1340) RECORD TIME HOURS _____ MINUTES____

SECTION 1: WOMAN'S BASIC CHARACTERISTICS 101) RECORD THE TIME HOUR_____ MINUTES____

INTERVIEWER VISITS FIRST VISIT DATE_________ DAY___ MONTH___ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE_________ TIME_________ SECOND VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE____ TIME____ THIRD VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 FINAL VISIT DAY_________ MONTH_________ YEAR_____ INT. NO._________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 TOTAL NUMBER OF VISITS_________ LANGUAGE OF QUESTIONNAIRE______ PORTUGUESE 1 CHOKWE/KIOKO 2 FIOTE 3 KIKONGO/UKONGO 4 KIMBUNDU 5 KWANHAMA 6 LUVALE 7 MUHUMBI 8 NGANGUELA 9 NHANECA 10 UMBUNDU 11 OTHER (SPECIFY)____ 96 TRANSLATOR USED (YES =1, NO=2) ____ SUPERVISOR NAME_________ NUMBER_________

INTERVIEWER VISITS FIRST VISIT DATE_________ DAY___ MONTH___ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE_________ TIME_________ SECOND VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE____ TIME____ THIRD VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 FINAL VISIT DAY_________ MONTH_________ YEAR_____ INT. NO._________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 TOTAL NUMBER OF VISITS_________ LANGUAGE OF QUESTIONNAIRE______ PORTUGUESE 1 CHOKWE/KIOKO 2 FIOTE 3 KIKONGO/UKONGO 4 KIMBUNDU 5 KWANHAMA 6 LUVALE 7 MUHUMBI 8 NGANGUELA 9 NHANECA 10 UMBUNDU 11 OTHER (SPECIFY)____ 96 TRANSLATOR USED (YES =1, NO=2) ____ SUPERVISOR NAME_________ NUMBER_________

INTERVIEWER VISITS FIRST VISIT DATE_________ DAY___ MONTH___ INTERVIEWER'S NAME_________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE_________ TIME_________ SECOND VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 NEXT VISIT: DATE____ TIME____ THIRD VISIT DATE____ DAY____ MONTH____ INTERVIEWER'S NAME____ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 FINAL VISIT DAY_________ MONTH_________ YEAR_____ INT. NO._________ RESULT* COMPLETED 1 ABSENT 2 POSTPONED 3 REFUSED 4 INCOMPLETE 5 INCAPACITATED 6 OTHER (SPECIFY) ________ 7 TOTAL NUMBER OF VISITS_________ LANGUAGE OF QUESTIONNAIRE______ PORTUGUESE 1 CHOKWE/KIOKO 2 FIOTE 3 KIKONGO/UKONGO 4 KIMBUNDU 5 KWANHAMA 6 LUVALE 7 MUHUMBI 8 NGANGUELA 9 NHANECA 10 UMBUNDU 11 OTHER (SPECIFY)____ 96 TRANSLATOR USED (YES =1, NO=2) ____ SUPERVISOR NAME_________ NUMBER_________

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

124) How long have you lived in this province? IF LESS THAN A YEAR, RECORD '00' YEARS YEARS____ ALWAYS 95 (GO TO 201) VISITOR 96 (GO TO 201)

125) In which province or country did you live before moving here? CABINDA 01 ZAIRE 02 UIGE 03 LUANDA 04 NORTHERN CUANZA 05 SOUTHERN CUANZA 06 MALANJE 07 NORTHERN LUNDA 08 BENGUELA 09 HUAMBO 10 BIE 11 MOXICO 12 CUANDO CUBANGO 13 NAMIBE 14 HUILA 15 CUNENE 16 SOUTHERN LUNDA 17 BENGO 18 OTHER COUNTRY (COUNTRY)_____96

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

103) How old were you at your last birthday? COMPARE AND CORRECT 102 AND 103 IF INCONSISTENT AGE IN COMPLETED YEARS_____

102) In what month and year were you born? MONTH ____ DON'T KNOW MONTH 98 YEAR ____ DON'T KNOW YEAR 9998

102) In what month and year were you born? MONTH ____ DON'T KNOW MONTH 98 YEAR ____ DON'T KNOW YEAR 9998