMBER __
HOUSEHOLD NUMBER ___
HOUSEHOLD ADDRESS ____
NAME OF HEAD OF HOUSEHOLD ________
PLACE NAME ________
NAME OF HOUSEHOLD HEAD_______
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
PROVINCE_______
STATE/REGION______
DISTRICT_____
TOWNSHIP_____
WARD/VILLAGE TRACT____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
LINE NUMBER OF WOMAN___
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
NAME AND CODE OF REGION _______
NAME OF VILLAGE/TOWN/CITY _________
DHS CLUSTER NUMBER _______
HOUSEHOLD NUMBER ________
NAME OF HOUSEHOLD HEAD __________
NAME AND LINE NUMBER OF WOMAN ________
NAME AND THE CODE OR REGION __________
PLACE (LOCALITY) NAME __________
CLUSTER NAME _____
HOUSEHOLD NUMBER _____
IDENTIFICATION
DISTRICT NAME AND NUMBER
VILLAGE/MUNICIPALITY NAME AND NUMBER
WARD NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
CITY/TOWN/COUNTRYSIDE
NAME OF HOUSEHOLD HEAD
NAME AND LINE NUMBER OF WOMAN
NAME AND CODE OF DISTRICT ________________
NAME AND CODE OF VILLAGE/MUNICIPALITY __________
WARD NUMBER ____________
CLUSTER NUMBER __________
HOUSEHOLD NUMBER ______________
NAME OF HOUSEHOLD HEAD_____
NAME AND LINE NUMBER OF WOMAN ____________
NAME AND CODE OF DISTRICT
NAME AND CODE OF VILLAGE/MUNICIPALITY
WARD NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
CITY/TOWN/RURAL
NAME AND LINE NUMBER OF WOMAN
NAME OF HOUSEHOLD HEAD
NAME AND CODE OF VILLAGE/MUNICIPALITY _____________
WARD NUMBER _____________
CLUSTER NUMBER _____________
NAME AND LINE NUMBER OF WOMAN _____________
NAME OF HOUSEHOLD HEAD _____________
NAME AND CODE OF DISTRICT
NAME AND CODE OF VILLAGE/MUNICIPALITY
WARD NUMBER
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN
PLACE NAME ___
NAME OF HOUSEHOLD HEAD ___
CONCESSION NUMBER ___
HOUSEHOLD NUMBER ___
CLUSTER NUMBER ___
DEPARTMENT ___
DISTRICT ___
COUNTY ___
PLACE NAME __________
CLUSTER NUMBER __________
COMPOUND NUMBER __________
HOUSEHOLD NUMBER ________
REGION __________
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD _____
NAME OF PLACE ___________
CLUSTER NUMBER ___________
CONCESSION NUMBER ____________
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD ____________
REGION _____________
PLACE NAME _________________________
NAME OF RESPONDENT __________________________
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
STATE __
STATE _____
LOCAL GOVT. AREA_____
ENUMERATION AREA_____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____
NAME AND LINE NUMBER OF WOMEN_____
PLACE NAME_______________
NAME OF HOUSEHOLD____________
PROVINCE ____
URBAN/RURAL
MAJOR CITY/DIVISION/DISTRICT ____
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
MAJOR CITY/SMALL CITY, TOWN/VILLAGE
NAME AND LINE NUMBER OF WOMEN______________
NAME AND LINE NUMBER OF HUSBAND (IF ELIGIBLE)
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
REGION
PLACE NAME_____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____
TEHSIL _______
NAME OF HOUSEHOLD HEAD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER _________
NAME AND LINE NUMBER OF WOMAN _______
NAME OF LOCALITY _____
NAME OF HOUSEHOLD HEAD ______
PROVINCE ______
DISTRICT _____
SECTOR _____
CLUSTER NUMBER _____
STRUCTURE NUMBER _____
HOUSEHOLD NUMBER _____
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD STRUCTURE NUMBER
HOUSEHOLD NUMBER
MINECOFIN
MINISTRY OF HEALTH
NATIONAL INSTITUTE OF STATISTICS
IDENTIFICATION
PROVINCE____
DISTRICT____
SECTOR____
NAME OF HOUSEHOLD HEAD____
CLUSTER NUMBER____
HOUSEHOLD STRUCTURE NUMBER____
HOUSEHOLD NUMBER____
NAME AND LINE NUMBER OF WOMAN:
NAME____
LINE NO.____
VILLAGE____
DEPARTMENT____
NEIGHBORHOOD/REGION____
ARRONDISSEMENT/COMMUNE____
SUB-DISTRICT____
PARCELLE NUMBER____
CONCESSION NUMBER (a group of houses on a plot, usually centered around the huts of a man and his wives) ____
HOUSEHOLD NUMBER _____
PLACE NAME (COMMUNE/VILLAGE) _____
NAME OF HEAD OF HOUSEHOLD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____
REGION_____
PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
COMPOUND NUMBER _____
CLUSTER NUMBER _____
REGION _____
PLACE NAME_____
NAME OF HEAD OF HOUSEHOLD_____
HOUSEHOLD NUMBER_____
CONCESSION NUMBER _____
CLUSTER NUMBER _____
REGION _____
DEPARTMENT_____
SANITARY DISTRICT______
PLACE NAME ________________
NAME OF HEAD OF HOUSEHOLD ______________
PLOT NUMBER ___________
CLUSTER NUMBER ____________
REGION ___________
PLACE NAME ________
NAME OF HEAD OF HOUSEHOLD _________
HOUSEHOLD NUMBER __________
PLOT NUMBER ___________
CLUSTER NUMBER ____________
REGION_________
DEPARTMENT________
SANITARY DISTRICT _________
PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER ____
PLOT NUMBER ____
CLUSTER NUMBER _____
REGION ____
DEPARTMENT ____
SANITATION DISTRICT ____
URBAN/RURAL
MILIEU ____
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
WOMAN'S NAME AND LINE NUMBER _____
CHECK COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE
HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?
