Survey Text
Afghanistan 2015
Survey form
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101. RECORD THE TIME.
HOUR___
MINUTES____
Angola 2015
No questionnaire text is available for this sample.
Bangladesh 1994
No questionnaire text is available for this sample.
Bangladesh 1997
No questionnaire text is available for this sample.
Bangladesh 2000
No questionnaire text is available for this sample.
Bangladesh 2004
No questionnaire text is available for this sample.
Bangladesh 2007
No questionnaire text is available for this sample.
Bangladesh 2011
No questionnaire text is available for this sample.
Bangladesh 2014
No questionnaire text is available for this sample.
Benin 1996
No questionnaire text is available for this sample.
Benin 2001
No questionnaire text is available for this sample.
Benin 2006
No questionnaire text is available for this sample.
Benin 2011
No questionnaire text is available for this sample.
Benin 2017
Survey form
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Instructions:
Only one code should appear in any box
Column 1 requires a code in every month.
Information to be coded for each column.
Column 1: Births, Pregnancies, Contraceptive Use
B Birth
P Pregnancies
T Terminations
0 No method
1 Female sterilization
2 Male sterilization
3 IUD
4 Injectables
5 Implants
6 Pill
7 Condom
8 Female condom
9 Emergency contraception
J Standard Days Method
K Lactational Amenorrhea Method
L Rhythm method
M Withdrawal
X Other modern method
Y Other traditional method
Column 2: Discontinuation of contraceptive use
0 Infrequent sex/husband away
1 Became pregnant while using
2 Wanted to become pregnant
3 Husband/partner disapproved
4 Wanted more effective method
5 Side effects/health concerns
6 Lack of access/too far
7 Costs too much
8 Inconvenient to use
F Up to God/Fatalist
A Difficult to get pregnant/menopausal
D Marital dissolution/separation
X Other (specify)
Z Don't know
Column 1 Column 2
2017 (1)
12 Dec 01
11 Nov 02
10 Oct 03
09 Sept 04
08 Aug 05
07 Jul 06
06 Jun 07
05 May 08
04 Apr 09
03 Mar 10
02 Feb 11
01 Jan 12
2016
12 Dec 13
11 Nov 14
10 Oct 15
09 Sept 16
08 Aug 17
07 Jul 18
06 Jun 19
05 May 20
04 Apr 21
03 Mar 22
02 Feb 23
01 Jan 24
2015
12 Dec 25
11 Nov 26
10 Oct 27
09 Sept 28
08 Aug 29
07 Jul 30
06 Jun 31
05 May 32
04 Apr 33
03 Mar 34
02 Feb 35
01 Jan 36
2014
12 Dec 37
11 Nov 38
10 Oct 39
09 Sept 40
08 Aug 41
07 Jul 42
06 Jun 43
05 May 44
04 Apr 45
03 Mar 46
02 Feb 47
01 Jan 48
2013
12 Dec 49
11 Nov 50
10 Oct 51
09 Sept 52
08 Aug 53
07 Jul 54
06 Jun 55
05 May 56
04 Apr 57
03 Mar 58
02 Feb 59
01 Jan 60
2012
12 Dec 61
11 Nov 62
10 Oct 63
09 Sept 64
08 Aug 65
07 Jul 66
06 Jun 67
05 May 68
04 Apr 69
03 Mar 70
02 Feb 71
01 Jan 72
Burkina Faso 1993
No questionnaire text is available for this sample.
Burkina Faso 2003
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME ______
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY _____
MONTH _____
YEAR 2003
INT. NUMBER ______
RESULT __________
COMPLETED 1
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
TOTAL NUMBER OF VISITS _____
Burkina Faso 2010
No questionnaire text is available for this sample.
Burundi 2010
Survey form
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CALENDAR
INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN EACH BOX
COLUMN 1 REQUIRES A CODE IN EVERY MONTH.
INFORMATION TO BE CODED FOR EACH COLUMN.
COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE
B BIRTH
P PREGNANCIES
T TERMINATIONS
0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM OR JELLY
K LACTATIONAL AMENORRHEA METHOD
L RHYTHM METHOD
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD
COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALIST
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY) _____
Z DON'T KNOW
2011:
04 APR 01 ____ ____
03 MAR 02 ____ ____
02 FEB 03 ____ ____
01 JAN 04 ____ ____
2010:
12 DEC 05 ____ ____
11 NOV 06 ____ ____
10 OCT 07 ____ ____
09 SEPT 08 ____ ____
08 AUG 09 ____ ____
07 JUL 10 ____ ____
06 JUN 11 ____ ____
05 MAY 12 ____ ____
04 APR 13____ ____
03 MAR 14____ ____
02 FEB 15____ ____
01 JAN 16____ ____
2009:
12 DEC 17____ ____
11 NOV 18 ____ ____
10 OCT 19 ____ ____
09 SEPT 20 ____ ____
08 AUG 21 ____ ____
07 JUL 22 ____ ____
06 JUN 23 ____ ____
05 MAY 24 ____ ____
04 APR 25____ ____
03 MAR 26____ ____
02 FEB 27____ ____
01 JAN 28____ ____
2008:
12 DEC 29 ____ ____
11 NOV 30 ____ ____
10 OCT 31 ____ ____
09 SEPT 32 ____ ____
08 AUG 33 ____ ____
07 JUL 34 ____ ____
06 JUN 35 ____ ____
05 MAY 36 ____ ____
04 APR 37____ ____
03 MAR 38____ ____
02 FEB 39____ ____
01 JAN 40____ ____
2007:
12 DEC 41 ____ ____
11 NOV 42 ____ ____
10 OCT 43 ____ ____
09 SEPT 44 ____ ____
08 AUG 45 ____ ____
07 JUL 46 ____ ____
06 JUN 47 ____ ____
05 MAY 48 ____ ____
04 APR 49____ ____
03 MAR 50____ ____
02 FEB 51____ ____
01 JAN 52____ ____
2006:
12 DEC 53 ____ ____
11 NOV 54 ____ ____
10 OCT 55 ____ ____
09 SEPT 56 ____ ____
08 AUG 57 ____ ____
07 JUL 58 ____ ____
06 JUN 59 ____ ____
05 MAY 60 ____ ____
04 APR 61____ ____
03 MAR 62____ ____
02 FEB 63____ ____
01 JAN 64____ ____
2005:
12 DEC 65 ____ ____
11 NOV 66 ____ ____
10 OCT 67 ____ ____
09 SEPT 68 ____ ____
08 AUG 69 ____ ____
07 JUL 70 ____ ____
06 JUN 71 ____ ____
05 MAY 72 ____ ____
04 APR 73____ ____
03 MAR 74____ ____
02 FEB 75____ ____
01 JAN 76____ ____
Burundi 2016
No questionnaire text is available for this sample.
Cameroon 1991
No questionnaire text is available for this sample.
Cameroon 2004
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____
Cote d'Ivoire 1998
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
Egypt 1992
Survey form
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701. ENTER THE LINE NUMBER AND NAME OF EACH BIRTH SINCE JANUARY 1987 IN THE TABLE. BEGIN WITH THE LAST BIRTH. RECORD TWINS OR TRIPLETS IN SEPARATE COLUMNS. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).
LINE NUMBER FROM Q212 ___
NAME
ALIVE
DEAD
Egypt 1995
Survey form
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INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIEWER _____
SUPERVISOR _____
ASSISTANT SUPERVISOR _____
RESULT ______
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 ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
ASSISTANT SUPERVISOR _____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _______ 7
TOTAL NUMBER OF VISITS __
Egypt 2000
Survey form
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NAME OF HOUSEHOD HEAD______
ADDRESS IN DETAIL______
NAME OF WOMAN_______
LINE NUMBER OF WOMAN_________
INTERVIEWER VISITS (REPEAT FOR INTERVIEW VISITS 1 AND 2)
DATE_____
TEAM_____
INTERVIEWER_______
SUPERVISOR______
RESULT*______
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)________ 7
NEXT VISIT
DATE_____
TIME______
TOTALVISITS_______
Egypt 2003
No questionnaire text is available for this sample.
