Literal question
NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
TELEPHONE:
CELLULAR _________
LANDLINE _________
GOVERNATE _________
PSU/SEGMENT NO.__________
HOUSEHOLD NO.________
SUBSAMPLE_____
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIWER _____
SUPERVISOR _____
RESULT ______
NEXT VISIT:
DATE _____
TIME ______
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INT. NUMBER _____
SUP. NUMBER _____
RESULT _____
TOTAL NUMBER OF VISITS __