Research INTEL Questionnaire
1
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 spring Level II: __communal faucet
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Transcript of Research INTEL Questionnaire
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:_______________________________________
