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Annex VII: Household QuestionnaireRepublic of YemenMinistry of Public Health and PopulationOffice of Public Health and Population, Lahj GovernorateNutritional Status and Mortality Survey – Lahj Governorate – July 2012Household Questionnaire (Form 1)First: Explain to the residents of the household (adults) about the survey and inform them of the agencyconducting the survey and survey staff (team members). Then request their verbal agreement to participate in thesurvey.1. Yes.Consent2. No. Go to the end.Date of interviewday month yearØ 2 Ø 1 2District Ozla (Sub-district) Village or neighborhoodname Name nameName of head of householdSurvey teamnumberHousehold andanthropometric dataNameSignature……….………Mortality dataTeam leaderIndicate which situation applies:1. Absence of household upon first visit which necessitated a second visit2. Absence of child upon first visit which necessitated a second visit ** If the child is not present, all data should be filled in except anthropometric measurements and edemawhich should be completed only if the child is present.Note: The data inside the cover is for field and administrative use by the team members.64