Post on 27-Dec-2015
description
Name of Child: ___________________________
Age: ______
Address: ________________________________
Name of Mother: _________________________
Date child had Diarrhea: ___________________
Socio economic status:__above 30,000__20,001 – 30,000__10,001 – 20,000__1,001 – 10,000__below 1,000
Water Level Facility:Level I:__protected well__developed springLevel II:__communal faucetLevel III:__waterworks system / individual household__purified water / mineral water
Interviewed by:_______________________________________Date of interview:_______________________________________