Questionnaire Text

Questionnaire form view entire document: text image

I. Location identification
101. Province ____ _ _
102. Regency/municipality (cross out category not used) ____ _ _
103. Sub-regency/sub-district _____ _ _
104. Village ____ _ _ _
105. Area

[] 1 Urban
[] 2 Rural

Questionnaire instructions view entire document: text image

Question 105: Classification of village/Kelurahan
If the village/kelurahan is an urban area circle code 1, and if it is a rural area circle code 2, then write the code into the provided boxes on the right. The information on urban/rural is obtained from the supervisor/investigator.