Milana HOS 2011 General Information Information on illness Information on care received

A B C D E F G H I J K L M N O P Q R S T U V
How many Was care sought How many How many How many
times person Days of for each How much How many How many rupees spent rupees in other people
How many How many How many has gotten How many school/work particular time spent people How many rupees spent on medicine/ other missed work
members Profession rupees does days in one Schooling Does this sick in the days has missed from sickness? / How travelling for involved in rupees spent on doctor's medical expenses during Is the
permanently (current this person month does (mark next to person have past month? each instance each sickness? many times care care? (hrs or travel for on travel? / fee? / Total in supplies? / were there? / sickness? / person
residing in occupation, if earn in one this person ca if currently chronic (No chronic of sickness / Days missed What were the symptoms of the sickness? sought for Why did person seek or not seek Where did person seek If person did not seek care at days) / Avg care? / Avg Avg for past month Total for Total for Avg for sick right
household? Age Gender any) day of work? work? attending) conditions? conditions) lasted? b/c of chronic / Describe chronic conditions chronic? healthcare? healthcare? Milana's clinic, why not? for chronic for chronic chronic for chronic chronic chronic chronic now?

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
1 _____ (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
2 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
3 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
4 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
5 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
6 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
7 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed

None ca:___ 1) 1) 1) 1) Y N 1) 1) 1) 1) 1) 1) 1)

Male (K-5) _____ 2) 2) 2) 2) Y N 2) 2) 2) 2) 2) 2) 2)

_____
8 (6-10) 3) 3) 3) 3) Y N 3) 3) 3) 3) 3) 3) 3)

Female (11-12) Y N

Higher Ed
Additional Space: (Use codes, i.e. 4P)

Family Name Village Survey Administrator