Egypt 2005
Survey form
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FIRST VISIT
DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT
FINAL VISIT
DAY __ __
MONTH __ __
YEAR __ __
TEAM __ __
INT. NUMBER __ __
SUP. NUMBER __ __
RESULT __
TOTAL NUMBER OF VISITS __
Egypt 2008
Survey form
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NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
NAME OF WOMAN ______________
LINE NUMBER OF WOMAN ___________
GOVERNORATE_____
PSU/SEGMENT NO.____
HOUSEHOLD NO. _____
LINE NUMBER____
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIEWER _____
SUPERVISOR _____
RESULT ______
NEXT VISIT :
DATE _____
TIME ________
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INT. NUMBER _____
SUP. NUMBER _____
RESULT _____
Egypt 2014
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS):
DATE__________
TEAM__________
INTERVIEWER_________
SUPERVISOR__________
RESULT____
NEXT VISIT (FOR INTERVIEWERS 1 AND 2):
DATE__________
TIME__________
FINAL VISIT:
DAY__ __
MONTH __ __
YEAR__ __
TEAM __ __
INT. NUMBER__ __
SUP. NUMBER__ __
RESULT__
Eswatini (Swaziland) 2006
No questionnaire text is available for this sample.
Ethiopia 2005
No questionnaire text is available for this sample.
Ethiopia 2011
No questionnaire text is available for this sample.
Ethiopia 2016
No questionnaire text is available for this sample.
Ghana 1993
Survey form
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text
INTERVIEWER VISITS
INTERVIEW 1
DATE ____
INTERVIEWER'S NAME _____
RESULT*** ____
NEXT VISIT:
DATE ____
TIME ____
INTERVIEW 2
DATE ____
INTERVIEWER'S NAME _____
RESULT*** ____
NEXT VISIT:
DATE ____
TIME ____
INTERVIEW 3
DATE ____
INTERVIEWER'S NAME _____
RESULT*** ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ___
Ghana 2003
Survey form
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INTERVIEWER VISITS
VISIT 1
DATE _________
NTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________
VISIT 2
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________
INTERVIEWER VISIT 3
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
FINAL VISIT
DAY __
MONTH __
YEAR 2003
NAME ___
RESULT __
Ghana 2008
Survey form
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INTERVIEW 1
DATE ____
INTERVIEWER'S NAME ____
RESULT*____
NEXT VISIT:
DATE ___
TIME____
INTERVIEW 2
DATE ____
INTERVIEWER'S NAME ____
RESULT*____
NEXT VISIT:
DATE ___
TIME____
INTERVIEW 2 DATE ____
INTERVIEWER'S NAME ____
RESULT*____
FINAL VISIT
DAY___
MONTH ___
YEAR 2008
INT. NUMBER ____
RESULT____
Ghana 2014
Survey form
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INTERVIEW VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____7
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR 2014
INT. NUMBER _____
RESULT ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____7
Guinea 2005
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH _____
YEAR 2005
NAME _____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ______ 7
Guinea 2018
Survey form
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2018 (1)
12 Dec 01
11 Nov 02
10 Oct 03
09 Sept 04
08 Aug 05
07 Jul 06
06 Jun 07
05 May 08
04 Apr 09
03 Mar 10
02 Feb 11
01 Jan 12
2017
12 Dec 13
11 Nov 14
10 Oct 15
09 Sept 16
08 Aug 17
07 Jul 18
06 Jun 19
05 May 20
04 Apr 21
03 Mar 22
02 Feb 23
01 Jan 24
2016
12 Dec 25
11 Nov 26
10 Oct 27
09 Sept 28
08 Aug 29
07 Jul 30
06 Jun 31
05 May 32
04 Apr 33
03 Mar 34
02 Feb 35
01 Jan 36
2015
12 Dec 37
11 Nov 38
10 Oct 39
09 Sept 40
08 Aug 41
07 Jul 42
06 Jun 43
05 May 44
04 Apr 45
03 Mar 46
02 Feb 47
01 Jan 48
2014
12 Dec 49
11 Nov 50
10 Oct 51
09 Sept 52
08 Aug 53
07 Jul 54
06 Jun 55
05 May 56
04 Apr 57
03 Mar 58
02 Feb 59
01 Jan 60
2013
12 Dec 61
11 Nov 62
10 Oct 63
09 Sept 64
08 Aug 65
07 Jul 66
06 Jun 67
05 May 68
04 Apr 69
03 Mar 70
02 Feb 71
01 Jan 72
(1) We assume that the collection year is 2018. For collection starting in 2019, all references to calendar year must be increased by one year: for example, 20112 must be changed to 2013, 2013 to 2014, 2014 to 2015, and so on for all years in the questionnaire.
