IDENTIFICATION PLACE NAME ________ NAME OF HOUSEHOLD HEAD_______ PROVINCE_______ MUNICIPALITY_____ COMMUNITY_______ NEIGHBORHOOD/VILLAGE______ CENSUS SECTION______ AREAS OF RESIDENCE URBAN 1 RURAL 2 CLUSTER NUMBER (ID. IIMS)______ HOUSEHOLD NUMBER_______ NAME AND LINE NUMBER OF WOMAN_______ THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE YES 1 NO 2

IDENTIFICATION PLACE NAME ________ NAME OF HOUSEHOLD HEAD_______ PROVINCE_______ MUNICIPALITY_____ COMMUNITY_______ NEIGHBORHOOD/VILLAGE______ CENSUS SECTION______ AREAS OF RESIDENCE URBAN 1 RURAL 2 CLUSTER NUMBER (ID. IIMS)______ HOUSEHOLD NUMBER_______ NAME AND LINE NUMBER OF WOMAN_______ THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE YES 1 NO 2

IDENTIFICATION PLACE NAME ________ NAME OF HOUSEHOLD HEAD_______ PROVINCE_______ MUNICIPALITY_____ COMMUNITY_______ NEIGHBORHOOD/VILLAGE______ CENSUS SECTION______ AREAS OF RESIDENCE URBAN 1 RURAL 2 CLUSTER NUMBER (ID. IIMS)______ HOUSEHOLD NUMBER_______ NAME AND LINE NUMBER OF WOMAN_______ THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE YES 1 NO 2

INTERVIEWER VISITS FIRST VISIT DATE_________ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3 POSTPONED 4 REFUSED 5 DWELLING VACANT OR ADDRESS NOT AT DWELLING 6 DWELLING DESTROYED 7 DWELLING NOT FOUND 8 OTHER (SPECIFY)_________ 9 NEXT VISIT: DATE_________ TIME_________ SECOND VISIT DATE_________ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3 POSTPONED 4 REFUSED 5 DWELLING VACANT OR ADDRESS NOT AT DWELLING 6 DWELLING DESTROYED 7 DWELLING NOT FOUND 8 OTHER (SPECIFY)_________ 9 NEXT VISIT: DATE_________ TIME_________ THIRD VISIT DATE_________ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3 POSTPONED 4 REFUSED 5 DWELLING VACANT OR ADDRESS NOT AT DWELLING 6 DWELLING DESTROYED 7 DWELLING NOT FOUND 8 OTHER (SPECIFY)_________ 9 FINAL VISIT DAY____ MONTH___ YEAR____ INTERVIEWER NUMBER_____ RESULT* COMPLETED 1 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3 POSTPONED 4 REFUSED 5 DWELLING VACANT OR ADDRESS NOT AT DWELLING 6 DWELLING DESTROYED 7 DWELLING NOT FOUND 8 OTHER (SPECIFY)_________ 9 TOTAL NUMBER OF VISITS_________

705) RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00' NAME_________ LINE NUMBER________