Literal question
IDENTIFICATION
PLACE NAME ________
NAME OF HOUSEHOLD HEAD_______
PROVINCE_______
MUNICIPALITY_____
COMMUNITY_______
NEIGHBORHOOD/VILLAGE______
CENSUS SECTION______
AREAS OF RESIDENCE
URBAN 1
RURAL 2
CLUSTER NUMBER (ID. IIMS)______
HOUSEHOLD NUMBER_______
NAME AND LINE NUMBER OF WOMAN_______
THE WOMAN WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE
YES 1
NO 2