Survey Text
Angola 2015
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE_________
DAY___
MONTH___
INTERVIEWER'S NAME_________
RESULT
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
NEXT VISIT:
DATE_________
TIME_________
SECOND VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
FINAL VISIT
DAY_________
MONTH_________
YEAR_____
INT. NO._________
RESULT
COMPLETED 1
ABSENT 2
POSTPONED 3
REFUSED 4
INCOMPLETE 5
INCAPACITATED 6
OTHER (SPECIFY) ________ 7
Bangladesh 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
Bangladesh 1997
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
Bangladesh 2000
Survey form
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FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____
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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INTERVIEWER VISITS
FIRST VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
SECOND VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
THIRD VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
NEXT VISIT:
DATE __________
TIME ____________
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __
RESULT* __
TOTAL NUMBER OF VISITS __
Burkina Faso 1993
No questionnaire text is available for this sample.
Burkina Faso 1998
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 _____
INT. NUMBER _____
RESULT _____
COMPLETED 1
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTIALLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
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
Survey form
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INTERVIEWER VISITS
FIST 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 2010
INT. NAME _____
RESULT _____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____ 7
Burundi 2010
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_____
INTERVIEWER'S NAME_____
RESULT
NEXT VISIT
DATE____
TIME____
FINAL VISIT
DAY_____
MONTH____
YEAR____
INT. NUMBER____
RESULT____
Burundi 2016
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
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
Cameroon 1991
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
Cameroon 1998
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME___
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY): ___ 7
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 ____
Cameroon 2011
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
UNABLE 6
OTHER (SPECIFY): ___ 7
Cameroon 2018
Survey form
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INTERVIEWER VISITS
DATE______
INTERVIEWER'S NAME_______
RESULT*________
NEXT VISIT
DATE_______
TIME_______
FINAL VISIT
DAY_______
MONTH_______
YEAR __2018__
INT. NO. _______
RESULT*_______
TOTAL NUMBER OF VISITS________
*RESULT CODES:
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)_______
Central African Republic 1995
Survey form
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INTERVIEWER 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____
NAME____
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)____ 7
NEXT VISIT
DATE
TIME
Chad 1996
No questionnaire text is available for this sample.
Chad 2004
Survey form
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INTERVIEWER VISITS
FIRST INTERVIEWER VISIT
DATE______
INTERVIEWER'S NAME__________
RESULT*
SECOND INTERVIEWER VISIT
DATE_____
INTERVIEWER'S NAME________
RESULT*
THIRD INTERVIEWER VISIT
DATE_____
INTERVIEWER'S NAME______
RESULT*
FINAL VISIT
DAY____
MONTH____
YEAR 200__
NAME_______
RESULT___
NEXT VISIT
DATE_____
TIME_____
Chad 2014
Survey form
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Check cover of household questionnaire: Household was selected for the men's survey and the HIV test?
YES 1
NO 2
HOUSEHOLD SELECTED FOR MEN'S SURVEY
IF YES (=1) CHECK Q. 403 OF HOUSEHOLD QUESTIONNAIRE: WOMAN SELECTED FOR THE "DOMESTIC VIOLENCE" MODULE? (YES=1, NO=2). IF THE HOUSEHOLD IS NOT SELECTED FOR THE MEN'S SURVEY, LEAVE THE SPACE BLANK.
WOMAN SELECTED FOR THE "DOMESTIC VIOLENCE" SURVEY
INTERVIEWER VISITS
1 2 3
DATE_____
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY__ __
MONTH __ __
YEAR 201__
INT. NUMBER__ __ __
CODE RESULT __
NEXT VISIT
DATE_______
TIME________
Congo (Democratic Republic) 2007
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
Congo (Democratic Republic) 2013
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 ____
INTERVIEWER'S NAME ____
RESULT*
THIRD VISIT DATE ____
INTERVIEWER'S NAME ____
RESULT*
FINAL VISIT
DAY ____
MONTH ____
YEAR 201_
INTERVIEWER CODE ____
RESULT
Congo Brazzaville 2005
No questionnaire text is available for this sample.
