Universal ID
Houshold #
DataFax Study Number
DataFax Plate Number
Visit Code
Team ID
1.Routine/Extended Quest.
1st Attempt: Date(mm)
1st Attempt: Date(dd)
1st Attempt: Date(yy)
1st Attempt: Date
1st Attempt Staff ID
1st Attempt: Result Code
2nd Attempt: Date(mm)
2nd Attempt: Date(dd)
2nd Attempt: Date(yy)
2nd Attempt: Date
2nd Attemp Staff ID
2nd Attempt: Result Code
3rd Attempt: Date(mm)
3rd Attempt: Date(dd)
3rd Attempt: Date(yy)
3rd Attempt: Date
3rd Attempt Staff ID
3rd Attempt: Result Code
5. Total # in household
6. Total eligible
7. Total given PTID
8. Main source of water
8m. Other, specify text
9a. Electricity
9b. Radio
9c. Television
9d. Mobile telephone
9e. Non-mobile telephone
9f. Refrigerator
9g. Stove
9h. Watch
9i. REF
Member #1: Usual member?
Member #1: Slept here?
Member #1: Gender
Member #1: Age (years)
Member #1: Eligible?
Member #1: Enroll Status
Member #2: Usual member?
Member #2: Slept here?
Member #2: Gender
Member #2: Age (years)
Member #2: Eligible?
Member #2: Enroll Status
Member #3: Usual member?
Member #3: Slept here?
Member #3: Gender
Member #3: Age (years)
Member #3: Eligible?
Member #3: Enroll Status
HC-2:No additional member
Member #4: Usual member?
Member #4: Slept here?
Member #4: Gender
Member #4: Age (years)
Member #4: Eligible?
Member #4: Enroll Status
Member #5: Usual member?
Member #5: Slept here?
Member #5: Gender
Member #5: Age (years)
Member #5: Eligible?
Member #5: Enroll Status
Member #6: Usual member?
Member #6: Slept here?
Member #6: Gender
Member #6: Age (years)
Member #6: Eligible?
Member #6: Enroll Status
Member #7: Usual member?
Member #7: Slept here?
Member #7: Gender
Member #7: Age (years)
Member #7: Eligible?
Member #7: Enroll Status
Member #8: Usual member?
Member #8: Slept here?
Member #8: Gender
Member #8: Age (years)
Member #8: Eligible?
Member #8: Enroll Status
HC-3:No additional member
Member #9: Usual member?
Member #9: Slept here?
Member #9: Gender
Member #9: Age (years)
Member #9: Eligible?
Member #9: Enroll Status
Member #10: Usual member?
Member #10: Slept here?
Member #10: Gender
Member #10: Age (years)
Member #10: Eligible?
Member #10: Enroll Status
Member #11: Usual member?
Member #11: Slept here?
Member #11: Gender
Member #11: Age (years)
Member #11: Eligible?
Member #11: Enroll Status
Member #12: Usual member?
Member #12: Slept here?
Member #12: Gender
Member #12: Age (years)
Member #12: Eligible?
Member #12: Enroll Status
Member #13: Usual member?
Member #13: Slept here?
Member #13: Gender
Member #13: Age (years)
Member #13: Eligible?
Member #13: Enroll Status
HC-4:No additional member
Member #14: Usual member?
Member #14: Slept here?
Member #14: Gender
Member #14: Age (years)
Member #14: Eligible?
Member #14: Enroll Status
Member #15: Usual member?
Member #15: Slept here?
Member #15: Gender
Member #15: Age (years)
Member #15: Eligible?
Member #15: Enroll Status
Member #16: Usual member?
Member #16: Slept here?
Member #16: Gender
Member #16: Age (years)
Member #16: Eligible?
Member #16: Enroll Status
Member #17: Usual member?
Member #17: Slept here?
Member #17: Gender
Member #17: Age (years)
Member #17: Eligible?
Member #17: Enroll Status
Member #18: Usual member?
Member #18: Slept here?
Member #18: Gender
Member #18: Age (years)
Member #18: Eligible?
Member #18: Enroll Status
HC-5:No additional member
Member #19: Usual member?
Member #19: Slept here?
Member #19: Gender
Member #19: Age (years)
Member #19: Eligible?
Member #19: Enroll Status
Member #20: Usual member?
Member #20: Slept here?
Member #20: Gender
Member #20: Age (years)
Member #20: Eligible?
Member #20: Enroll Status
Member #21: Usual member?
Member #21: Slept here?
Member #21: Gender
Member #21: Age (years)
Member #21: Eligible?
Member #21: Enroll Status
Member #22: Usual member?
Member #22: Slept here?
Member #22: Gender
Member #22: Age (years)
Member #22: Eligible?
Member #22: Enroll Status
Member #23: Usual member?
Member #23: Slept here?
Member #23: Gender
Member #23: Age (years)
Member #23: Eligible?
Member #23: Enroll Status
HC-6:No additional member
Member #24: Usual member?
Member #24: Slept here?
Member #24: Gender
Member #24: Age (years)
Member #24: Eligible?
Member #24: Enroll Status
Member #25: Usual member?
Member #25: Slept here?
Member #25: Gender
Member #25: Age (years)
Member #25: Eligible?
Member #25: Enroll Status
Member #26: Usual member?
Member #26: Slept here?
Member #26: Gender
Member #26: Age (years)
Member #26: Eligible?
Member #26: Enroll Status
Member #27: Usual member?
Member #27: Slept here?
Member #27: Gender
Member #27: Age (years)
Member #27: Eligible?
Member #27: Enroll Status
Member #28: Usual member?
Member #28: Slept here?
Member #28: Gender
Member #28: Age (years)
Member #28: Eligible?
Member #28: Enroll Status