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____
INTERVIEWER NUMBER_____
RESULT
TOTAL NUMBER OF VISITS_________
RESULT CODES
RESULT CODES
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
INTERVIEWER 1
(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 __
NAME__
RESULT__
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: 2007
INT. NUMBER____
RESULT:
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:
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME_____
RESULT**___
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER'S NAME____
RESULT ____
NEXT VISIT
DATE___
TIME____
FINAL VISIT
DAY____
MONTH____
YEAR 2001
NAME___
RESULT____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_____
INTERVIEWER NAME_____
RESULT _____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_______
INTERVIEWER'S NAME________
RESULT ____
NEXT VISIT
DATE ________
TIME________
FINAL VISIT
DAY_____
MONTH_______
YEAR 2011
INTERVIEWER CODE_________
RESULT ____
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
INTERVIEWER 1
(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 __
NAME__
RESULT__
PLACE NAME ____
NAME OF HOUSEHOLD HEAD ____
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
TOTAL NUMBER OF 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
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
INTERVIEWER 1
(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 __
NAME__
RESULT__
INTERVIEWER 1
(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__
TOTAL NUMBER OF VISITS____
FINAL VISIT
DAY
MONTH
YEAR
INT. NO
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER'S NAME____
RESULT*
FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT
NEXT VISIT
DATE____
TIME____
TOTAL NO. OF VISITS____
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
SECOND INTERVIEWER VISIT
THIRD INTERVIEWER VISIT
FINAL VISIT
NEXT VISIT
INTERVIEWER VISITS
1 2 3
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY__ __
MONTH__ __
YEAR 201__
INT. NUMBER
CODE RESULT
NEXT VISIT
DATE____
TIME____
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*
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____ /201
INTERVIEWER'S NAME
RESULT*____
NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE____ /201
TIME______
FINAL VISIT
DAY_______
MONTH_______
YEAR 201
INTERVIEWER CODE________
RESULT______
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME_____
RESULT____
PSU/SEGMENT NO. ________
BUILDING NO._________
HOUSE NO. ______________
URBAN 1
RURAL 2
LARGE CITY 1
SMALL CITY 2
TOWN 3
VILLAGE 4
SUBSAMPLE:
YES 1
NO 2
NAME OF HOUSEHOLD HEAD _______
ADDRESS IN DETAIL _____
GOVERNORATE __
PSU/SEGMENT NO. ___
HOUSEHOLD NO. ____
URBAN/RURAL ____
LOCALITY ___
SUBSAMPLE ___
INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIWER'S NAME_____
SUPERVISOR'S NAME _____
RESULT ______
FINAL VISIT
DAY ____ MONTH ____ YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
RESULT _____
TOTAL VISITS ____
NEXT VISIT:
DATE _____
TIME ________
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
ASSISTANT SUPERVISOR ___
RESULT _____
TOTAL VISITS __
FINAL VISIT
DAY___
MONTH_____
YEAR 2000
TEAM_____
INTERVIEWER______
SUPERVISOR______
RESULT______
TOTAL VISITS_____
TOTAL IN HOUSEHOLD______
TOTAL ELIGIBLE WOMEN______
LINE NO. OF RESPONDENT FROM HOUSEHOLD SCHEDULE_______
WOMAN/CHILD/ADOLESCENT REFERRED FOR SEVERE ANEMIA
ADDRESS CHECKED (BY NAME:______)
REINTERVIEW:
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
TELEPHONE:
CELLULAR _________
LANDLINE _________
GOVERNATE _________
PSU/SEGMENT NO.__________
HOUSEHOLD NO.________
SUBSAMPLE_____
INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIWER _____
SUPERVISOR _____
RESULT ______
NEXT VISIT:
DATE _____
TIME ______
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INT. NUMBER _____
SUP. NUMBER _____
RESULT _____
TOTAL NUMBER OF VISITS __
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
NEXT VISIT:
DATE_______
TIME________
FINAL VISIT
DAY______
MONTH______
YEAR 2006
INT. NUMBER______
RESULT_______
NEXT VISIT:
