Identity | |||||
Questionnaire numberFilled on: …………………….at…………. hour |
| ||||
LocationA.1 Region: KEDOUGOUA.2 Department: KEDOUGOUA.3 Health District: KEDOUGOU | |||||
Interviewer identity: A.4 Last name and first name of the interviewer: ____________________________________ A.5. interviewer code; ___________________A.6. Telephone number: / / / / / / / / / / | |||||
Supervisor identity: A.7. Last name and first name ___________________________________________________ A.8. telephone number: / / / / / / / / / / |