Submission Time

Survey country

District Name

Sub-County/Division/Town Council Masaka

Parish/Ward Masaka

Is the village originally selected or a replacement?

Village name

Is the household originally selected or a replacement?

Name of Household Head

Is village rural or urban?

Interviewer name:

Interview date:

Supervisor name:

Consent obtained from household head to proceed?

Does the household keep livestock?

Is there a pregnant woman or mother of a child aged less than 4 years living in the household, and with her husband or partner?

How many members are in your household:

Sex:

What is the relationship of ${name} to the head of the household?

How old is ${name} in completed years?