Note: You may also use this form to capture geographic coordinates for locations other than health facilities
*
Indicates required field(s)
Field Data collection guidelines
*
1. Name of Health Facility/Clinic (
please DO NOT enter acronym ONLY
):
(
example: “Ahmadu Bello University Teaching Hospital (ABUTH), Zaria”
)
2.
Government
Private
*
3. Region/State:
North Central
North East
North West
South East
South West
South South
Abia
Abuja, FCT
Adamawa
Akwa Ibom
Anambra
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Edo
Ekiti
Enugu
Ebonyi
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nassarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
*
4. Local Government Area:
5. Ward:
6. Village/Community:
7. Official Population/Year of Census:
*
8. Enter Coordinates in Decimal Degrees:
Latitude
Longitude
or Degrees, Minutes, Seconds:
Please check ONLY ONE location from list below for geographic coordinates entered above
Borehole/Water source
Motor park
Church
Pastor's house
Fuel
Pharmacy
Government Office
Primary school
Health Facility (providing RI)
Secondary school
Health Facility
University
Household (female-headed)
Settlement
Household
Village head's house
Imam's house
Ward head's house
LGA Headquarters
Point of interest (
please specify in box below
)
Market
Mosque
*
9. Date Completed : (
dd/mm/yyyy
)
10. Enter your Email:
