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Cluster: _______/Date: _/Study Team: _______

ICR 201609-0920-018 · OMB 0920-1137 · Object 68264501.

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Cluster: ___________________/Date: _______________________/Study Team: _________________
Author	Tim Dignam
Last Modified By	Writer
File Modified	2016-06-18
File Created	2026-10-10
Conversion State	complete

Extracted Text

Cluster (e.g., SJ-1): ____-____   	Date: _____/_____/__________ 		Investigation Team: ____________      

House ID
Not a home/Vacant
Occupied, but no one home
Occupied, present, refused
Occupied, present, participated
Other: specify
B





C





D





E





F





G





H





I





J





K





J





L





M





N





O





P





Q





R





S





T





U





V





W





X





Y





Z

Cluster: ___________________/Date: _______________________/Study Team: _________________

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Extracted Text

Cluster: _______/Date: _/Study Team: _______