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Bangladesh 2014

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<strong>Bangladesh</strong> Demographic and Health Survey <strong>2014</strong><br />

COMMUNITY QUESTIONNAIRE<br />

IDENTIFICATION<br />

DIVISION ___________________________________________________________________<br />

(BARISAL=1; CHITTAGONG=2; DHAKA=3; KHULNA=4; RAJSHAHI=5; RANGPUR=6, SYLHET=76)<br />

DISTRICT ___________________________________________________________________<br />

THANA ______________________________________________________________________<br />

UNION/WARD ________________________________________________________________<br />

VILLAGE/MOHALLA/BLOCK _____________________________________________________<br />

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

TYPE OF AREA:<br />

GPS READING:<br />

1 = RURAL AREA; 2 = CITY CORPORATION<br />

3 = OTHER THAN CITY CORPORATION<br />

LATITUDE .......................................<br />

LONGITUDE ...................................<br />

N<br />

E<br />

Degrees Minutes Thousandths<br />

Degrees Minutes Thousandths<br />

WAYPOINT .....................................................................<br />

DATE OF VISIT ________________________________<br />

DAY ...................................................................................<br />

MONTH ..............................................................................<br />

RESULTS OF THE INTERVIEW:<br />

[COMPLETED =1, INCOMPLETE = 2,<br />

OTHER (SPECIFY) = 6]<br />

NAME OF INTERVIEWER _______________________<br />

YEAR ...................................................................<br />

RESULT ....................................................................................<br />

INTERVIEWER CODE ......................................................<br />

NAME OF PERSONS INTERVIEWED<br />

1 ___________________________________________<br />

2 ___________________________________________<br />

3 ___________________________________________<br />

4 ___________________________________________<br />

5 ___________________________________________<br />

6 ___________________________________________<br />

BEGINNING TIME:<br />

POSITION<br />

SEX<br />

ELECTED OFFICIAL .................. 01 MALE ........... 1<br />

RELIGIOUS LEADER ................. 02 FEMALE ....... 2<br />

TEACHER/EDUCATOR .............. 03<br />

DOCTOR/HEALTH OFFICIAL .... 04<br />

SERVICE HOLDER ..................... 05<br />

BUSINESS PERSON ................. 06<br />

OTHER ____________________ 96<br />

(SPECIFY)<br />

HOUR .....................................................................................<br />

MINUTES ...............................................................................<br />

310 • Appendix E<br />

# 2

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