Literal question
INTERVIEWER VISITS
FIRST VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT __________
SECOND VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT __________
THIRD VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT __________
FINAL VISIT
DAY ___
MONTH __________
YEAR _____
ID NUMBER ___
RESULT __________
NEXT VISIT
DATE _____
TIME _____