Literal question
Interviewer visits (for 1, 2, 3 and final visits)
Date _____
Interviewer's name __________
Result __________
Time __________
Day __________
Month __________
Year _____
Name __________
Result __________
Next visit:
Date
Time
Total number of visits:
Result codes:
1 Completed
2 Not at home
3 Postponed
4 Refused
5 Partly Completed
6 Incapacitated
7 Other (specify) __________
Language questionnaire: English
Language used in interview
Respondent's local language
Translator used (not at all = 1; sometimes = 2; all the time = 3)
Language:
1 Ateso-Karamojong
2 Luganda
3 Lugbara
4 Luo
5 Runy Ankole-Rukiga
6 Runyoro-Rutoro
7 English
8 Other
Supervisor
Name __________
Date _____
Field editor
Name __________
Date _____
Office editor ___
Keyed by ___