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National Bureau of Statistics
General Household Survey [2008]

Reference Number _ _ _ _

Please write responses in printed capital letters without touching the box edges.
Shade boxes like this: [the form shows a box fully shaded]
Not like this: [the form shows a boxed with marks exceeding the box space]

Part A: Identification

Interviewer's name ____
Interviewer's code _ _ _
Supervisor's code _ _ _
Survey month: _ _
Survey year: _ _
HU MS number: _ _
HU listed: _ _ _ _
HU sampled: _ _
HH listed: _ _ _ _
HH sampled: _ _

1. State _ _
2. LGA _ _
3. RIC _ _ _ _
4. EA code _ _ _ _
5. Enumeration area name ____
6. Sector _
7. HU No _ _ _
8. Name of head of HH ____
9. Address ____

10. Response status

[] 1 Completed
[] 2 Partly completed
[] 3 Not at home
[] 4 Refused
[] 5 Household not located
[] 6 Moved away
[] 7 Other (specify)

Questionnaire Ref. No:
HH No. within HU _ of _

Questionnaire within HH _ of _

12. Major source of water for drinking and cooking

[] 1 Pipe borne water treated
[] 2 Pipe borne water untreated
[] 3 Bore hole/hand pump
[] 4 Well/spring protected
[] 5 Well/spring unprotected
[] 6 Rain water
[] 7 Streams/pond/river
[] 8 Tanker/truck/vendor
[] 9 Other ____

13. Distance to source of water

[] 1 In dwelling
[] 2 Within 500m
[] 3 500m-1km
[] 4 1km or more

14. Type of housing unit

[] 1 Single room
[] 2 Flat
[] 3 Duplex
[] 4 Whole building
[] 5 Other ____

15. Number of living rooms in housing unit _ _

16. Tenure

[] 1 Normal rent
[] 2 Free
[] 3 Nominal/subsidized rent
[] 4 Owner occupier

17. Monthly rent (in =N=) for housing unit: _ _ _ _ _ _

18. Material of dwelling floor:

[] 1 Wood/tile
[] 2 Planks/concrete
[] 3 Dirt/straw/without concrete
[] 4 Other ____

19. Toilet facilities

[] 1 None
[] 2 Toilet on water
[] 3 Flush to sewage
[] 4 Flush to septic tank
[] 5 Pail/bucket
[] 6 Covered pit latrine
[] 7 Uncovered pit latrine
[] 8 V.I.P. latrine
[] 9 Other ____

20. Distance of toilet facility from the dwelling:

[] 1 In dwelling
[] 2 Within 500m
[] 3 500m-1km
[] 4 1km or more

21. Type of refusal disposal most often used:

[] 1 HH bin collected by government
[] 2 HH bin collected private agency
[] 3 Government bin or shed
[] 4 Disposal within compound
[] 5 Unauthorized refuse heap
[] 6 Other ____

22. Type of fuel used for cooking

[] 1 Electricity
[] 2 Gas
[] 3 Kerosene
[] 4 Wood
[] 5 Coal

23. Electricity supply

[] 1 PHCN (NEPA) only
[] 2 Rural electrification only
[] 3 Private generator only
[] 4 PHCN (NEPA) / generator
[] 5 Rural electricity / generator
[] 6 Solar energy
[] 7 None

24. Information and communication technology (ICT)

Radio

[] 1 Own
[] 2 Access
[] 3 None

Television

[] 1 Own
[] 2 Access
[] 3 None

Telephone (fixed)

[] 1 Own
[] 2 Access
[] 3 None

Telephone (mobile)

[] 1 Own
[] 2 Access
[] 3 None

Personal computer (PC)

[] 1 Own
[] 2 Access
[] 3 None

Internet service

[] 1 Own
[] 2 Access
[] 3 None

Part B: Person(s) in household (including those absent at the time of interview)

Member number _ _

1. List all members of household (including those absent at the time of interview) ____

2. Relationship to head

[] 1 Head
[] 2 Spouse
[] 3 Own child
[] 4 Step child
[] 5 Grand child
[] 6 Brother/sister
[] 7 Niece/nephew
[] 8 Brother/sister-in-law
[] 9 Parent
[] 10 Parent-in-law
[] 11 Other relative
[] 12 Maid/nanny/house servant
[] 13 Non-relative

