12.07.2015 Views

Final Report (PDF, 2132K) - Measure DHS

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MINISTRY OF HEALTH, C, OVERNMENT OF ONDO STATEDEMOGRAPHIC AND HEALTH SURVEYSINDIVIDUAL OUESTIONNAIREIDENTIFICATIONPLACE NAMECLUSTER NUMBER ....................................IIHOUSEHOLD NUMBER (in cluster) .....................IILINE NUMBER OF WOMAN (in household schedule} .......IIINTERVIEWERVISITS1 2 3 ~ FINAL VISITDATE ... o * i . . . , . o o o omonth L a fyearINTERVIEWER'S NAME..RESULT (.) .........NEXT VISIT:datetimeTotml numberof visits(*) RESULT CODES .... 1 COMPLETED 3 DEFERRED 5 PARTLY COMPLETED2 NOT AT HOME 4 REFUSED 6 OTHERNATIVE LANGUAGE OF RESPONDENT: YORUBA ( ] OTHER [ ] SPECIFY:FIELD EDITORSUPERVISORdate: .... / .... / ....date: .... / .... / _ _103

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