Zambia Demographic and Health Survey 2001-2002 - Measure DHS

SUPERVISOR FIELD EDITOR OFFICE EDITOR KEYED BYNAME +)))0))),*!!!*!!!*DATE.)))2)))-NAME +)))0))),*!!!*!!!*DATE.)))2)))-+)))0))),*!!!*!!!*.)))2)))-+)))0))),*!!!*!!!*.)))2)))-SECTION 1. RESPONDENT’S BACKGROUNDINFORMED CONSENTHello. My name isand I am working with the Central Board of Health and the Central Statistical Office. We areconducting a national survey about the health of men, women and children. We would very much appreciate your participation inthis survey. I would like to ask you some questions about yourself and your family. This information will help the government toplan health services. The survey usually takes about 30 to 40 minutes to complete. Whatever information you provide will be keptstrictly confidential and 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 aboutthe 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 ))