3. Age (last birthday) _ _

4. Sex

[] 1 Male
[] 2 Female

5. Marital status

[] 1 Married
[] 2 Divorced
[] 3 Separated
[] 4 Widowed
[] 5 Never married

6. If married, what form of marriage?

[] 1 Ordinance
[] 2 Customary
[] 3 Mutual agreement

7. Attendance at formal school

[] 1 Never
[] 2 Now in school
[] 3 Before but not now

8. Highest level reached

[] 1 Below primary
[] 2 Primary
[] 3 JSS
[] 4 Vocational/Commercial
[] 5 SSS
[] 6 NCE/OND/Nursing
[] 7 B.A./B.Sc./B.ED/HND
[] 8 M.Sc./M.A/M.Adm.
[] 9 Doctorate
[] 10 Others (specify)

9. Highest grade completed

Nursery
[] 1 Pre-class
[] 2 Nursery 1
[] 3 Nursery 2
Primary
[] 4 Primary 1
[] 5 Primary 2
[] 6 Primary 3
[] 7 Primary 4
[] 8 Primary 5
[] 9 Primary 6
Secondary
[] 10 JSS 1
[] 11 JSS 2
[] 12 JSS 3
[] 13 SSS 1
[] 14 SSS 2
[] 15 SSS 3
Post-secondary
[] 16 A/L/OD
[] 17 BSC/HD
[] 18 P/Grad
[] 19 Others

10. Literacy in any language

[] 1 Yes
[] 2 No

Part B: Persons(s) present in household continued… (For persons age 10 years and above)
[Applies to questions 11-63]

Member number _ _

11. Main job previous week

(If options 1-5 go to Col. 14, and if options 6 or 7 go to Col. 22)

[] 1 Worked for pay
[] 2 Got job but did not work
[] 3 Worked for profit
[] 4 On attachment but didn't work
[] 5 Apprenticeship
[] 6 Kept home
[] 7 Went to school
[] 8 Did nothing

12. If person did nothing, what was the reason?

(If options 6-8 go to col. 27)

[] 1 Looked for job
[] 2 Sick
[] 3 Believed no job available
[] 4 Laid off 30 days or less
[] 5 Waiting to join work
[] 6 Retired
[] 7 Invalid
[] 8 Others

13. Length of unemployment

(From the last paid work)

[] 1 Less than 1 month
[] 2 Between 1 and 2 months
[] 3 Between 2 and 3 months
[] 4 Between 3 and 4 months
[] 5 More than 4 months
[] 6 Never had a paid work

Go to Col. 27

14. Do you like to change job?

[] 1 Yes
[] 2 No

If no to Col. 14 skip to Col. 16

15. Reason for the change

[] 1 Low income in present job
[] 2 Job doesn't match skill
[] 3 Job environment not congenial
[] 4 Excessive hours of work
[] 5 Precarious job(s)
[] 6 Inadequate tools
[] 7 Equipment or training for assigned task
[] 8 Travel to work difficulties
[] 9 Inconvenient work schedules
[] 10 Recurring work stoppage
[] 11 Prolonged non wage payment

16. Primary or main occupation _ _

See occupational codes on page 12

17. Industry of primary or main occupation _ _

See industry codes on page 12

18. Employment status

[] 1 Employer
[] 2 Employee
[] 3 Own account worker
[] 4 Members of producer coop.
[] 5 Unpaid family worker
[] 6 Others

19. Hours of work per week _ _

20. Institutional sector

[] 1 Private company
[] 2 Public company
[] 3 Parastatals
[] 4 Ministries
[] 5 Others

21. Contribute to National Health Insurance Scheme (NHIS)?

[] 1 Yes
[] 2 No

22. Secondary job _ _

See occupational codes on page 12

23. Industry of secondary job _ _

See industry codes on page 12

24. Employment status in the secondary job

[] 1 Employer
[] 2 Employee
[] 3 Own account worker
[] 4 Producer coop. member
[] 5 Unpaid family worker
[] 6 Others

25. Hours of work per week _ _

Check: if Col. 19 + Col. 25 is 40 hours or more, go to col. 27, else [continue]

If you are given extra hours will you do it?

