Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
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Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
Gather signature:
Check box:
Respondent's signature
Please ask the respondent to sign or check the box in agreement of their participation.
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010a. Hello. My name is ________________________________ and I am working for COUNTRY PARTNER in collaboration with OTHER PARTNERS. We are conducting a local survey about various health issues. We would very much appreciate your participation in this survey. This information will help us inform the government to better plan health services. Whatever information you provide will be kept strictly confidential and will not be shown to anyone other than members of our survey team.
Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important.
I am going to ask you questions about your family and other household members. We would then like to ask a different set of questions to female members of this household who are between the ages of 15 and 49 years.
At this time, do you want to ask me anything about the survey?
Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?
Then, ask:
May I begin the interview now?