Literal question
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT* ___
*RESULT CODES
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY ____
MONTH _____
YEAR _____
INT. NO. _____
RESULT* ___
*RESULT CODES
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
TOTAL NUMBER OF VISITS ____