26a. Voluntary
[] 1 Yes
[] 2 No

26b. Involuntary
[] 1 Yes
[] 2 No

27. Are you engaged in voluntary/social work?

[] 1 Yes
[] 2 No

If no, skip to Col. 30

28. In which area of volunteering?

If yes in col. 27

[] 1 Art and recreation
[] 2 Education/research
[] 3 Health
[] 4 Social services
[] 5 Environment
[] 6 Development and housing
[] 7 Civil advocacy
[] 8 Philanthropy
[] 9 Religion
[] 10 International
[] 11 Business/professional
[] 12 Other (specify)

29. Hours of work per week _ _

30. Income last month (in '000=N=) from all jobs and including all allowances _ _ _ _ _

Do you personally own any of the following?
[Applies to questions 31-36]

31. Radio

[] 1 Yes
[] 2 No

32. Television

[] 1 Yes
[] 2 No

33. Mobile phone

[] 1 Yes
[] 2 No

34. Fixed phone

[] 1 Yes
[] 2 No

35. Personal computer

[] 1 Yes
[] 2 No

36. Internet service

[] 1 Yes
[] 2 No

How many do you own of any of the following?
[Applies to questions 37-42]

If no in Col. 31-36, skip the corresponding Col. In 37-42

37. Radio _

38. Television _

39. Mobile phone _

40. Fixed phone _

41. Personal computer _

42. Internet service _

Do you have access to any of the following?
[Applies to questions 43-48]

43. Radio

[] 1 Yes
[] 2 No

44. Television

[] 1 Yes
[] 2 No

45. Mobile phone

[] 1 Yes
[] 2 No

46. Fixed phone

[] 1 Yes
[] 2 No

47. Personal computer

[] 1 Yes
[] 2 No

48. Internet service

[] 1 Yes
[] 2 No

What is your source of access to any of the following?
[Applies to questions 49-54]

If no in Col. 43-48, skip the corresponding Col. In 49-54

49. Radio

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

50. Television

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

51. Mobile phone

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

52. Fixed phone

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

53. Personal computer

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

54. Internet service

[] 1 Owned
[] 2 Family member/friend/neighbor
[] 3 Umbrella centre
[] 4 Workplace
[] 5 Business centre
[] 6 Other

List in order of preference, three of your favorite TV stations
[Applies to questions 55-57]

55. 1st preference

[] 1 DBN
[] 2 Channels
[] 3 Minaj
[] 4 NTA
[] 5 AIT
[] 6 MITV
[] 7 Silver Bird
[] 8 Galaxy
[] 9 State TV
[] 10 Foreign/Cable
[] 11 Others specify

56. 2nd preference

[] 1 DBN
[] 2 Channels
[] 3 Minaj
[] 4 NTA
[] 5 AIT
[] 6 MITV
[] 7 Silver Bird
[] 8 Galaxy
[] 9 State TV
[] 10 Foreign/Cable
[] 11 Others specify

57. 3rd preference

[] 1 DBN
[] 2 Channels
[] 3 Minaj
[] 4 NTA
[] 5 AIT
[] 6 MITV
[] 7 Silver Bird
[] 8 Galaxy
[] 9 State TV
[] 10 Foreign/Cable
[] 11 Others specify

58. Do you operate and ICT business outfit?

[] 1 Yes
[] 2 No

If no to Col. 58, skip to Col. 64

59. Which of the following ICT business outfits do you operate?

[] 1 Umbrella centre
[] 2 Business centre

60. What kind of service do you provide in the ICT business outfit?

[] 1 Telephone calls
[] 2 Computer services
[] 3 Cyber-cafe
[] 4 Other

61. How many persons work in the ICT business outfit?

_ _ Male
_ _ Female

62. How many persons do you attend to in a day in the ICT business outfit? _ _ _

63. What is your daily income in the ICT business outfit? _ _ _ _ _ _

Housing project (For persons age 20 years and above)
[Applies to questions 64-67]

64. Did you start any new building in 20…?

[] 1 Yes
[] 2 No

If no to Col. 64, skip to part C

65. What is the type of building?

[] 1 Residential
[] 2 Commercial
[] 3 Industrial
[] 4 Other

66. What is the state of completion of the building as at December 31, 20…?

[] 1 Foundation level
[] 2 Window level
[] 3 Lintel level
[] 4 Roofing level
[] 5 Completed totally

