IDENTIFICATION STATISTICAL CONFIDENTIALITY: BY THE TERMS GIVEN IN ARTICLE 11 OF THE LAW NO. 3/11, FROM THE 14TH OF JANUARY, LAW OF THE NATIONAL STATISTICS SYSTEM, ALL INDIVIDUAL DATA COLLECTED BY OFFICIAL STATISTICS ORGANIZATIONS, IN THIS CASE THE INE, ARE STRICTLY CONFIDENTIAL. COLLECTED DATA IS PROTECTED FROM ANY NON-STATISTICAL PURPOSES OR FROM ANY UNAUTHORIZED DISSEMINATION, ONLY TO BE USED FOR THE PRODUCTION OF OFFICIAL STATISTICS. PLACE NAME/ADDRESS________ NAME OF HOUSEHOLD HEAD________ PROVINCE ____ MUNICIPALITY ____ COMMUNE ____ NEIGHBORHOOD/VILLAGE ____ CENSUS SECTION ____ HOUSEHOLD AREA ____ URBAN 1 RURAL 2 CLUSTER NUMBER (ID. IIMS) ____ HOUSEHOLD NUMBER ____ HOUSEHOLD SELECTED FOR MAN'S SURVEY? YES 1 NO 2 HOUSEHOLD SELECTED FOR CHILDREN'S SURVEY? 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_________ 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_________

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_________

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