INTERVIEWER VISITSFIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME _____
DATE _____
RESULT*
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
INTERVIEW NUMBER ____
RESULT* _____
NEXT VISIT
DATE _____
TIME ____
TOTAL NUMBER OF VISITS _____
* RESULT CODES
1COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
LANGUAGE OF QUESTIONNAIRE _____
LANGUAGE OF INTERVIEW _____
INTERPRETER
YES 1
NO 2
LANGUAGE CODES:
1 FRENCH
2 WOLOF
3 POULAR
4 SERER
5 MANDINGUE
6 DIOLA
8 OTHER
SUPERVISOR
NAME _____
DATE _____