67. If col. 66=code 5 then, when was it completed?

[] 1 1st quarter
[] 2 2nd quarter
[] 2 3rd quarter
[] 4 4th quarter

Part C: Usual resident absent (For persons not available in the household during the period of the survey)
[Applies to questions 0-8]

0. Member number _ _

Name of household member ____

1. Relationship to head

[] 1 Head
[] 2 Spouse
[] 3 Own child
[] 4 Step child
[] 5 Grand child
[] 6 Brother/sister
[] 7 Niece/nephew
[] 8 Brother/sister-in-law
[] 9 Parent
[] 10 Parent-in-law
[] 11 Other relative
[] 12 Maid/nanny/house servant
[] 13 Non-relative

2. Sex

[] 1 Male
[] 2 Female

3. Age (last birthday) _ _

4. Marital status

[] 1 Married
[] 2 Divorced
[] 3 Separated
[] 4 Widowed
[] 5 Never married

5. Attendance at formal school

[] 1 Never
[] 2 Now in school
[] 3 Before but not now

6. Date last in HH _ _ / _ _ / _ _

7. Date expected back in HH _ _ / _ _ / _ _

8. Reason for absence

[] 1 Schooling
[] 2 Visitation
[] 3 Hospitalisation
[] 4 Temporary transfer
[] 5 On holiday
[] 6 Other (specify)

Part D: Contraceptive prevalence (For both male and female)

For all persons aged 15 years and over
[Applies to questions 0-8]

0. List persons age 15 years and above ____

1. Member number _ _

2. Relationship to head

[] 1 Head
[] 2 Spouse
[] 3 Own child
[] 4 Step child
[] 5 Grand child
[] 6 Brother/sister
[] 7 Niece/nephew
[] 8 Brother/sister-in-law
[] 9 Parent
[] 10 Parent-in-law
[] 11 Other relative
[] 12 Maid/nanny/house servant
[] 13 Non-relative

3. Age (last birthday) _ _

4. Sex

[] 1 Male
[] 2 Female

5. Education level

[] 1 Below primary
[] 2 Primary
[] 3 Secondary
[] 4 Post Secondary
[] 5 Quranic
[] 6 None

6. If ever married, age at first marriage _ _

7. Currently using FP?

[] 1 Yes
[] 2 No

If no and male, go to next person
If no and female, go to D9

8. Which method?

[] 1 Pill
[] 2 Condom
[] 3 Injection
[] 4 IUD
[] 5 Female sterilization
[] 6 Male sterilization
[] 7 Douche
[] 8 Norplant
[] 9 Foaming tab
[] 10 Diaphragm
[] 11 Foam jelly
[] 12 Traditional methods
[] 13 Abstinence
[] 14 Withdrawal
[] 15 Rhythm
[] 16 Others

If male, go to next person
If female, go to D9

Children ever born by women married or aged 15 years and over
[Applies to questions 9-16]

9. Ever pregnant?

[] 1 Yes
[] 2 No

If no, go to next person

10. Number of own children living in this HH

Male _
Female _

11. Number of own children living elsewhere

Male _
Female _

12. Number of own children that have died

Male _
Female _

13. Currently pregnant

[] 1 Yes
[] 2 No

If no, go to next person

If pregnant…
[Applies to questions 14-16]

14. Are you registered with the clinic?

[] 1 Yes
[] 2 No

If no, go to next person

15. How many times do you go to the clinic in a month? _ _

16. Received anti-tetanus?

[] 1 Yes
[] 2 No

Part E: Births in the last 12 months

0. Name of child ____

1. Child member number _ _

2. Mother member number _ _

3. Age of mother _ _

4. Sex of child

[] 1 Male
[] 2 Female

5. Date of birth _ _ / _ _ / _ _

6. Weight at birth _ _. _

7. Delivered by trained attendant?

If 2=No, go to part F

[] 1 Yes
[] 2 No

8. What type of trained birth attendant?

[] 1 Doctor
[] 2 Trained nurse/midwife
[] 3 Auxiliary midwife
[] 4 Trained traditional midwife
[] 5 Traditional birth attendant

