Literal question
INTERVIEWER VISITS:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE: _______
INTERVIEWER'S NAME _________
RESULT*
*RESULT CODES
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _____
FINAL VISIT
DAY ____
MONTH ____
YEAR _____
INT. NUMBER ____
RESULT* _____
NEXT VISIT
DATE _____
TIME _____