(2) Codes can be added for other methods, like those based on knowledge of fertility.
India 1992
Survey form
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INTERVIEW VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT ______
India 2005
Survey form
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text
FINAL VISIT
DATE ______
MONTH ______
YEAR ______
INT. NO. ______
RESULT CODE _____
India 2015
No questionnaire text is available for this sample.
Jordan 1990
No questionnaire text is available for this sample.
Jordan 1997
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR 1997
NAME
RESULT
TOTAL NUMBER OF VISITS
Jordan 2002
No questionnaire text is available for this sample.
Jordan 2007
Survey form
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COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 HEALTH CONCERNS
6 SIDE EFFECTS
7 LACK OF ACCESS/ TOO FAR
8 COSTS TOO MUCH
9 INCONVENIENT TO USE
F FATALISTIC
A DIFFICULT TO GET PREGNANT/ MENOPAUSAL
D WIDOW/ DIVORCE/ SEPARATION
R RAMADAN
X OTHER (SPECIFY)_________________
Z DON'T KNOW
2007
12 DEC 01_ _
11 NOV 02_ _
10 OCT 03_ _
09 SEP 04_ _
08 AUG 05_ _
07 JUL 06_ _
06 JUN 07_ _
05 MAY 08_ _
04 APR 09_ _
03 MAR 10_ _
02 FEB 11_ _
01 JAN 12_ _
2006
12 DEC 13_ _
11 NOV 14_ _
10 OCT 15_ _
09 SEP 16_ _
08 AUG 17_ _
07 JUL 18_ _
06 JUN 19_ _
05 MAY 20_ _
04 APR 21_ _
03 MAR 22_ _
02 FEB 23_ _
01 JAN 24_ _
2005
12 DEC 25_ _
11 NOV 26_ _
10 OCT 27_ _
09 SEP 28_ _
08 AUG 29_ _
07 JUL 30_ _
06 JUN 31_ _
05 MAY 32_ _
04 APR 33_ _
03 MAR 34_ _
02 FEB 35_ _
01 JAN 36_ _
2004
12 DEC 37_ _
11 NOV 38_ _
10 OCT 39_ _
09 SEP 40_ _
08 AUG 41_ _
07 JUL 42_ _
06 JUN 43_ _
05 MAY 44_ _
04 APR 45_ _
03 MAR 46_ _
02 FEB 47_ _
01 JAN 48_ _
2003
12 DEC 49_ _
11 NOV 50_ _
10 OCT 51_ _
09 SEP 52_ _
08 AUG 53_ _
07 JUL 54_ _
06 JUN 55_ _
05 MAY 56_ _
04 APR 57_ _
03 MAR 58_ _
02 FEB 59_ _
01 JAN 60_ _
2002
12 DEC 61_ _
11 NOV 62_ _
10 OCT 63_ _
09 SEP 64_ _
08 AUG 65_ _
07 JUL 66_ _
06 JUN 67_ _
05 MAY 68_ _
04 APR 69_ _
03 MAR 71_ _
02 FEB 71_ _
01 JAN 72_ _
Jordan 2009
Survey form
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CALENDAR
INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. IN COLUMN 1, ALL MONTHS SHOULD BE FILLED IN.
INFORMATION TO BE CODED FOR EACH COLUMN.
COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVES USE
BIRTHS B
PREGNANCIES P
TERMINATIONS T
NO METHOD 0
FEMALE STERILIZATION 1
MALE STERILIZATION 2
PILL 3
IUD 4
INJECTABLES 5
IMPLANTS 6
CONDOM 7
FAMLE CONDOM 8
DIAPHRAGM 9
FOAM OR JELLY J
LACTATIONAL AMENORRHEA METHOD K
PERIODIC ASTINENCE L
WITHDRAWL M
OTHER(SPECIFY) ________________ X
NOTE: In case of multiple birth which ended with live and non-live birth outcomes record BIRTH to the calendar
COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
INFREQUENT SEX/HUSBAND AWAY 0
BECAME PREGNANT WHILE USING 1
WANTED TO BECOME PREGNANT 2
HUSBAND DISAPPROVED 3
WANTED MORE EFFECTIVE METHOD 4
HEALTH CONCERNS 5
SIDE EFFECTS 6
LACK OF ACCESS/TOO FAR 7
COSTS TOO MUCH 8
INCONVIENT TO USE 9
FATALISTIC F
DIFFICULT TO GET PREGNANT/MENOPAUSAL A
WIDOW/DIVORCE/SEPARATION D
RAMADAN R
OTHER(SPECIFY) _____________ X
DON'T KNOW Z
2009
12 DEC 01 __
11 NOV 02 __
10 OCT 03 __
09 SEP 04 __
08 AUG 05 __
07 JUL 06 __
06 JUN 07 __
05 MAY 08 __
04 APR 09 __
03 MAR 10 __
02 FEB 11 __
01 JAN 12 __
2008
12 DEC 13 __
11 NOV 14 __
10 OCT 15 __
09 SEP 16 __
08 AUG 17 __
07 JUL 18 __
06 JUN 19 __
05 MAY 20 __
04 APR 21 __
03 MAR 22 __
02 FEB 23 __
01 JAN 24 __
2007
12 DEC 25 __
11 NOV 26 __
10 OCT 27 __
09 SEP 28 __
08 AUG 29 __
07 JUL 30 __
06 JUN 31 __
05 MAY 32 __
04 APR 33 __
03 MAR 34 __
02 FEB 35 __
01 JAN 36 __
2006
12 DEC 37 __
11 NOV 38 __
10 OCT 39 __
09 SEP 40 __
08 AUG 41 __
07 JUL 42 __
06 JUN 43 __
05 MAY 44 __
04 APR 45 __
03 MAR 46 __
02 FEB 47 __
01 JAN 48 __
2005
12 DEC 49 __
11 NOV 50 __
10 OCT 51 __
09 SEP 52 __
08 AUG 53 __
07 JUL 54 __
06 JUN 55 __
05 MAY 56 __
04 APR 57 __
03 MAR 58 __
02 FEB 59 __
01 JAN 60 __
2004
12 DEC 61 __
11 NOV 62 __
10 OCT 63 __
09 SEP 64 __
08 AUG 65 __
07 JUL 66 __
06 JUN 67 __
05 MAY 68 __
04 APR 69 __
03 MAR 70 __
02 FEB 71 __
01 JAN 72 __
Jordan 2012
Survey form
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INTERVIEWER VISITS (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME __________
RESULT*
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 _____
INTERVIEW NUMBER _____
RESULT____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ______ 7
Jordan 2017
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIWER'S NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ________________ 7
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ________________ 7
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ________________ 7
Kenya 1993
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
Kenya 1998
Survey form
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text
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT***
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
Kenya 2003
Survey form
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INTERVIEWER VISIT
INTERVIEW VISIT 1 (REPEAT FOR INTERVIEW VISIT 2 AND VISIT 3)
DATE ______
INTERVIEWER'S NAME __________
RESULT** ____________
NEXT VISIT:
DATE _____________
TIME ______________
FINAL VISIT
DAY ____________
MONTH ____________
YEAR 2003 __________
INT. CODE __________
RESULT ___________
Kenya 2008
Survey form
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text
NAME AND LINE NUMBER OF WOMAN
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
Kenya 2014
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE ______
INTERVIEWER'S NAME __________
RESULT* _________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
SECOND VISIT
DATE ______
INTERVIEWER'S NAME __________
RESULT* _________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
THIRD VISIT
DATE ______
INTERVIEWER'S NAME __________
RESULT* _________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY ____
MONTH _____
YEAR _____
INTERVIEW NUMBER _____
RESULT* ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
Lesotho 2009
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT___
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____
FINAL VISIT
DAY ___ ___
MONTH ___ ___
YEAR ___ ___ ___ ___
INT. NUMBER ___ ___ ___
Lesotho 2014
Survey form
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INTERVIEWER VISITS:
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE ____
TIME ____
THIRD VISIT
DATE ____
INTERVIEWER'S NAME____
RESULT CODE**
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
FINAL VISIT
DAY ____
MONTH ____
YEAR 2014
INT. NUMBER ____
RESULT CODE**
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
TOTAL NUMBER OF VISITS ____
Liberia 2013
No questionnaire text is available for this sample.