IF HOUSEHOLD SELECTED FOR DV, CHECK WOMEN'S SELECTION TABLE (Q157A OF HOUSEHOLD QUESTIONNAIRE)
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?
PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER ____
PLOT NUMBER ____
CLUSTER NUMBER _____
REGION ____
DEPARTMENT ____
SANITATION DISTRICT ____
URBAN/RURAL
MILIEU ____
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
WOMAN'S NAME AND LINE NUMBER _____
CHECK COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE
HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?
IF HOUSEHOLD SELECTED FOR DV, CHECK WOMEN'S SELECTION TABLE (Q157A OF HOUSEHOLD QUESTIONNAIRE)
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?
IDENTIFICATION
PROVINCE
DISTRICT
EA NUMBER
EA TYPE
SADHS CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN
NAME OF HOUSEHOLD HEAD
PLACE NAME ______________
NAME OF HOUSEHOLD HEAD ______________
CLUSTER NUMBER ________
HOUSEHOLD NUMBER ____
NAME AND LINE NUMBER OF WOMAN ________________ ____
REGION
PROVINCE
PLACE NAME
URBAN/RURAL
CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN
NAME OF HOUSEHOLD HEAD ______________________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
REGION ___________________ ___
DISTRICT __________________ ___
WARD __________________ ___
REGION___
DISTRICT___
WARD___
E.A. NUMBER___
TRCHS CLUSTER NUMBER___
HOUSEHOLD NUMBER___
REGION
DISTRICT
WARD
ENUMERATION AREA
NAME OF HOUSEHOLD HEAD
TDHS NUMBER
HOUSEHOLD NUMBER
REGION_______
DISTRICT________
WARD_______
ENUMERATION AREA______
NAME OF HOUSEHOLD HEAD_____
TDHS NUMBER_____
HOUSEHOLD NUMBER_____
QST. No. ______
1) PROVINCE
2) NAME AND CLUSTER NUMBER____
3) HOUSEHOLD NUMBER____
4) LINE NUMBER OF WOMAN____
IDENTIFICATION
DISTRICT _____________
SUBCOUNTY/TOWN _____________
PARISH/WARD _____________
SUBPARISH/RC2 _____________
CLUSTER NUMBER
HOUSEHOLD NUMBER
LINE NUMBER OF WOMAN
REGION ________________________
DISTRICT ________________________
COUNTY ________________________
SUB-COUNTY/TOWN ________________________
PARISH/RC2 NAME ________________________
EA NAME ________________________
UDHS NUMBER
REGION
DISTRICT
COUNTY
SUBCOUNTY/TOWN
PARISH/LC2 NAME
EA NAME
UDHS NUMBER
NAME OF HOUSEHOLD HEAD
HOUSEHOLD NUMBER
NAME AND LINE NUBER OF WOMAN
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
SECTION NUMBER____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
HOUSEHOLD CLUSTER NUMBER____
NAME OF HOUSEHOLD HEAD____
PROVINCE _________________ ___
DISTRICT _____________________ ___
CSA NUMBER ___
SEA NUMBER ___
HOUSEHOLD NUMBER ___
NAME OF HOUSEHOLD HEAD _______________ ___
CLUSTER NUMBER ___
PROVINCE _________________ ___
DISTRICT _____________________ ___
HOUSEHOLD NUMBER ___
NAME OF HOUSEHOLD HEAD _______________ ___
LOCALITY NAME ___________________ ___
NAME OF HOUSEHOLD HEAD ____________________ ___
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE _________________ ___
LOCALITY NAME ___________________ ___
NAME OF HOUSEHOLD HEAD ____________________ ___
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE _________________ ___
LOCALITY NAME__________________
CLUSTER NUMBER________________
HOUSEHOLD NUMBER_________________
PROVINCE_________________
IDENTIFICATION
PLACE NAME _________________________
NAME OF HOUSEHOLD HEAD _________________________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
PLACE NAME __________
PROVINCE __________
STRATA ___
DHS SEGMENT NUMBER _____
HOUSEHOLD NUMBER ___
LINE NUMBER OF WOMEN ___
WARD/VILLAGE __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE __________
NAME OF HOUSEHOLD HEAD __________
WARD NAME __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE ___
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE ___
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER