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 _________
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN ______
TOTAL ELIGIBLE MEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______
*RESULT CODES:
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) __________