Madagascar 1992
Survey form
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INTERVIEWER VISITS:
DATE ____
INTERVIEWER'S NAME _____
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY _____
MONTH ____
YEAR ____
NAME ____
RESULT ____
COMPLETED 1
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
Madagascar 2003
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME ______
RESULT _____
1 COMPLETED
2 NOT AT HOME
3 DEFERRED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY _____
MONTH _____
YEAR 2003
INT. NUMBER _______
RESULT ______
Madagascar 2008
Survey form
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NAME AND LINE NUMBER OF WOMAN
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
Malawi 1992
Survey form
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text
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME ___
RESULT* ___
Malawi 2000
Survey form
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text
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____
Malawi 2004
Survey form
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text
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____
Malawi 2010
Survey form
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text
NAME AND LINE NUMBER OF WOMAN
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
Malawi 2016
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S NUMBER
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
TOTAL NUMBER OF VISITS:
Mali 2001
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____
Mali 2006
Survey form
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NAME AND LINE NUMBER OF WOMAN
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
Mali 2012
Survey form
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INTERVIEWER VISITS
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE________
INTERVIEWER'S NAME____________
RESULT*______________
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 2012
INTERVIEWER______
RESULT*____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____________ 7
Mali 2018
Survey form
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INTERVIEWER VISITS
1 2 3
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
FINAL VISIT
DAY
MONTH
YEAR 2018
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NEXT VISIT
DATE
TIME
Morocco 1992
No questionnaire text is available for this sample.
Morocco 2003
No questionnaire text is available for this sample.
Mozambique 1997
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME_____
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR_____
NAME______
RESULT_____
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED/INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
Mozambique 2003
Survey form
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INTERVIEWER VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
INTERVIEWER'S NAME______
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR 2003
CODE_____
RESULT______
Mozambique 2011
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME_________
RESULT____
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE_________
TIME_________
FINAL VISIT
DAY_________
MONTH_________
YEAR 2011
CODE_________
RESULT_________
Myanmar 2015
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER___(SPECIFY) 7
NEXT VISIT:
DATE___
TIME___
SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER___(SPECIFY) 7
NEXT VISIT:
DATE___
TIME___
THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER___(SPECIFY) 7
FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO.____
RESULT____
Namibia 1992
No questionnaire text is available for this sample.
Namibia 2006
Survey form
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text
INTERVIEWER VISIT 1
DATE ___
INTERVIEWER'S NAME ____
RESULT____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE ___
TIME ____
INTERVIEWER VISIT 2
DATE ___
INTERVIEWER'S NAME ____
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE___
TIME ____
INTERVIEWER VISIT 3
DATE ____
INTERVIEWER'S NAME ____
RESULT ___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
FINAL VISIT
DAY __
MONTH ___
YEAR 200__
INT.NUMBER ___
RESULT ___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
Namibia 2013
Survey form
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text
INTERVIEW VISITS:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
Nepal 2006
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
TOTAL NUMBER OF VISITS
Nepal 2011
No questionnaire text is available for this sample.
Nepal 2016
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_________ 7
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_________ 7
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_________ 7
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_________ 7
Niger 1992
Survey form
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INTERVIEWER:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULTS___
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]:
DATE__
TIME__
FINAL VISIT:
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
Niger 2006
Survey form
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INTERVIEWER 1
DATE _____
DAY _____
MONTH _____
YEAR 2006
INTERVIEWER NAME __________
RESULT * __________
COMPLETED 1
NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) __________ 7
INTERVIEWER 2
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________
COMPLETED 1
NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) __________ 7
INTERVIEWER 3
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________
COMPLETED 1
NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) __________ 7
Niger 2012
Survey form
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text
INTERVIEWER VISITS
DATE _____________
INTERVIEWER'S NAME ______________
RESULT* ____________
FINAL VISIT
DAY _______________
MONTH ______________
YEAR 2012 ____________
INTERVIEWER _____________
RESULT _____________
NEXT VISIT
DATE _________
TIME _________
Nigeria 1990
Survey form
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text
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
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
TOTAL NUMBER OF VISITS
Nigeria 2008
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT _____________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___________ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME ___________
FINAL VISIT
DAY ____
MONTH ____
YEAR 2008
INT. NUMBER ____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___________ 7
Nigeria 2013
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*
Nigeria 2018
Survey form
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text
Pakistan 1991
No questionnaire text is available for this sample.
