Literal question
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___________ 9
NEXT VISIT:
DATE __________
TIME ___________
FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER CODE ____
RESULT* _____
TOTAL NUMBER OF VISITS __
TOTAL PERSONS IN HOUSEHOLD __
TOTAL WOMEN 15-49__
TOTAL MEN 15-54 __
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __