Literal question
NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
NAME OF WOMAN ______________
LINE NUMBER OF WOMAN ___________
GOVERNORATE_____
PSU/SEGMENT NO.____
HOUSEHOLD NO. _____
LINE NUMBER____
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIEWER _____
SUPERVISOR _____
RESULT ______
NEXT VISIT :
DATE _____
TIME ________
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INT. NUMBER _____
SUP. NUMBER _____
RESULT _____