Congo Brazzaville 2011
No questionnaire text is available for this sample.
Cote d'Ivoire 1994
Survey form
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FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME_____
FINAL VISIT
DAY___
MONTH___
YEAR 94
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 ____
Cote d'Ivoire 2011
Survey form
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INTERVIEWER VISITS
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____ /201__
INTERVIEWER'S NAME
RESULT____
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT 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)________________ 9
NEXT VISIT (REPEAT FOR INTERVIEWER 2)
DATE____ /201__
TIME______
FINAL VISIT
DAY_______
MONTH_______
YEAR 201___
INTERVIEWER CODE________
RESULT______
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT 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)________________ 9
Egypt 1992
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. ___
URBAN/RURAL ___
LOCALITY ___
LINE NUMBER ___
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
SUPERVISOR 'S NAME_____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
FINAL VISIT: DAY ____ MONTH ____ YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
RESULT _____
TOTAL NUMBER OF VISITS ___
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
Survey form
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LANGUAGE OF QUESTIONNAIRE 2
LANGUAGE OF INTERVIEW:_____
LANGUAGE:
SISWATI 1
ENGLISH 2
OTHER 3
Ethiopia 2000
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____
Ethiopia 2005
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
Ghana 1993
Survey form
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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 1998
Survey form
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INTERVIEW 1
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 ___
INTERVIEW 2
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 ___
INTERVIEW 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 _19__
NAME ___
RESULT ___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) ____ 6
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
Ghana 2016
Survey form
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INTERVIEWER VISITS
VISITS 1, 2, AND 3
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 2016
INTERVIEWER NUMBER __________
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER ____________(SPECIFY) 7
Guinea 1999
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 1999
NAME _____
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 2012
Survey form
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INTERVIEWER 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 2012
INT. NUMBER_____________
RESULT___________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NEXT VISIT____________
DATE___________
TIME__________
Guinea 2018
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
FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___ 7
NEXT VISIT
DATE
TIME
TOTAL NUMBER OF VISITS
India 1992
Survey form
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INTERVIEW VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT ______
India 1998
Survey form
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INTERVIEWER VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ________
RESULT _______
India 2005
Survey form
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FINAL VISIT
DATE ______
MONTH ______
YEAR ______
INT. NO. ______
RESULT CODE _____
India 2015
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
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
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
NEXT VISIT
DATE_______
TIME_______
FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INT. NO ______
RESULT CODE ______
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)________ 7
TOTAL NUMBER OF VISITS _______
SUPERVISOR'S NAME_______
SUPERVISOR NUMBER ________
Jordan 1990
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
NAME
RESULT
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
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 2002
NAME
RESULT
TOTAL NUMBER OF VISITS
Jordan 2007
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 2007
INT. NUMBER__
RESULT:
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___________ 7
Jordan 2009
Survey form
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INTERVIEWER VISITS:
FIRST VISIT
DATE _______
INTERVIEWER NAME _______
RESULT* ________
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPCITATED 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
INCAPCITATED 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
INCAPCITATED 6
OTHER (SPECIFY) _______ 7
FINAL VISIT
DAY _______
MONTH _______
YEAR 2009
INT. NUMBER _______
RESULT* _______
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPCITATED 6
OTHER (SPECIFY) _______ 7
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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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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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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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 2004
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 ______
RESULT _____
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 2007
No questionnaire text is available for this sample.
