i t g_ S°· &> ij, ~ " ~ ~ APP£NDIXCl FAMUSBVICIANDPl OGRESSRKORD NEAD Of nt E FAMILY: FAMILY NUMIER: _______ _ I, I. Assesfflieat of the Fmlly, Ho~and Environmental Conditions: Al. Membffl of the Household FAMILY MEMIEII 1111,AT'ION Bllnt OATt MARITAl H1Gll£ST OCCUP~TION ilo. TO HEAD SEX STATUS l DUC. Typeof """' Month Year COMPL£Ti D Woni Platt -Al. Famllv Members not residing In the household but affect family re1ourc. e generation and use FAMl Y MEMBER Ra ATION ll RTMDATl MAIUT'-L H[GHEST OCCUPATION TO HEAD Stlt STATUS EDUC. typeof No. Name Month Year COMPll TEO Work Plate ~ A. Home and Environment Dat1! Assessect: ____ ~---1. Home a. Ownership: ( ) owned ( ) rented ( ) rent-free b. Construction. materials used: ( ) Light ( ) Mixed ( ) Strong c. Number of rooms used for sleeping: ______ _ d, Ugtlt1ng hitllltles: l 1 Eleetriti. ty ( ) Kerosene j ) Others: Specify e. General-sanitarycondillon: ________ __________ _ REMAJ. KS/ DAT£ ENTEREO REMARKS/ DATl ENl HE O 