DATE_____
TIME_______
TOTAL NUMBER OF VISITS_______
RESULT CODES:
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT
TOTAL NUMBER OF VISITS
DATE____
INTERVIEWER'S NAME_____
RESULT____
NEXT VISIT
DATE___
TIME___
FINAL VISIT
MONTH____
YEAR____
TOTAL NUMBER OF 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
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME _______
RESULT _______
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWR'S NAME _______
RESULT ______
FIRST VISIT
DATE___
INTERVIEWER'S NAME____
RESULT CODE___
NEXT VISIT
DATE____
TIME____
SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT CODE___
NEXT VISIT
DATE___
TIME___
THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT CODE___
SUPERVISOR'S NAME_____
FINAL VISIT
DAY___
MONTH__
YEAR__
INT. NO.___
RESULT__
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 1997
NAME
RESULT
TOTAL NUMBER OF 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 2002
NAME
RESULT
TOTAL NUMBER OF 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 2007
INT. NUMBER__
RESULT:
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 2009
INT. NUMBER
RESULT*
TOTAL NUMBER OF 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. NO.
RESULT*
INTERVIEWER VISIT 2
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________
INTERVIEWER VISIT 3
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
FINAL VISIT
DAY __
MONTH __
YEAR __
NAME ___
RESULT __
INTERVIEWER VISIT 2
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
NEXT VISIT:
DATE _______
TIME ________
INTERVIEWER VISIT 3
DATE _________
INTERVIEWER'S NAME __________
RESULT* __________
FINAL VISIT
DAY __
MONTH __
YEAR __
NAME ___
RESULT __
INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT** ______________
NEXT VISIT:
DATE ______
TIME _____
INTERVIEWER 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) ___
INT. CODE ___
RESULT ____
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
INTERVIEWER 1
(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 __
NAME__
RESULT__
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**
FINAL VISIT
DAY____
MONTH____
YEAR 2014
INT. NUMBER____
RESULT CODE**
TOTAL NUMBER OF 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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
DATE ____
INTERVIEWER'S NAME ____
DATE ___
INTERVIEWER'S NAME ____
RESULT____
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
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:
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
FINAL VISIT
DAY__
MONTH__
YEAR 1996
INTERVIEWER__
RESULTS ___
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE___
INTERVIEWER'S NAME___
RESULT*____
NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE___
TIME___
FINAL VISIT
DAY___
MONTH___
YEAR 2012
NAME___
RESULT___
INTERVIEWER'S NAME
FINAL VISIT
DAY
MONTH
YEAR 201
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME _____
RESULT*
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
TOTAL NUMBER OF VISITS
TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
SUPERVISOR
NAME
FIELD EDITOR
NAME
OFFICE EDITOR
KEYED BY
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_______
INTERVIEWER'S NAME______
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT REPEAT FOR SECOND AND THIRD VISITS)
NEXT VISIT
FINAL VISIT
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
INTERVIEWER 1
(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 __
NAME__
RESULT__
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____
INTERVIEWER VISIT 2
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____
INTERVIEWER'S VISIT 3
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
FINAL VISIT
DAY ___
MONTH___
YEAR 200__
INT. NUMBER___
RESULT___
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
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
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME __________
INT. CODE __
RESULT
TOTAL PERSONS IN HOUSEHOLD __
TOTAL WOMEN ELIGIBLE __
TOTAL ELIGIBLE MEN __
LINE NO. OF RESP. TO HOUSEHOLD QUEST.