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 1997
Survey form
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INTERVIEWER VISITS
INTERVIEW ONE (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ____
INTERVIEWER'S NAME ____
NEXT VISIT
DATE ____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR 1997
INT. NUMBER ____
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 1995
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR 1996
INTERVIEWER NAME____
RESULT ____
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
Survey form
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INTERVIEWER VISITS:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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)_________ 9
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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)_________ 9
TOTAL NUMBER OF VISITS
Morocco 2003
Survey form
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INTERVIEWER VISITS:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT 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) __________
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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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
Survey form
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INTERVIEWER VISIT 1 (REPEAT FOR INTERVIEWER VISITS 2 AND 2)
DATE_____
INTERVIEWER'S NAME_____
RESULT_____
NEXT VISIT:
DATE____
TIME_____
FINAL VISIT
DAY____
MONTH_____
YEAR_____
NAME_____
RESULT_____
Namibia 2000
Survey form
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INTERVIEWER VISITS:
INTERVIEWER 1(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:
DATE ___
TIME ___
FINAL VISIT
DAY ___
MONTH ___
YEAR 20___
INT. COD ___
RESULT ___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___ 7
Namibia 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
Namibia 2013
Survey form
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INTERVIEW VISITS:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
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 1998
Survey form
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INTERVIEWER 1:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULTS___
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
INCAPABLE 6
OTHER (SPECIFY): ___ 7
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]:
DATE__
TIME__
FINAL VISIT:
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
INCAPABLE 6
OTHER (SPECIFY): ___ 7
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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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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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 1999
Survey form
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INTERVIEWER'S 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
DWELLING DESTROYED 7
OTHER (SPECIFY) ___________ 8
NEXT VISIT:
DATE __________
TIME ___________
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT _____
Nigeria 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 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _________________
NEXT VISIT:
DATE __________
TIME ___________
FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ____
RESULT _____
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _________________
Nigeria 2008
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 (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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INTERVIEWER VISITS
VISIT 1
DATE_____
INTERVIEWER'S NAME_____
RESULT*_____
NEXT VISIT:
DATE_____
TIME_____
FINAL VISIT
DAY____
MONTH_____
YEAR_____
INT. NO._____
RESULT*_____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER_____ 7
Pakistan 1991
Survey form
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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
Pakistan 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
Pakistan 2012
Survey form
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INTERVIEW VISITS:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
Pakistan 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 _______
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 ______
THIRD 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 ______
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
TOTAL NUMBER OF VISITS _________
Rwanda 1992
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
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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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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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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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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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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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
Survey form
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INTERVIEWER VISITS
FIRST VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
SECOND VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
THIRD VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
NEXT VISIT:
DATE __________
TIME ____________
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __
RESULT* __
TOTAL NUMBER OF VISITS __
Senegal 2016
Survey form
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INTERVIEWER VISITS
FIRST VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
SECOND VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
THIRD VISIT:
DATE ________
INTERVIEWER'S NAME ______________
RESULT* ___________
NEXT VISIT:
DATE __________
TIME ____________
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __
RESULT* __
TOTAL NUMBER OF VISITS __
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 1998
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
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
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S NAME
RESULT
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ___________________ 7
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 1999
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 (FOR INTERVIEWERS 1 AND 2)
DATE______
TIME______
FINAL VISIT
DAY____
MONTH____
YEAR 19___
INTER. ID NUMBER___
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 1998
No questionnaire text is available for this sample.
Togo 2013
No questionnaire text is available for this sample.
Uganda 1995
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
NAME
RESULT*
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _____________ 7
TOTAL NUMBER OF VISITS
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 2013
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT 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'S NAME
RESULT*
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT 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'S NAME
RESULT*
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT 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 NO COMPETENT RESPONDENT 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
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 1996
Survey form
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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND 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
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
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _________ 7
Zambia 2001
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 ___
NAME ___
RESULT* ____
COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) _________ 7
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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INTERVIEWER VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _______________
INTERVIEWER'S NAME _______________
RESULT* _______________
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _______________
NEXT VISIT:
DATE _____
TIME _____
FINAL VISIT:
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____
TOTAL NUMBER OF VISITS _____
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
Survey form
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INTERVIEWER VISITS
FIRST VISIT
DATE_______________
INTERVIEWER'S NAME_____________________
RESULT*________________
SECOND VISIT
DATE_______________
INTERVIEWER'S NAME_____________________
RESULT*________________
THIRD VISIT
DATE_______________
INTERVIEWER'S NAME_____________________
RESULT*________________
NEXT VISIT:
DATE_____________
TIME______________
FINAL VISIT
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __
RESULT*___
TOTAL NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD __ __
TOTAL ELIGIBLE WOMEN __ __
TOTAL ELIGIBLE MEN __ __
LINE NO. RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __