PLACE NAME__
NAME OF HOUSEHOLD HEAD__
CLUSTER NUMBER___
HOUSEHOLD 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 ______

URBAN/RURAL

LOCATION

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

LOCATION (DETAIL) ______

WOMAN'S NAME AND LINE NUMBER _____

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)?