Name (Representative of the Family): Name (Representative of the Family):

_________________________________ _________________________________
Age: ______ With Toilet (Mark Check): Age: ______ With Toilet (Mark Check):
Sex:_____ Yes__ No__ Sex:_____ Yes__ No__

Family Members: Name Age Sex Family Members: Name Age Sex
(1) ____________________ ____ ____ (1) ____________________ ____ ____
(2) ____________________ ____ ____ (2) ____________________ ____ ____
(3) ____________________ ____ ____ (3) ____________________ ____ ____
(4) ____________________ ____ ____ (4) ____________________ ____ ____
(5) ____________________ ____ ____ (5) ____________________ ____ ____
(6) ____________________ ____ ____ (6) ____________________ ____ ____
(7) ____________________ ____ ____ (7) ____________________ ____ ____
(use the additional space below) (use the additional space below)

Is/are there any pregnant family member/s? Is/are there any pregnant family member/s?
Yes ___ None___ Yes ___ None___

Name (Representative of the Family): Name (Representative of the Family):

_________________________________ _________________________________
Age: ______ With Toilet (Mark Check): Age: ______ With Toilet (Mark Check):
Sex:_____ Yes__ No__ Sex:_____ Yes__ No__

Family Members: Name Age Sex Family Members: Name Age Sex
(1) ____________________ ____ ____ (1) ____________________ ____ ____
(2) ____________________ ____ ____ (2) ____________________ ____ ____
(3) ____________________ ____ ____ (3) ____________________ ____ ____
(4) ____________________ ____ ____ (4) ____________________ ____ ____
(5) ____________________ ____ ____ (5) ____________________ ____ ____
(6) ____________________ ____ ____ (6) ____________________ ____ ____
(7) ____________________ ____ ____ (7) ____________________ ____ ____
(use the additional space below) (use the additional space below)

Is/are there any pregnant family member/s? Is/are there any pregnant family member/s?
Yes ___ None___ Yes ___ None___