Literal question
IDENTIFICATION
GOVERNORATE __________
KISM/MARKAZ __________
SHIAKHA/VILLAGE __________
HOUSEHOLD NO. ___________
PSU/SEGMENT NO. ________
BUILDING NO._________
HOUSE NO. ______________
URBAN 1
RURAL 2
LARGE CITY 1
SMALL CITY 2
TOWN 3
VILLAGE 4
SUBSAMPLE:
YES 1
NO 2
NAME OF HOUSEHOLD HEAD _______
ADDRESS IN DETAIL _____
GOVERNORATE __
PSU/SEGMENT NO. ___
HOUSEHOLD NO. ____
URBAN/RURAL ____
LOCALITY ___
SUBSAMPLE ___
INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIWER'S NAME_____
SUPERVISOR'S NAME _____
RESULT ______
FINAL VISIT
DAY ____ MONTH ____ YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
RESULT _____
TOTAL VISITS ____