SUPERVISOR
FIELD EDITOR
OFFICE EDITOR __
KEYED BY __
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
TOTAL NUMBER OF VISITS
VISIT 1
DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________
NEXT VISIT:
DATE _________
TIME _________
VISIT 2
DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________
NEXT VISIT:
DATE _________
TIME _________
VISIT 3
DATE __________
INTERVIEWER'S NAME _____________
RESULT ___________
NEXT VISIT:
DATE _________
TIME _________
FINAL VISIT
DAY ___________
MONTH __________
YEAR __________
INT. NUMBER __________
RESULT _________
TOTAL NUMBER OF VISITS __________
TOTAL PERSONS IN HOUSEHOLD _________
TOTAL ELIGIBLE WOMEN ________
TOTAL ELIGIBLE MEN ________
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ________
SUPERVISOR
NAME __________
DATE __________
OFFICE EDITOR __________
KEYED BY __________
INTERVIEWER:
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULTS___
FIRST VISIT (REPEAT FOR INTERVIEWERS 1 AND 2)
DATE _____
DAY _____
MONTH _____
YEAR 2006
INTERVIEWER NAME __________
RESULT * __________
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME ____
RESULT* ____
NEXT VISIT________
DATE_________
TIME_______
FINAL VISIT
DAY_______
MONTH_______
YEAR 2012
NAME________
RESULT*__________
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
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 ____
NAME ____
RESULT _____
FIRST INTERVIEW (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 ___
NAME ____
RESULT _____
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:
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*
DATE_____
INTERVIEWER'S NAME_____
RESULT*_____
FINAL VISIT
DAY_____
MONTH_____
YEAR_____
INT. NO_____
RESULT*_____
TOTAL NUMBER OF 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
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______
SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______
THIRD VISIT
DATE _______
INTERVIWER'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. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______
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
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
In this survey, I would like to first ask you some questions about your household. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since yours views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?
Signature of interviewer: _______________
Date: ____________
RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS):
DATE____
INTERVIEWER NAME______
RESULT*___
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE_____
INTERVIEWER NAME_____
RESULT___
INTERVIEW 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
INTERVIEWER NAME_____
RESULT___
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__________
INTERVIEWER'S NAME____________
RESULT*_______
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME ____
RESULT*
FINAL VISIT
DAY _____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT*
NEXT VISIT:
DATE ______
TIME _____
TOTAL NUMBER OF VISITS __________
*RESULT CODES:
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME ______
DATE _____
RESULT
FINAL VISIT:
DAY ____
MONTH ___
YEAR ____
INTERVIEW NUMBER ____
RESULT _____
NEXT VISIT:
DATE _____
TIME ____
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME RESULT
TOTAL NO. OF VISITS
TOTAL IN HOUSEHOLD
TOTAL ADULTS 15 YEARS AND OVER
TOTAL WOMEN 15-49 YEARS
LINE NO. OF RESP. TO HOUSEHOLD SCHEDULE
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
TOTAL NUMBER OF 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
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
INTERVIEWER 1
(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 __
NAME__
RESULT__
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
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
INTERVIEWER NUMBER
RESULT
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 __
FIRST VISIT
DATE
INTERVIEWER NAME
RESUT
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. NU,
RESULT
TOTAL NUMBER OF VISITS
FIRST VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
RESULT CODE*
NEXT VISIT
DATE
TIME
SECOND VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
RESULT CODE*
NEXT VISIT
DATE
TIME
FINAL VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
RESULT CODE*
KEYED BY____
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*
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
First Visit (Repeat for second and third visits)
Date _____
Interviewer's name __________
Result ____
Next Visit
Date _____
Time _____
Final Visit
Day ____
Month ____
Year ____
Name ____
Result ____
INTERVIEWER 1
(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 __
NAME__
RESULT__
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
NEXT VISIT:
FINAL VISIT:
TOTAL NUMBER OF VISITS _____
DATE____
INTERVIEWER'S NAME_____
RESULT____
NEXT VISIT
DATE___
TIME___
FINAL VISIT
MONTH____
YEAR____
TOTAL NUMBER OF VISITS____
RESULT CODES
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
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:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
FIRST VISIT
SECOND VISIT
THIRD VISIT
NEXT VISIT:
FINAL VISIT
TOTAL NUMBER OF VISITS