Literal question
IDENTIFICATION
PLACE NAME _______
NAME OF HEAD OF HOUSEHOLD _______
HOUSEHOLD NUMBER ____
PLOT NUMBER ____
CLUSTER NUMBER _____
REGION ____
URBAN/RURAL
URBAN 1
RURAL 2
MILIEU
DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4
MILIEU (DETAIL) ________
MAN'S NAME AND LINE NUMBER ______
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER _____ (SPECIFY)
FINAL VISIT
DAY ____
MONTH ____
YEAR _____
INT. NUMBER ____
RESULT ____
NEXT VISIT
DATE _____
TIME _____