FIRST VISIT
DATE_________
DAY___
MONTH___
INTERVIEWER'S NAME_________
RESULT
NEXT VISIT:
DATE_________
TIME_________
SECOND VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
FINAL VISIT
DAY_________
MONTH_________
YEAR_____
INT. NO._________
RESULT
FIELD EDITOR
NAME __________
DATE ______
OFFICE EDITOR __________
KEYED BY __________
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
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER 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:
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. NUMBER____
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 ____
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 (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
FIRST VISIT (REVIEW 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 ______
FIST 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____
INT. NUMBER____
RESULT____
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
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 (REVIEW 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___
RESULT ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
NEXT VISIT
DATE_______
TIME_______
FINAL VISIT
DAY_______
MONTH_______
YEAR __2018__
INT. NO. _______
RESULT*_______
TOTAL NUMBER OF VISITS________
*RESULT CODES:
INTERVIEWER'S NAME____
RESULT
FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT
NEXT VISIT
DATE
TIME
FIRST VISIT (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
FIRST INTERVIEWER VISIT
SECOND INTERVIEWER VISIT
THIRD INTERVIEWER VISIT
FINAL VISIT
NEXT VISIT
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
NEXT VISIT
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 (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
FIRST VISIT (REVIEW 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______
FINAL VISIT
MONTH______
YEAR______
INTERVIEWER'S NAME____
RESULT____
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 ___
NEXT VISIT:
DATE _____
TIME ________
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
ASSISTANT SUPERVISOR _____
RESULT _____
TOTAL NUMBER OF VISITS __
INTERVIEWER VISITS (REPEAT FOR INTERVIEW VISITS 1 AND 2)
DATE_____
TEAM_____
INTERVIEWER_______
SUPERVISOR______
RESULT*______
NEXT VISIT
DATE_____
TIME______
TOTALVISITS_______
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
TEAM
INTERVIEWER
SUPERVISOR ASSISTANT
SUPERVISOR
RESULT
FIELD EDITOR
NAME
DATE
SIGNATURE
OFFICE EDITOR
NAME
DATE
SIGNATURE
CODER
NAME
DATE
SIGNATURE
KEYER
NAME
DATE
SIGNATURE
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 __
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 _____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
NEXT VISIT:
DATE____
TIME_____
FINAL VISIT
DAY____
MONTH____
YEAR 2006
INT. NUMBER____
RESULT____
TOTAL NUMBER OF VISITS____
RESULT CODES:
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
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
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT* ___
NEXT VISIT
DATE___
TIME___
FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO.___
RESULT___
TOTAL NUMBER OF VISITS
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
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 _19__
NAME ___
RESULT ___
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
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
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
VISITS 1, 2, AND 3
NEXT VISIT:
FINAL VISIT
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 INTERVIEWS)
DATE_____
NAME_____
RESULT____
INTERVIEWER'S NAME
RESULT___
FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
TOTAL NUMBER OF VISITS
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT ______
FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ________
RESULT _______
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S 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
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 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* _______
To be filled in after completing interview.
Person Interviewed:
Specific Questions:
Other Aspects:
Name of Interviewer:
Date:
SUPERVISOR'S OBERVATIONS
Name of Supervisor:
Date:
EDITOR'S OBSERVATIONS
Name of Field Editor:
Date:
Name of Keyer:
Date:
FIRST VISIT (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
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
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 ___________
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'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**
FINAL VISIT
DAY ____
MONTH ____
YEAR 2014
INT. NUMBER ____
RESULT CODE**
TOTAL NUMBER OF VISITS ____
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
DATE ____
INTERVIEWER'S NAME _____
INTERVIEW ONE (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ____
INTERVIEWER'S NAME ____
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
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
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER 1(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
MONTH__
YEAR 1987
INTERVIEWER NAME____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR 1996
INTERVIEWER NAME____
RESULT ____
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
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
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE________
INTERVIEWER'S NAME____________
RESULT*______________
NEXT VISIT
DATE________
TIME__________
FINAL VISIT
DAY____
MONTH____
YEAR 2012
INTERVIEWER______
RESULT*____
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR 2018
RESULT
NEXT VISIT
DATE
TIME
(TO BE FILLED IN AFTER COMPLETING INTERVIEW)
NAME: ____
DATE: ____
INSPECTOR'S OBSERVATIONS
SUPERVISOR: ____
DATE: ____
SUPERVISOR'S OBSERVATIONS
SUPERVISOR: ____
DATE: ____
FIELD EDITOR'S AND INPUT AGENT'S OBSERVATIONS
NAME OF FIELD EDITOR: ____
DATE: ____
NAME OF INPUT AGENT: ____
DATE: ____
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
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
FIRST VISIT (REVIEW 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___
