PDF, 1536K - Measure DHS
PDF, 1536K - Measure DHS
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 __________________