Important
Create a reference number by combining the EA code, village number, household number, and the questionnaire numbers. Write this number now on the top of all pages.
Number of visits (write day of visit)
____ 1
____ 2
____ 3
____Final Visit
Total persons in household
_ _ Males
_ _ Females
Final results code
[] 1 Completed
[] 2 No household member at home
[] 3 Entire household absent for extended period of time
[] 4 Dwelling vacant
[] 5 Dwelling destroyed
[] 6 Other