Literal question
INTERVIEWER VISITS
FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______
SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______
THIRD VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______
FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT. NO. _______
RESULT* _______
TOTAL NUMBER OF VISITS _________
*RESULT CODES
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _________