Literal question
INTERVIEWER VISITS
FIRST VISIT
DATE_________
INTERVIEWER'S NAME_________
RESULT*
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
NEXT VISIT
DATE____
TIME____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
NEXT VISIT
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
FINAL VISIT
DAY_________
MONTH_________
YEAR_____
INT. NO._________
RESULT*_________
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
TOTAL NUMBER OF VISITS_________
LANGUAGE OF QUESTIONNAIRE:
PORTUGUESE 1
CHOKWE/KIOKO 2
FIOTE 3
KIKONGO/UKONGO 4
KIMBUNDU 5
KWANHAMA 6
LUVALE 7
MUHUMBI 8
NGANGUELA 9
NHANECA 10
UMBUNDU 11
OTHER (SPECIFY) ____ 96
TRANSLATOR USED:
YES 1
NO 2
SUPERVISOR
NAME_________
NUMBER_________