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Zambia Demographic and Health Survey 2001-2002 - Measure DHS

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SECTION 1. RESPONDENT’S BACKGROUNDINTRODUCTION AND CONSENTINFORMED CONSENTHello. My name is<strong>and</strong> I am working with CBOH/CSO. We are conducting a nationalsurvey about the health of women <strong>and</strong> children. We would very much appreciate your participation in this survey. I would like toask you about your health (<strong>and</strong> the health of your children). This information will help the government to plan health services.Whatever information you provide will be kept strictly confidential <strong>and</strong> will not be shown to other persons.We hope that you will participate in this survey since your views are important.At this time, do you want to ask me anything about the survey?May I begin the interview now?Signature of interviewer:Date:RESPONDENT AGREES TO BE INTERVIEWED ..... 1?RESPONDENT DOES NOT AGREE TO BE INTERVIEWED ..... 2 ))

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