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
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
NAME OF THE HOUSEHOLD HEAD____
NAME AND LINE NUMBER OF WOMAN____
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
1500) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE: WOMAN SELECTED FOR MODULE ON DOMESTIC VIOLENCE?
IF YES, CHECK SCHEDULE 35A FOR THE SELECTION OF ELIGIBLE WOMEN FOR THE SECTION OF "HOUSEHOLD RELATIONSHIPS." WAS THE WOMAN WHO YOU ARE SURVEYING SELECTED?
IF THE HOUSEHOLD HAS NOT BEEN SELECTED FOR THE MEN'S SURVEY, CHECK 514 OF THE HOUSEHOLD QUESTIONNAIRE: HAS THIS WOMAN BEEN SELECTED FOR THE HOUSEHOLD RELATIONS SECTION?
1101) Check cover page of household questionnaire: Woman selected for domestic violence section
ADDRESS IN DETAIL
NAME OF WOMAN
LINE NUMBER OF WOMAN
WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION
1100. CHECK HOUSEHOLD QUESTIONNAIRE: IDENTIFICATION PAGE FOR SUB-SAMPLE AND Q300 FOR LINE NUMBR OF SELECTED WOMAN:
LOCALITY NAME:
NAME OF HOUSEHOLD HEAD:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
NAME AND LINE NUMBER OF WOMAN:
HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION AND DV?
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?
WOMAN SELECTED FOR DOMESTIC VIOLENCE
PLACE NAME:
NAME OF HOUSEHOLD HEAD:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
NAME AND LINE NUMBER OF WOMAN:
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE?
HOUSEHOLD NUMBER_______
NAME AND LINE NUMBER OF WOMAN_______
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE___
STATE/REGION______
DISTRICT_____
TOWNSHIP_____
WARD/VILLAGE TRACT____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
LINE NUMBER OF WOMAN___
WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE
CHECK HOUSEHOLD QUESTIONNAIRE DVH01: WOMAN SELECTED FOR DV MODULE?
PROVINCE/REGION
DISTRICT ______
TEHSIL ________
NAME OF HOUSEHOLD HEAD _______
CLUSTER NUMBER _______
HOUSEHOLD NUMBER _______
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
HOUSEHOLD SELECTED FOR DV?
PLACE NAME _____
NAME AND NUMBER OF HEAD OF HOUSEHOLD _____
PLOT NUMBER ______
CLUSTER NUMBER ____
REGION ____
DEPARTMENT ____
HEALTH DISTRICT____
URBAN/RURAL
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?
(1400) CHECK COVER PAGE: WOMAN SELECTED FOR 13 MODULE?