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Name of Household Head (optional)______________________________Date of interview: _________

Address: ____________________________________________________

In what type of building does the household reside?

____ Single house _____ Multi-unit residential (apartments,compound, etc)


____ Duplex _____ Other housing unit (boat, cave, trailers, carts, others)

How many members are there in the household including the respondent?

_____ 3 and below _____ 6 to 9


_____ 4 to 6 _____ 10 and above

How many members are working?

_____ 1 _____ 4- 5
_____ 2-3 _____ 6 and more

How much is the combined monthly income?

_____ 5,000 and below _____ 10, 001 to 15, 000 _____ 20, 000 and above
_____ 5, 001 t0 10,000 _____ 15, 001 to 20,000

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