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PDF, 1536K - Measure DHS

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CENTRAL STATISTICAL AUTHORITY<br />

ETHIOPIAN DEMOGRAPHIC AND HEALTH SURVEY<br />

WOMAN’S QUESTIONNAIRE<br />

IDENTIFICATION<br />

REGION ________________________________ ZONE _________________________________<br />

WOREDA _______________________________ TOWN _________________________________<br />

KEBELE ________________________________ ENUMERATION AREA____________________<br />

REGION<br />

CLUSTER NUMBER<br />

CLUSTER NUMBER...............................................................................<br />

URBAN/RURAL: URBAN ...................................1 RURAL..............................................2<br />

TYPE OF PLACE: LARGE CITY ..........................1 SMALL CITY.....................................2<br />

TOWN.....................................3 COUNTRYSIDE................................4<br />

HOUSEHOLD NUMBER.........................................................<br />

NAME OF HOUSEHOLD HEAD _______________________________________________________<br />

NAME AND LINE NUMBER OF WOMAN _______________________________________________<br />

URBAN/<br />

RURAL<br />

TYPE OF<br />

PLACE<br />

HOUSEHOLD NUMBER<br />

LINE NUMBER<br />

OF WOMAN<br />

INTERVIEWER VISITS<br />

1 2 3 FINAL VISIT<br />

DATE<br />

________________<br />

_________________<br />

_________________<br />

DAY<br />

MONTH<br />

YEAR<br />

1 9<br />

INTERVIEWER’S NAME<br />

________________<br />

_________________<br />

_________________<br />

INTERVIEWER<br />

RESULT*<br />

________________<br />

_________________<br />

_________________<br />

RESULT<br />

NEXT VISIT: DATE ________________ _________________ TOTAL NO.<br />

OF VISITS<br />

TIME ________________ _________________<br />

*RESULT CODES:<br />

1 COMPLETED<br />

2 NOT AT HOME<br />

3 POSTPONED<br />

QUESTIONNAIRE<br />

4 REFUSED<br />

5 PARTLY COMPLETED<br />

6 INCAPACITATED<br />

LANGUAGE<br />

INTERVIEW<br />

7 OTHER __________________________<br />

(SPECIFY)<br />

RESPONDENT’S NATIVE<br />

LANGUAGE<br />

TRANSLATOR USED<br />

DURING INTERVIEW<br />

AMARIGNA .............................1<br />

OROMIGNA .............................2<br />

TIGRIGNA................................3<br />

SOMALIGNA............................4<br />

AFARIGNA...............................5<br />

OTHER _________________ 6<br />

(SPECIFY)<br />

AMARIGNA ............................. 1<br />

OROMIGNA............................. 2<br />

TIGRIGNA ............................... 3<br />

SOMALIGNA ........................... 4<br />

AFARIGNA .............................. 5<br />

OTHER__________________ 6<br />

(SPECIFY)<br />

AMARIGNA.............................. 1<br />

OROMIGNA............................. 2<br />

TIGRIGNA ............................... 3<br />

SOMALIGNA ........................... 4<br />

AFARIGNA .............................. 5<br />

OTHER _________________ 6<br />

(SPECIFY)<br />

YES................................ 1<br />

NO.................................. 2<br />

SUPERVISOR FIELD EDITOR OFFICE<br />

EDITOR<br />

KEYED BY<br />

NAME _________________<br />

NAME _________________<br />

DATE _________________<br />

DATE __________________

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