Literal question
IDENTIFICATION
NAME AND CODE OF DISTRICT ______________
NAME AND CODE OF VILLAGE MUNICIPALITY __________________
WARD NUMBER _______
CLUSTER NUMBER _________
CITY/TOWN/COUNTRYSIDE
CITY 1
TOWN 2
COUNTRYSIDE 3
NAME OF HOUSEHOLD HEAD _______________
NAME OF RESPONDENT ______________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY
YES 1
NO 2