Literal question
INTERVIEWER VISITS
VISIT 1
DATE _____________
INTERVIEWER'S NAME _____________
RESULT* _____________
*RESULT CODES:
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 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
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW _____________
NATIVE LANGUAGE OF RESPONDENT _____________