Pakistan 2006
No questionnaire text is available for this sample.
Pakistan 2012
No questionnaire text is available for this sample.
Pakistan 2017
No questionnaire text is available for this sample.
Rwanda 1992
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER NAME__________
RESULT___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
OTHER (SPECIFY)_____ 6
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME____
FINAL VISIT
DAY__________
MONTH__________
YEAR_____
NAME__________
RESULT__________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
OTHER (SPECIFY)_____ 6
Rwanda 2000
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
RESULT*____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)____ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME___
FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT*_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)____ 7
Rwanda 2005
Survey form
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text
INTERVIEWER VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ____
INTERVIEWER'S NAME ____
RESULT* _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ____
TIME _____
FINAL VISIT
DAY____
MONTH___
YEAR 200__
CODE ____
RESULT ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
Rwanda 2008
No questionnaire text is available for this sample.
Rwanda 2010
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*
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
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
Rwanda 2014
Survey form
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text
INTERVIEWER VISITS:
FIRST VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE_____
TIME____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
FINAL VISIT
DAY____
MONTH____
YEAR____
INT. NUMBER____
RESULT____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
TOTAL NUMBER OF VISITS
Senegal 1992
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME____
RESULT*___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
ILL/INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR _____
INTERVIEWER_____
RESULT*_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
ILL/INCAPACITATED 6
OTHER (SPECIFY) ____ 7
Senegal 1997
Survey form
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INTERVIEWER VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE______
INTERVIEWER NAME______
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR _____
INTERVIEWER_____
RESULT_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
ILL/INCAPACITATED 6
OTHER (SPECIFY) ______ 7
Senegal 2005
Survey form
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INTERVIEWER VISITS
INTERVIEW 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
INTERVIEWER NAME_____
RESULT*___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
INCAPACITATED 6
OTHER (SPECIFY) ______ 7
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR 2005
INTERVIEWER_____
RESULT*_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
INCAPACITATED 6
OTHER (SPECIFY) ______ 7
Senegal 2010
Survey form
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text
INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT___
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 201___
INT. NUMBER _____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
Senegal 2012
Survey form
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INTERVIEWER VISITS
DATE _____________
INTERVIEWER'S NAME _____________
RESULT____
FINAL VISIT
DAY ______________
MONTH __________
YEAR 201__
INT. NUMBER__________
RESULT ____________
NEXT VISIT
DATE ___________
TIME ___________
Senegal 2014
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_________
INTERVIEWER'S NAME___________
RESULT* ___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
FINAL VISIT
DAY ____
MONTH ____
YEAR 201__
INT. NUMBER_____
RESULT* _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
Senegal 2015
No questionnaire text is available for this sample.
Senegal 2016
No questionnaire text is available for this sample.
Senegal 2017
Survey form
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INTERVIEWER VISITS:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE: _______
INTERVIEWER'S NAME _________
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
FINAL VISIT
DAY ____
MONTH ____
YEAR _____
INT. NUMBER ____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
NEXT VISIT
DATE _____
TIME _____
South Africa 2016
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
FINAL VISIT
DAY____
MONTH____
YEAR 201__
INT. NUMBER____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7
TOTAL NUMBER OF VISITS____
Tanzania 1991
Survey form
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INTERVIEWER VISITS
INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) _________ 6
INTERVIEWER VISIT 2
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) _________ 6
INTERVIEWER VISIT 3
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) _________ 6
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
ID NO. ____
RESULT* ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) _________ 6
TOTAL NUMBER OF VISITS __
Tanzania 1996
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _________ 7
FINAL VISIT
DAY ____
MONTH ____
YEAR 96
ID NO. ___
RESULT ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _________ 7
Tanzania 2004
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR 200_
INT. NUMBER
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
Tanzania 2010
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
Tanzania 2015
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT
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
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
TOTAL NUMBER OF VISITS _____
Togo 2013
No questionnaire text is available for this sample.
