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

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:

NAME AND LINE NUMBER OF ELIGIBLE WOMAN ___

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 ________________

NAME AND LINE NUMBER OF WOMAN _____________________

1) LINE NUMBER

We would like some information about people who usually live in your household or are staying with you now.

1. LINE NUMBER:

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

001) 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?

2) FIRST AND LAST NAME:
Please give me the name of the people who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1 Line number (the number of persons listed by the respondent)

Now we would like some information about the people who usually live in your household or who are staying with you now.

1) Line no.

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_________________

1) LINE NO.

1) LINE NUMBER

1 Line number (the number of persons listed by the respondent)

1 Line number (the number of persons listed by the respondent)

001. LINE NO.

002. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.

AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT YOU HAVE A COMPLETE LISTING. THEN GO ON TO 006-024.

001. LINE NO.

1) LINE NUMBER: (the number of persons listed by the respondent)

1) LINE NUMBER

001. LINE NO

001) LINE NO.

001. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

PLACE NAME___
NAME OF HOUSEHOLD HEAD___
CLUSTER NUMBER___
HOUSEHOLD NUMBER___
NAME AND LINE NUMBER OF WOMAN___

1. LINE NO.

1. LINE NO. (1)

1 Line number (the number of persons listed by the respondent)

1. LINE NO.

1) LINE NO.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON

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 ____________________

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

NAME AND LINE NUMBER OF WOMAN

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

Now we would like some information about the people who usually live in your household or who are staying with you now.

1. LINE NUMBER

Now we would like some information about the people who usually live in your household or who are staying with you now.

1) LINE NO.

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: _______________

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-18 FOR EACH PERSON.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

CLUSTER NUMBER ___________

HOUSEHOLD NUMBER __

NAME OF HOUSEHOLD HEAD ____________________

NAME AND LINE NUMBER OF WOMAN __________________________ ___

TELEPHONE/MOBLIE NUMBER (IF AVAILABLE) _______________________

1. LINE NO.

1 Line number (the number of persons listed by the respondent)

1) LINE NUMBER: (the number of persons listed by the respondent)

1) LINE NUMBER

1. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

Please give me the names of the persons who live in your household and guests of the household who stayed here last night, starting with the head of the household.

1. LINE NO.

1) LINE NO.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

1) LINE NUMBER

1) LINE NUMBER

We would now like information on the persons who usually live in your household and who are currently living with you.

LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

WOMAN'S QUESTIONNAIRE

IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
NAME AND LINE NUMBER OF WOMAN

WOMAN'S NAME: ____

IDENTIFICATION:

PROVINCE OR PREFECTURE: ____

CIRCLE: ____

MUNICIPALITY: Autonomous Center/Rural Commune: ____

CENTER: ____

PRIMARY UNIT NUMBER: ____

SECONDARY UNIT NUMBER: ____

LEVEL: ____

HOUSEHOLD NUMBER: ____

WOMAN'S LINE NUMBER: ____

HOUSEHOLD ADDRESS: ____

1) LINE NUMBER _____

2) FIRST AND LAST NAME ____

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1. LINE NO.

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

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 _____________

1 Line number (the number of persons listed by the respondent)

1. LINE NUMBER (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

(1) LINE NO. (1) (01-26) (*THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

(1) LINE NO. (1) (01-14)

(1) LINE NO. (1) (01-23)

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)

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TEHSIL _______

NAME OF HOUSEHOLD HEAD ______

CLUSTER NUMBER ______

HOUSEHOLD NUMBER _________

NAME AND LINE NUMBER OF WOMAN _______

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

1) LINE NO.

1) LINE NUMBER:

1. LINE NO.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1. LINE NO.

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

Now we would like some information about the people who usually live in your household or who are staying with you now.

(1) LINE NO.

Please give me the names of the persons who live in your household and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-28 FOR EACH PERSON.

Now we would like some information about the people who usually live in your household or who are staying with you now.

(1) LINE NO.

(2) USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NUMBER

1) FIRST NAMES AND LAST NAMES OF USUAL RESIDENTS AND VISITORS

1 Line number (the number of persons listed by the respondent)

LINE NUMBER____

1. LINE NO.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

1)LINE NO.

101) NAME Please give me the names of the persons who usually live in your household starting with the head of the household.

JUST TO MAKE SURE I HAVE A COMPLETE LISTING:

Are there any other persons, such as small children or infants whom we have not listed? IF ANSWER IS "YES", ENTER EACH IN TABLE.

In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here? IF ANSWER IS "YES", ENTER EACH IN TABLE.

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK QUESTIONS IN COLUMNS 5-35 FOR EACH PERSON.

1 Line number (the number of persons listed by the respondent)

1) LINE NO. (THE NUMBER OF PERSONS LISTEN BY THE RESPONDENT)

1) LINE NO.

1. LINE NO.

1) LINE NUMBER: (the number of persons listed by the respondent)

1) LINE NUMBER

1) LINE NO.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON. ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.