Part F: National programme on immunization (NPI) (For children 1 year or less)
[Applies to questions 0-16]

0. List of all children one year or less in this household ____

1. Child member number _ _

2. Age of child (in completed months) _ _

3. Sex of child

[] 1 Male
[] 2 Female

Vaccination records

BCG: Bovis, camette, gverin
DPT: Diphterial, pertusis, and tetanus
OPV: Oral polio vaccine
MMR: Measles, mumps, and rubella

4. Do you have a card?

[] 1 Yes
[] 2 No

5. Measles

[] 1 Yes
[] 2 No

6. BCG

[] 1 Yes
[] 2 No

7. DPT 1

[] 1 Yes
[] 2 No

8. DPT 2

[] 1 Yes
[] 2 No

9. DPT 3

[] 1 Yes
[] 2 No

10. OPV 0

[] 1 Yes
[] 2 No

11. OPV 1

[] 1 Yes
[] 2 No

12. OPV 2

[] 1 Yes
[] 2 No

13. OPV 3

[] 1 Yes
[] 2 No

14. Yellow fever

[] 1 Yes
[] 2 No

15. MMR

[] 1 Yes
[] 2 No

16. Vitamin A

[] 1 Yes
[] 2 No

Part G: Child nutrition (Breastfeeding module) (For children less than 1 year old)
[Applies to questions 0-32]

0. List of all children less than one year old in this household

1. Child member number _ _

2. Age of child (in months) _ _

3. Has [the child] ever been breastfed?

If 2=No or 3=Don't know, go to G22

[] 1 Yes
[] 2 No
[] 3 Don't know

4. Did [the child] get first milk (Colostrum, yellow coloured breast milk)?

If 1=Yes or 3=Don't know, go to G13

[] 1 Yes
[] 2 No
[] 3 Don't know

Why did [the child] not get first milk?
[Applies to questions 5-12]

5. Bad milk

[] 1 Yes
[] 2 No

6. Mother ill/weak

[] 1 Yes
[] 2 No

7. Child ill/weak

[] 1 Yes
[] 2 No

8. Mother died

[] 1 Yes
[] 2 No

9. Nipple/breast problem

[] 1 Yes
[] 2 No

10. Child refused

[] 1 Yes
[] 2 No

11. Didn't produce milk

[] 1 Yes
[] 2 No

12. Other

[] 1 Yes
[] 2 No

13. Since the time of birth, for how long (in months) was [the child] fed exclusively on breast milk (without water, herbal tea or any fluid except vitamin, medicine and ORS)? _ _

Why were you not able to exclusively breastfeed [the child] for 6 months?
[Applies to questions 14-20]

14. Nature of work

[] 1 Yes
[] 2 No

15. Shortage of breast milk

[] 1 Yes
[] 2 No

16. Mother's health

[] 1 Yes
[] 2 No

17. Child's refusal

[] 1 Yes
[] 2 No

18. Tradition

[] 1 Yes
[] 2 No

19. Age less than 6 months

[] 1 Yes
[] 2 No

20. Other

[] 1 Yes
[] 2 No

21. Is [the child] still being breastfed?

If 2 or 3, answer col. 30

[] 1 Yes
[] 2 No
[] 3 Don't know

Since this time yesterday, did [the child] receive any of the following?
[Applies to questions 22-29]