RESULT ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
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___
INT. NO.____
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
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
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
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
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
DATE
INTERVIEWER'S NAME ___________
INT. CODE ________
RESULT* ___
NEXT VISIT
LANGUAGE
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW
HOME LANGUAGE OF RESPONDENT
WAS A TRANSLATOR USED
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
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW _____________
NATIVE LANGUAGE OF RESPONDENT _____________
NEXT VISIT [FOR INTERVIEWERS 1 AND 2]:
DATE__
TIME__
FINAL VISIT:
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__
INTERVIEWER 2
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________
INTERVIEWER 3
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________
DATE _____________
INTERVIEWER'S NAME ______________
RESULT* ____________
FINAL VISIT
DAY _______________
MONTH ______________
YEAR 2012 ____________
INTERVIEWER _____________
RESULT _____________
NEXT VISIT
DATE _________
TIME _________
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 _____
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 (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME ___________
FINAL VISIT
DAY ____
MONTH ____
YEAR 2008
INT. NUMBER ____
RESULT _____
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*
NEXT VISIT:
DATE
TIME
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DATE
INTERVIEWER NAME
RESULT
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DAY
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YEAR
INT. NUMBER
RESULT*
VISIT 1
NEXT VISIT:
FINAL VISIT
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DATE
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INTERVIEWER'S NAME
RESULT***
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MONTH
YEAR
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TIME
TOTAL NUMBER OF VISITS
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
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DATE
INTERVIEWER NAME
RESULT
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DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
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 _________
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___
RESULT ____
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
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DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
FIRST VISIT
DATE
NAME OF THE INTERVIWER
RESULT*
NEXT VISIT:
DATE
HOURS
SECOND VISIT
DATE
NAME OF THE INTERVIEWER
RESULT*
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DATE
HOURS
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DATE
NAME OF THE INTERVIWER
RESULT*
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DAY
MONTH
YEAR
CODE
RESULT
TOTAL NUMBER OF VISITS
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____
INTERVIEWER NAME____
RESULT___
FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME____
RESULT*___
FIRST VISIT (REVIEW 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___
RESULT ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
DATE _____________
INTERVIEWER'S NAME _____________
RESULT____
Hello. My name is ___. I am working with the National Agency for Statistics and Demography in collaboration with the Ministry of Health and Social Action. We are conducting a survey about health all over Senegal. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions?
May I begin the interview?
SIGNATURE OF INTERVIEWER ____
DATE ____
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S 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 201__
INT. NUMBER____
RESULT
TOTAL NUMBER OF VISITS____
OFFICER EDITED BY
NAME
DATE
CODED BY
NAME
DATE
KEYED BY
NAME
DATE
ALL INFORMATION COLLECTED IS CONFIDENTIAL AND IS ONLY FOR RESEARCH
INTERVIEWER VISIT 1
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
INTERVIEWER VISIT 2
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
INTERVIEWER VISIT 3
DATE ______________
INTERVIEWER'S NAME _______________
RESULT* ______________
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___
RESULT ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
FIRST VISIT (REVIEW 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 INTERVIEWS)
DATE_____
NAME_____
RESULT____
INTERVIEWER CODE
RESULT
NUMBER OF VISITS
NAME ____
DATE ____
FIELD EDITED BY ____
OFFICE EDITED BY ____
KEYED BY ____
CODE KEYED ____
NEXT VISIT
DATE____
TIME_____
FINAL VISIT
MONTH______
YEAR______
TOTAL NUMBER OF 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 ____
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
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
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:
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TIME
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STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
RESULT
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TIME
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NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
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DATE
TIME
FINAL VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
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DATE
TIME
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DATE
INTERVIEWER'S NAME
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INT. NUMBER
RESULT*
TOTAL NUMBER OF VISITS
*RESULT CODES
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 (REVIEW 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___
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
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
NEXT VISIT:
FINAL VISIT:
TOTAL NUMBER OF VISITS _____
NEXT VISIT
DATE____
TIME_____
FINAL VISIT
MONTH______
YEAR______
TOTAL NUMBER OF VISITS___
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
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____