NAME
DATE

FIELD EDITED BY
OFFICE EDITED BY
KEYED BY
KEYED BY

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S CODE
RESULT*

TOTAL NUMBER OF VISITS:

TOTAL PERSONS IN HOUSEHOLD:
TOTAL ELIGIBLE WOMEN:
TOTAL ELIGIBLE MEN:
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE:

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT
DAY
MONTH

YEAR
CODE
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:

TOTAL NUMBER OF VISITS____

FINAL VISIT
DAY _____
MONTH _____
YEAR 2003
INT. NUMBER ______
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_______

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

*RESULT CODES:
1COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)

LANGUAGE OF INTERVIEW**
INTERPRETER

**LANGUAGE CODES
01 FRENCH
02 CHADIAN ARABIC
03 SARA
04 GORANE
05 KANEMBOU
06 MABA (OUADDAIEN)
07 MOUDANG
08 MOUSSEYE
09 PEUL/FOULF/BODORE
10 LELE/MARBA
11 TOUPOURI
12 BOULALA
13 ZAGHAWA/BERI.BIDEYAT
96 OTHER CHADIAN LANGUAGES (SPECIFY)

SUPERVISOR
NAME___________
DATE____

FIELD EDITOR
NAME___________
DATE____

OFFICE EDITOR

KEYED BY

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 __

NEXT VISIT:
DATE____
TIME_____

FINAL VISIT
DAY____
MONTH____
YEAR 2006
INT. NUMBER____
RESULT____

TOTAL NUMBER OF VISITS____

RESULT CODES:

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___

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'S NAME
RESULT___

FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TOTAL NUMBER OF VISITS

FIRST VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______

SECOND VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______

THIRD VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______

NEXT VISIT
DATE_______
TIME_______

FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INT. NO ______
RESULT CODE ______

TOTAL NUMBER OF VISITS _______

SUPERVISOR'S NAME_______

SUPERVISOR NUMBER ________

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

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

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'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'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

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___

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

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

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

DATE

INTERVIEWER'S NAME ______
INT. CODE __

NEXT VISIT

DATE ____
TIME _____

TOTAL VISITS ________

RESULT

LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW

HOME LANGUAGE OF RESPONDENT

WAS A TRANSLATOR USED?

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

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF INTERVIEW _____________

NATIVE LANGUAGE OF RESPONDENT _____________

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 _______
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

FIRST VISIT
DATE
NAME OF THE INTERVIWER
RESULT*

NEXT VISIT:
DATE
HOURS

SECOND VISIT
DATE
NAME OF THE INTERVIEWER
RESULT*

NEXT VISIT:
DATE
HOURS

THIRD VISIT
DATE
NAME OF THE INTERVIWER
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
CODE
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

LANGUAGE OF QUESTIONNAIRE _____
LANGUAGE OF INTERVIEW _____

INTERPRETER

LANGUAGE CODES:

SUPERVISOR

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 201__
INT. NUMBER____
RESULT

TOTAL NUMBER OF VISITS____

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
MONTH
YEAR

TOTAL NUMBER OF VISITS

TOTAL NUMBER OF VISITS __

TOTAL IN HOUSEHOLD __

TOTAL ELIG. WOMEN __

TOTAL ELIG. MEN __

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

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 ____

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
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

*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

NEXT VISIT:

FINAL VISIT:

TOTAL NUMBER OF VISITS _____

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___

COUNTRY SPECIFIC INFORMATION: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME