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Senegal 2017
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Senegal 2017
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IDENTIFICATION

PLACE NAME _____

NAME OF HEAD OF HOUSEHOLD ______

HOUSEHOLD NUMBER ____

PLOT NUMBER ____

CLUSTER NUMBER _____

REGION ____

DEPARTMENT ____

SANITATION DISTRICT ____

URBAN/RURAL

URBAN 1
RURAL 2

MILIEU ____

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

WOMAN'S NAME AND LINE NUMBER _____

CHECK COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

YES 1
NO 2

IF HOUSEHOLD SELECTED FOR DV, CHECK WOMEN'S SELECTION TABLE (Q157A OF HOUSEHOLD QUESTIONNAIRE)

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE (DV)?

YES 1
NO 2