Literal question
    
                                    DATE________
INTERVIEWER'S NAME_______________
RESULT*_____________
1COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
FINAL VISIT_________
DAY _______________
MONTH____________
YEAR 2012_______
INTERVIEWER___________
RESULT_____________
1COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
NEXT VISIT___________
DATE_________
TIME___________