TOTAL PERSONS IN HOUSEHOLD___ TOTAL ELIGIBLE WOMEN___ TOTAL ELIGIBLE MEN___ LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

INTERVIEWER VISITS FIRST VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ SECOND VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ THIRD VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ FINAL VISIT DAY __ __ MONTH __ __ YEAR __ __ __ __ INT. NO. __ __ __ RESULT CODE* __ NEXT VISIT: DATE____ TIME ____ TOTAL NUMBER OF VISITS __ SUPERVISOR'S NAME____________ SUPERVISOR NUMBER __ __ __

INTERVIEWER VISITS FIRST VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ SECOND VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ THIRD VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ FINAL VISIT DAY __ __ MONTH __ __ YEAR __ __ __ __ INT. NO. __ __ __ RESULT CODE* __ NEXT VISIT: DATE____ TIME ____ TOTAL NUMBER OF VISITS __ SUPERVISOR'S NAME____________ SUPERVISOR NUMBER __ __ __

INTERVIEWER VISITS FIRST VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ SECOND VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ THIRD VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ FINAL VISIT DAY __ __ MONTH __ __ YEAR __ __ __ __ INT. NO. __ __ __ RESULT CODE* __ NEXT VISIT: DATE____ TIME ____ TOTAL NUMBER OF VISITS __ SUPERVISOR'S NAME____________ SUPERVISOR NUMBER __ __ __

INTERVIEWER VISITS FIRST VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ SECOND VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ THIRD VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ FINAL VISIT DAY __ __ MONTH __ __ YEAR __ __ __ __ INT. NO. __ __ __ RESULT CODE* __ NEXT VISIT: DATE____ TIME ____ TOTAL NUMBER OF VISITS __ SUPERVISOR'S NAME____________ SUPERVISOR NUMBER __ __ __

101. RECORD THE TIME. HOUR __ __ MINUTES __ __

843. RECORD THE TIME HOUR __ __ MINUTES __ __

843. RECORD THE TIME HOUR __ __ MINUTES __ __

*RESULT CODES: 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER (SPECIFY)____________ **LANGUAGE CODES: 01 ASSAMESE 02 BENGALI 03 GUJARATI 04 HINDI 05 KANNADA 06 KASHMIRI 07 KONKANI 08 MALAYALAM 09 MANIPURI 10 MARATHI 11 NEPALI 12 ORIYA 13 PUNJABI 14 SINDHI 15 TAMIL 16 TELUGU 17 URDU 18 ENGLISH 19 GARO 20 KHASI 96 OTHER (SPECIFY)________

INTERVIEWER VISITS FIRST VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ SECOND VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ THIRD VISIT DATE_______ INTERVIEWER'S NAME________ RESULT CODE*________ FINAL VISIT DAY __ __ MONTH __ __ YEAR __ __ __ __ INT. NO. __ __ __ RESULT CODE* __ NEXT VISIT: DATE____ TIME ____ TOTAL NUMBER OF VISITS __ SUPERVISOR'S NAME____________ SUPERVISOR NUMBER __ __ __

SECTION 1. RESPONDENT'S BACKGROUND INTRODUCTION AND INFORMED CONSENT Namaste. My name is _______. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over India. The information on family welfare and health that we collect from households and individuals will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30-40 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Your participation in the survey is voluntary. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. If you have any questions about this survey you may ask me. ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS. Do you agree to participate in this survey? SIGNATURE OF INTERVIEWER___________ DATE_______ RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101) RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

IDENTIFICATION STATE_________ __ __ DISTRICT_____________ __ __ __ TEHSIL/TALUK__________ CITY/TOWN/VILLAGE_____________ TYPE OF PSU URBAN 1 RURAL 2 PSU NUMBER __ __ STRUCTURE NUMBER __ __ __ HOUSEHOLD NUMBER __ __ NAME AND LINE NUMBER OF MAN ______________ __ __ ADDRESS OF HOUSEHOLD____________