Questionnaire Text

Questionnaire form view entire document: text image

____ Province
____ Canton
____ District
____ Segment
____ Zone number
____ Section number

[] Urban
[] Rural

_ _ Office use
_ _ _ _ Dwelling number (visit order)
____ Neighborhood or hamlet
____ Highway, route, etc.
____ Avenues (numbers)
____ Streets (names)
____ Institution (name)

Questionnaire instructions view entire document: text image

The information referring to: Province, Canton, District, Segment, Zone, Section, Urban or Rural, should be taken from the title page of the folder, since they are equal for all forms of each segment.