NAME
DATE

FIELD EDITED BY
OFFICE EDITED BY
KEYED BY
KEYED BY

NAME
DATE

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S CODE
RESULT*

TOTAL NUMBER OF VISITS:

TOTAL PERSONS IN HOUSEHOLD:
TOTAL ELIGIBLE WOMEN:
TOTAL ELIGIBLE MEN:
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE:

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S CODE
RESULT

TOTAL NUMBER OF VISITS:

TOTAL PERSONS IN HOUSEHOLD:

TOTAL ELIGIBLE WOMEN:

TOTAL ELIGIBLE MEN:

LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE:

TOTAL PERSONS IN HOUSEHOLD____
TOTAL ELIGIBLE WOMEN____
TOTAL ELIGIBLE MEN____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

TOTAL PERSONS IN HOUSEHOLD__
TOTAL WOMEN 12 TO 49 YR.
TOTAL MEN 15 TO 54 YR.
TOTAL ADULTS 35 OR MORE YEARS__
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE__

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

LINE NUMBER OF RESPONDENT FROM HOUSEHOLD QUESTIONNAIRE _____

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.

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY__ __
MONTH__ __
YEAR 201__
INT. NUMBER
CODE RESULT

NEXT VISIT
DATE____
TIME____

TOTAL ELIGIBLE WOMEN ____

TOTAL ELIGIBLE MEN ____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

FINAL VISIT
DAY___
MONTH_____
YEAR 2000
TEAM_____
INTERVIEWER______
SUPERVISOR______
RESULT______

TOTAL VISITS_____

TOTAL IN HOUSEHOLD______
TOTAL ELIGIBLE WOMEN______
LINE NO. OF RESPONDENT FROM HOUSEHOLD SCHEDULE_______

WOMAN/CHILD/ADOLESCENT REFERRED FOR SEVERE ANEMIA
ADDRESS CHECKED (BY NAME:______)
REINTERVIEW:

TOTAL ELIGIBLE WOMEN __ __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

1. LINE NO. ____

TOTAL ELIGIBLE WOMEN ____

LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE ____

We are collecting information on the 2016 GMIS field staff. Please fill in the information below. The information will be part of the survey data files. Your name will not be in the data files; your information will remain anonymous. If there is any question you do not want to answer you may skip it and go to the next question.

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

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):____________

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

1) LINE NO.

FINAL VISIT
DAY ___
MONTH____
YEAR ____
NAME ___
RESULT___

TOTAL NUMBER OF VISITS ____

TOTAL IN HOUSEHOLD ___

TOTAL NUMBER-ELIGIBLE WOMEN ___

TOTAL NUMBER-ELIGIBLE MEN ___

LINE NUMBER OF HOUSEHOLD RESPONDENT ___

FIELD EDITED BY
NAME ____
DATE ____

OFFICE EDITED BY
NAME ____
DATE ____

KEYED BY
NAME ____
DATE ____

KEYED BY ___

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME _____
RESULT*

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME

FIELD EDITOR
NAME

OFFICE EDITOR

KEYED BY

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

INTERVIEWER'S NAME __________
INT. CODE __

RESULT

TOTAL PERSONS IN HOUSEHOLD __

TOTAL WOMEN ELIGIBLE __

TOTAL ELIGIBLE MEN __

LINE NO. OF RESP. TO HOUSEHOLD QUEST.

SUPERVISOR

FIELD EDITOR

OFFICE EDITOR __

KEYED BY __

NAME AND CODE OF DISTRICT

WARD NUMBER

CLUSTER NUMBER

HOUSEHOLD NUMBER

CITY/TOWN RURAL

NAME OF HOUSEHOLD HEAD

NAME OF RESPONDENT

HOUSEHOLD SELECTED FOR MALE SURVEY

ALTITUDE

VISIT 1

DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________

NEXT VISIT:
DATE _________
TIME _________

VISIT 2

DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________

NEXT VISIT:
DATE _________
TIME _________

VISIT 3

DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________

NEXT VISIT:
DATE _________
TIME _________

FINAL VISIT

DAY ___________
MONTH __________
YEAR __________
INT. NUMBER __________
RESULT _________

TOTAL NUMBER OF VISITS __________

TOTAL PERSONS IN HOUSEHOLD _________

TOTAL ELIGIBLE WOMEN ________

TOTAL ELIGIBLE MEN ________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ________

SUPERVISOR

NAME __________

DATE __________

OFFICE EDITOR __________

KEYED BY __________

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

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

IDENTIFICATION

STATE ____
LOCAL GOVT. AREA______
LOCALITY _____
ENUMERATION AREA_____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

DEATHS UNDER 5/SBs FROM Q. 38 __

FEMALE DEATHS AGE 12-49 FROM Q. 39 __

LINE NO. OF RESPONDENT __

LANGUAGE OF QUESTIONNAIRE: URDU

FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

THIRD VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT. NO. _______
RESULT* _______

TOTAL NUMBER OF VISITS _________

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN ______
TOTAL ELIGIBLE MEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

SUPERVISOR _____

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
NAME RESULT

TOTAL NO. OF VISITS

TOTAL IN HOUSEHOLD
TOTAL ADULTS 15 YEARS AND OVER
TOTAL WOMEN 15-49 YEARS
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE

TOTAL ELIGIBLE WOMEN 15-49

TOTAL ELIGIBLE MEN 15-49

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

FIELD EDITOR

OFFICE EDITOR ____

KEYED BY ____

TOTAL WOMEN 15 - 49

MEN 15 - 54

LINE NUMBER OF REPONDENT OF HOUSEHOLD SCHEDULE

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE OF INTERVIEW**:

NATIVE LANGUAGE OF RESPONDENT**:

TRANSLATOR USED

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS