Sex of respondent

Number of Accompanying Family Members

Number of Accompanying Female Family Members

Number of Accompanying Children Under the age of 18

Number of Accompanying Female Children

Number of household members left in CoA?

State you're returning to?

County you’re returning to?

Payam you're returning to?

Have you lived there before?

Is this place your area of origin?

What is your state of origin?

What is your country of origin?

What is your payam of origin?

Which country of asylum are you returning from?

Which camp/settlement in CoA?

Is your household registered as refugee's in CoA

Main reasons for returning back home?

Please specify other:

What means of transport did you use to get here?

Please specify other:

Did you pay for the trip to arrive to South Sudan with your own means or with some support?

Please specify other:

Have you encountered any of the following while you were travelling from CoA?

Please specify other:

How long do you intend to stay in SSD?

How many times have you returned to SSD since displaced?

Select bordering country

Interviewer agency

Enumerator Code

Comment / Observation

Message: