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:_______________________________________