Literal question
NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
NAME OF WOMAN ______________
LINE NUMBER OF WOMAN ___________
GOVERNORATE ___
PSU/SEGMENT NO.___
HOUSEHOLD NO. ___
URBAN/RURAL ___
LOCALITY ___
LINE NUMBER ___
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
SUPERVISOR 'S NAME_____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
FINAL VISIT: DAY ____ MONTH ____ YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
RESULT _____
TOTAL NUMBER OF VISITS ___