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<strong>2015</strong>-20<strong>16</strong> MALAWI DEMOGRAPHIC AND HEALTH SURVEY<br />

MALAWI GOVERNMENT - NATIONAL STATISTICAL OFFICE<br />

BIOMARKER QUESTIONNAIRE<br />

FORMATTING DATE:<br />

ENGLISH LANGUAGE:<br />

10 Oct. <strong>2015</strong><br />

10 Oct. <strong>2015</strong><br />

IDENTIFICATION<br />

PLACE NAME<br />

NAME OF HOUSEHOLD HEAD<br />

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

HOUSEHOLD NUMBER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

HOUSEHOLD SELECTED FOR MAN'S SURVEY? (1=YES, 2=NO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .<br />

FIELDWORKER VISITS<br />

1 2 3 FINAL VISIT<br />

DATE<br />

FIELDWORKER'S<br />

NAME<br />

NEXT VISIT: DATE<br />

TIME<br />

NOTES:<br />

DAY<br />

MONTH<br />

YEAR<br />

TOTAL NUMBER<br />

OF VISITS<br />

TOTAL ELIGIBLE<br />

WOMEN<br />

TOTAL ELIGIBLE<br />

MEN<br />

TOTAL ELIGIBLE<br />

CHILDREN<br />

0 1<br />

LANGUAGE OF LANGUAGE OF NATIVE LANGUAGE TRANSLATOR<br />

QUESTIONNAIRE** INTERVIEW** OF RESPONDENT** (YES = 1, NO = 2)<br />

ENGLISH<br />

LANGUAGE OF<br />

**LANGUAGE CODES:<br />

QUESTIONNAIRE** 01 ENGLISH 03 TUMBUKA<br />

02 CHICHEWA 09 OTHER<br />

(SPECIFY)<br />

SUPERVISOR OFFICE EDITOR KEYED BY<br />

NAME NUMBER NUMBER NUMBER<br />

Appendix F<br />

• 535

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