22. Vitamin, mineral supplements or medicine

[] 1 Yes
[] 2 No
[] 3 Don't know

23. Plain water

[] 1 Yes
[] 2 No
[] 3 Don't know

24. Sweetened, flavoured water or fruit juice or tea or infusion

[] 1 Yes
[] 2 No
[] 3 Don't know

25. Oral rehydration solution (ORS)

[] 1 Yes
[] 2 No
[] 3 Don't know

26. Tinned powered or fresh milk or infant formula

[] 1 Yes
[] 2 No
[] 3 Don't know

27. Any other liquids (specify…)

[] 1 Yes
[] 2 No
[] 3 Don't know

28. Solid or semi-solid (mushy) food

[] 1 Yes
[] 2 No
[] 3 Don't know

29 Received only breast milk

[] 1 Yes
[] 2 No
[] 3 Don't know

30. If [the child] is no longer breastfed, at what age (in months) was breastfeeding stopped? _ _

31. Since this time yesterday, has [the child] been given anything to drink from a bottle with a nipple or teat?

[] 1 Yes
[] 2 No
[] 3 Don't know

32. If [the child] is receiving complementary food, at what age (in months) was it introduced? _ _

Part H: Deaths in the last 12 months

0. Name of deceased ____

1. Age (in completed years at the time of death) _ _

2. Sex

[] 1 Male
[] 2 Female

3. Date of death _ _ / _ _ / _ _

4. Cause of death

[] 1 Illness
[] 2 Accident/injury
[] 3 Murder
[] 4 Suicide
[] 5 Died in sleep
[] 6 Others

Part I: Health (For all sick and/or injured persons in the household)
[Applies to questions 0-17]

0. Name of member ____

1. Member number _ _

2. Was [name] injured/sick in the last 7 days?

If 2=No, go to part J

[] 1 Yes
[] 2 No

What sort of sickness/injury did [name] suffer in the last 7 days?
[Applies to questions 3-11]

3. Fever/Malaria

[] 1 Yes
[] 2 No

4. Diarrhea/Abdominal pains

[] 1 Yes
[] 2 No

5. Pain in back, limbs or joints

[] 1 Yes
[] 2 No

6. Cough/breathing difficulty

[] 1 Yes
[] 2 No

7. Skin problem

[] 1 Yes
[] 2 No

8. Ear, nose, throat

[] 1 Yes
[] 2 No

9. Dental

[] 1 Yes
[] 2 No

10. Accident

[] 1 Yes
[] 2 No

11. Other

[] 1 Yes
[] 2 No

12. Did [name] miss work or school due to injury/sickness in the last 7 days?

[] 1 Yes
[] 2 No

13. How many days of work or school did [name] miss due to illness/injury in the last 7 days?

[] 1 None
[] 2 1-3 days
[] 3 4-7 days

14. Did [name] consult a health provider (traditional healer inclusive) for any reason in the last 7 days?

[] 1 Yes
[] 2 No

15. How did [name] pay for most of the consultation?

[] 1 Free
[] 2 Self paid
[] 3 Employer
[] 4 Insurance
[] 5 Other relative
[] 6 Spouse
[] 7 Parents
[] 8 Other

16. Which main health provider did [name] see in the last 7 days?

[] 1 Private dispensary/hospital
[] 2 Public dispensary/hospital
[] 3 Community health center
[] 4 Private doctors/dentist
[] 5 Traditional healer
[] 6 Religious hospital/dispensary
[] 7 Pharmacist/chemist
[] 8 Other

17. How many times did [name] use the service in the last 7 days?

[] 1 1 to 3
[] 2 4 to 6
[] 3 More than 6

Part J: Household enterprises

For own account worker and employee of informal sector only
[Applies to questions 1-14]

1. Does the household own any enterprise?

If 2=No, go to part K

[] 1 Yes
[] 2 No

2. Name of enterprises? ____

3. Kind of activity

_ _ Industry code
_ _ Occupation code

4. Location of enterprise ____

Number of persons engaged

Full time

Paid employee
5. Male _
6. Female _
Unpaid household member
7. Male _
8. Female _

Part time

Paid employee
9. Male _
10. Female _
Unpaid household member
11. Male _
12. Female _

13. Is enterprise registered?

[] 1 Yes
[] 2 No

14. Income/profit enterprises last month _ _ _ _ _ _ _

Part K: Household expenditure

How much did you spend in the last one month on the following items?
Food expenses include tomato, onion, salt, vegetable spices, etc.

_ _ _ _ _ _ _ 1. School fees
_ _ _ _ _ _ _ 2. Medical expenses
_ _ _ _ _ _ _ 3. House expenses
_ _ _ _ _ _ _ 4. Remittances
_ _ _ _ _ _ _ 5. Cloth expenses
_ _ _ _ _ _ _ 6. Transport expenses
_ _ _ _ _ _ _ 7. Food expenses
_ _ _ _ _ _ _ 8. Others

Number of visits _ _
Length of interview _ _ _

Field supervisor

Name ____
Date ____

State office editor

Name ____
Date ____

Edited by

Name ____
Date ____

Keyed by

Name ____
Date ____