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Exit Survey
 
 
Date of interview
   
 
 
 
Start time of interview
   
 
 
 
Mobile Number of the Household head
   
 
 
 
Name of the Household head
   
 
 
 
Name of the Respondent
   
 
 
 
Relationship of respondent with Household head
 
Self
 
Wife/Husband
 
Son
 
Daughter
 
Other
 
 
 
 
Gender of Household head
 
Male
 
Female
 
 
 
Village
   
 
 
 
Cluster
   
 
 
 
Block/District