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Demographic and Health Survey 2009-10 - Timor-Leste Ministry of ...

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NAME AND CODE OF DISTRICT<br />

NEW SUCO NAME AND NUMBER<br />

TIMOR-LESTE DEMOGRAPHIC AND HEALTH SURVEY (TLDHS)<br />

MAN'S QUESTIONNAIRE<br />

NATIONAL STATISTICS DIRECTORATE (NSD) AND MINISTRY OF HEALTH<br />

IDENTIFICATION<br />

CLUSTER NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

LOCATION ID NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

URBAN/RURAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

(URBAN=1, RURAL=2)<br />

NAME OF HOUSEHOLD HEAD<br />

NAME AND LINE NUMBER OF MAN<br />

INTERVIEWER VISITS<br />

DATE DAY<br />

MONTH<br />

YEAR<br />

INTERVIEWER'S<br />

NAME INT. NUMBER<br />

RESULT* RESULT<br />

20 July <strong>2009</strong><br />

FINAL VISIT<br />

NEXT VISIT: DATE<br />

TIME<br />

TOTAL NUMBER<br />

OF VISITS<br />

*RESULT CODES:<br />

1 COMPLETED 4 REFUSED<br />

2 NOT AT HOME 5 PARTLY COMPLETED 7 OTHER<br />

3 POSTPONED 6 INCAPACITATED (SPECIFY)<br />

LANGUAGE OF QUESTIONNAIRE<br />

LANGUAGE OF INTERVIEW<br />

NATIVE LANGUAGE OF RESPONDENT<br />

TRANSLATOR USED (YES=1; NO=2)<br />

LANGUAGE CODES: TETUM=1; BAHASA=2; PORTUGESE=3; OTHER=4<br />

SUPERVISOR FIELD EDITOR<br />

NAME NAME<br />

DATE DATE<br />

1 2 3<br />

OFFICE KEYED BY<br />

EDITOR<br />

Appendix E<br />

| 373

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