PUBLIC SECTOR

GOVERNMENT HOSPITAL/CLINIC A
GOVERNMENT HEALTH CENTER B
VCT CENTER C
GOVERNMENT HEALTH POST D
FAMILY PLANNING CLINIC E
STAND ALONE VCT CENTER F
OTHER PUBLIC (SPECIFY) ________G

NON-GOVERNMENT (NGO) HEALTH FACILITY H
STANDALONE VCT CENTER I

PRIVATE MEDICAL SECTOR

PRIVATE HOSPITAL/ CLINIC/DOCTOR J
STAND ALONE VCT CENTER K
PHARMACY L
OTHER PRIVATE MEDICAL (SPECIFY) ___________________ M

OTHER SOURCE

DRUG VENDOR N
SHOP O
TRADITIONAL HEALER P
OTHER (SPECIFY) _____________ X

NAME OF PLACE ___

PUBLIC SECTOR

GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
PUBLIC PHARMACY D
OTHER PUBLIC SECTOR (SPECIFY) E

NGO

HEALTH FACILITY F
OTHER NGO MEDICAL SECTOR (SPECIFY) G

PRIVATE MEDICAL SECTOR

PRIVATE HOSPITAL H
PRIVATE CLINIC I
PRIVATE PHARMACY J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) K

OTHER SOURCE

SHOP/MARKET L
TRADITIONAL PRACTITIONER M

OTHER (SPECIFY) X