No.	QUESTIONS -English	QUESTIONS -Bahasa Indonesia	PROMPT / OPTIONS -English	PROMPT / OPTIONS -Bahasa Indonesia	NOTES
##	ACKNOWLEDGEMENT OF QUESTIONNAIRE COMPLETION
	Acknowledged by:		supervisor
	signature
	date
	village representative
	signature
	date
	name of local notable
	signature
	date
##	CERTIFICATION OF QUESTIONNAIRE COMPLETION
	We, the undersigned, certify that the responses in this record provide an accurate account
	enumerator
	signature
	date
	respondent
	signature
	date