Literal question
NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
NAME OF WOMAN__________
LINE NUMBER OF WOMAN_________
GOVERNORATE_______
PSU/SEGMENT NO._______
HOUSEHOLD NO.______
SUBSAMPLE______
LINE NUMBER______
INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
RESULT* ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
RESULT* ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
RESULT* ______
NEXT VISIT: DATE _____ TIME ________
FINAL VISIT
MONTH ____ YEAR ____
TEAM _____
INTERVIEWER'S NAME _____
RESULT* ______
TOTAL NUMBER OF VISITS ___