Identity

Questionnaire number

Filled on: …………………….at…………. hour

Location

A.1 Region: KEDOUGOU

A.2 Department: KEDOUGOU

A.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: / / / / / / / / / /