1. Peridomestic:	a) Cement tank	b) Broken glass
	c) Tires	d) Other
2. Domestic:	a) Tanks	b) Earthen and plastic drum
	c) Plastic bucket	d) Metallic container	e) Other
3. External:	a) Tanks	b) Tree hole
	c) Coconut shell	d) Others
4. Larva containing sample No.:
5. Larva sample volume:
6. Sample examination report:
	a) Larva	b) Pupa