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Name of Enumerator
   
 
 
 
County
   
 
 
 
Name of Commune
   
 
 
 
Name of Hamlet
   
 
 
 
Details Useful to Locate the Residential Unit
   
 
 
 
Name of Respondent
   
 
 
 
Gender
 
Female
 
Male
 
 
 
Mobile Phone Contact
   
 
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