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. NUMBER _____
RESULT*
TOTAL NUMBER OF VISITS _____