Literal question
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)____ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____
FINAL VISIT
DAY____
MONTH___
YEAR 94
NAME____
RESULT___
TOTAL NUMBER OF VISITS____
LANGUAGE OF INTERVIEW_____
INTERPRETER USED?
YES
NO
SUPERVISOR
NAME___
DATE___
FIELD EDITOR
NAME___
DATE____
KEYED BY
NAME____
DATE____