| Screening Form | ||||||||
| 24-Jan-08 | ||||||||
| BF1_1 | Date | BF1_1 | ||||||
| Chsuno | Child survey number | Chsuno | ||||||
| Chsno | Child Serial number/women id number | Chsno | ||||||
| BF1_3 | Doctor code | BF1_3 | ||||||
| BF1_4 | Is the woman/child willing to participate and informed consent is available | BF1_4 | ||||||
| BF1_5 | Does the woman or child suffer from any acute or chronic diseases that makes | BF1_5 | ||||||
| it impossible to participate | ||||||||
| SUPERVISOR'S SIGNATURE | ||||||||
| DATA ENTRY 1 | ||||||||
| DATA ENTRY 2 | ||||||||