Uganda 2001
Survey form
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INTERVIEWER VISITS
DATE _____
INTERVIEWER'S NAME __________
*RESULT
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
Uganda 2006
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
NEXT VISIT:
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER NUMBER
RESULT
Uganda 2011
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NUMBER __ __ __
RESULT __
Uganda 2016
Survey form
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INTERVIEW VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 01
NOT AT HOME 02
POSTPONED 03
REFUSED 04
PARTLY COMPLETED 05
INCAPACITATED 06
OTHER _______ (SPECIFY) 07
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 01
NOT AT HOME 02
POSTPONED 03
REFUSED 04
PARTLY COMPLETED 05
INCAPACITATED 06
OTHER _______ (SPECIFY) 07
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 01
NOT AT HOME 02
POSTPONED 03
REFUSED 04
PARTLY COMPLETED 05
INCAPACITATED 06
OTHER _______ (SPECIFY) 07
NEXT VISIT:
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT
COMPLETED 01
NOT AT HOME 02
POSTPONED 03
REFUSED 04
PARTLY COMPLETED 05
INCAPACITATED 06
OTHER _______ (SPECIFY) 07
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
COMPLETED 01
NOT AT HOME 02
POSTPONED 03
REFUSED 04
PARTLY COMPLETED 05
INCAPACITATED 06
OTHER _______ (SPECIFY) 07
NEXT VISIT:
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
Yemen 1991
No questionnaire text is available for this sample.
Yemen 2013
No questionnaire text is available for this sample.
Zambia 1992
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) _________ 6
NEXT VISIT:
DATE ______
TIME _____
FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT ____
Zambia 2007
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT*___
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* ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _________ 7
Zambia 2013
Survey form
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FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS):
DATE_________
INTERVIEWER'S NAME______________
RESULT*_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) ___________________
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____________
TIME______________
FINAL VISIT
DAY________
MONTH__________
YEAR____________
INT. NUMBER__________
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) ___________________
Zambia 2018
Survey form
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2018
12 DEC 01
11 NOV 02
10 OCT 03
09 SEP 04
08 AUG 05
07 JULY 06
06 JUN 07
05 MAY 08
04 APR 09
03 MAR 10
02 FEB 11
01 JAN 12
2017
12 DEC 13
11 NOV 14
10 OCT 15
09 SEP 16
08 AUG 17
07 JULY 18
06 JUN 19
05 MAY 20
04 APR 21
03 MAR 22
02 FEB 23
01 JAN 24
2016
12 DEC 25
11 NOV 26
10 OCT 27
09 SEP 28
08 AUG 29
07 JULY 30
06 JUN 31
05 MAY 32
04 APR 33
03 MAR 34
02 FEB 35
01 JAN 36
2015
12 DEC 37
11 NOV 38
10 OCT 39
09 SEP 40
08 AUG 41
07 JULY 42
06 JUN 43
05 MAY 44
04 APR 45
03 MAR 46
02 FEB 47
01 JAN 48
2014
12 DEC 49
11 NOV 50
10 OCT 51
09 SEP 52
08 AUG 53
07 JULY 54
06 JUN 55
05 MAY 56
04 APR 57
03 MAR 58
02 FEB 59
01 JAN 60
2013
12 DEC 61
11 NOV 62
10 OCT 63
09 SEP 64
08 AUG 65
07 JULY 66
06 JUN 67
05 MAY 68
04 APR 69
03 MAR 70
02 FEB 71
01 JAN 72
Zimbabwe 1994
Survey form
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FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT***
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
Zimbabwe 1999
Survey form
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FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____
Zimbabwe 2005
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
TOTAL NUMBER OF VISITS
*RESULT CODES:
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________
Zimbabwe 2010
Survey form
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INTERVIEW VISITS:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
Zimbabwe 2015
No questionnaire text is available for this sample.