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:_______________________________________