Literal question
INTERVIEWER VISITS
VISIT 1
DATE __________
INTERVIEWER'S NAME _____________
RESULT* ___________
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ________________
NEXT VISIT:
DATE _________
TIME _________
VISIT 2
DATE __________
INTERVIEWER'S NAME _____________
RESULT* ___________
NEXT VISIT:
DATE _________
TIME _________
VISIT 3
DATE __________
INTERVIEWER'S NAME _____________
RESULT* ___________
NEXT VISIT:
DATE _________
TIME _________
FINAL VISIT
DAY ___________
MONTH __________
YEAR __________
INT. NUMBER __________
RESULT _________
TOTAL NUMBER OF VISITS __________
TOTAL PERSONS IN HOUSEHOLD _________
TOTAL ELIGIBLE WOMEN ________
TOTAL ELIGIBLE MEN ________
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ________
SUPERVISOR
NAME __________
DATE __________
OFFICE EDITOR __________
KEYED BY __________