Literal question
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME ____
RESULT*
FINAL VISIT
DAY _____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT*
NEXT VISIT:
DATE ______
TIME _____
TOTAL NUMBER OF VISITS __________
*RESULT CODES:
1COMPLETED
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)