Literal question
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S NUMBER
RESULT*
TOTAL NUMBER OF VISITS: