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INTDATECMC (V008)
Century month date of interview

Survey Text

Angola 2006 Gabon 2000 Malawi 2000 Senegal 1992
Angola 2011 Gabon 2012 Malawi 2004 Senegal 1997
Angola 2015 Gambia 2013 Malawi 2010 Senegal 2005
Bangladesh 1994 Gambia 2019 Malawi 2012 Senegal 2006
Bangladesh 1997 Ghana 1988 Malawi 2014 Senegal 2008
Bangladesh 2000 Ghana 1993 Malawi 2016 Senegal 2010
Bangladesh 2004 Ghana 1998 Malawi 2017 Senegal 2012
Bangladesh 2007 Ghana 2003 Mali 1987 Senegal 2014
Bangladesh 2011 Ghana 2008 Mali 1995 Senegal 2015
Bangladesh 2014 Ghana 2014 Mali 2001 Senegal 2016
Bangladesh 2018 Ghana 2016 Mali 2006 Senegal 2017
Benin 1996 Ghana 2019 Mali 2012 Senegal 2021
Benin 2001 Guinea 1999 Mali 2015 Sierra Leone 2008
Benin 2006 Guinea 2005 Mali 2018 Sierra Leone 2013
Benin 2011 Guinea 2012 Mali 2021 Sierra Leone 2016
Benin 2017 Guinea 2018 Morocco 1987 Sierra Leone 2019
Burkina Faso 1993 Guinea 2021 Morocco 1992 South Africa 1998
Burkina Faso 1998 India 1992 Morocco 2003 South Africa 2016
Burkina Faso 2003 India 1998 Mozambique 1997 Sri Lanka 1987
Burkina Faso 2010 India 2005 Mozambique 2003 Sudan 1989
Burkina Faso 2014 India 2015 Mozambique 2011 Tanzania 1991
Burkina Faso 2018 India 2019 Mozambique 2018 Tanzania 1996
Burundi 1987 Jordan 1990 Myanmar 2015 Tanzania 1999
Burundi 2010 Jordan 1997 Namibia 1992 Tanzania 2004
Burundi 2012 Jordan 2002 Namibia 2000 Tanzania 2010
Burundi 2016 Jordan 2007 Namibia 2006 Tanzania 2015
Cameroon 1991 Jordan 2009 Namibia 2013 Tanzania 2017
Cameroon 1998 Jordan 2012 Niger 1992 Togo 1988
Cameroon 2004 Jordan 2017 Niger 1998 Togo 1998
Cameroon 2011 Kenya 1989 Niger 2006 Togo 2013
Cameroon 2018 Kenya 1993 Niger 2012 Togo 2017
Cameroon 2022 Kenya 1998 Niger 2021 Tunisia 1988
Central African Republic 1995 Kenya 2003 Nigeria 1990 Uganda 1988
Chad 1996 Kenya 2008 Nigeria 1999 Uganda 1995
Chad 2004 Kenya 2014 Nigeria 2003 Uganda 2001
Chad 2014 Kenya 2015 Nigeria 2008 Uganda 2006
Comoros 1996 Kenya 2020 Nigeria 2010 Uganda 2009
Comoros 2012 Lesotho 2004 Nigeria 2013 Uganda 2011
Congo (Democratic Republic) 2007 Lesotho 2009 Nigeria 2015 Uganda 2014
Congo (Democratic Republic) 2013 Lesotho 2014 Nigeria 2018 Uganda 2016
Congo Brazzaville 2005 Liberia 1986 Nigeria 2021 Uganda 2018
Congo Brazzaville 2011 Liberia 2007 Pakistan 1991 Yemen 1991
Cote d'Ivoire 1994 Liberia 2009 Pakistan 2006 Yemen 2013
Cote d'Ivoire 1998 Liberia 2011 Pakistan 2012 Zambia 1992
Cote d'Ivoire 2011 Liberia 2013 Pakistan 2017 Zambia 1996
Egypt 1988 Liberia 2016 Rwanda 1992 Zambia 2001
Egypt 1992 Liberia 2019 Rwanda 2000 Zambia 2007
Egypt 1995 Madagascar 1992 Rwanda 2005 Zambia 2013
Egypt 2000 Madagascar 1997 Rwanda 2008 Zambia 2018
Egypt 2003 Madagascar 2003 Rwanda 2010 Zimbabwe 1988
Egypt 2005 Madagascar 2008 Rwanda 2013 Zimbabwe 1994
Egypt 2008 Madagascar 2011 Rwanda 2014 Zimbabwe 1999
Egypt 2014 Madagascar 2013 Rwanda 2017 Zimbabwe 2005
Eswatini (Swaziland) 2006 Madagascar 2016 Rwanda 2019 Zimbabwe 2010
Ethiopia 2000 Madagascar 2021 Sao Tome 2008 Zimbabwe 2015
Ethiopia 2005 Malawi 1992 Senegal 1986
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Angola 2006
Survey form view entire document:  text 
IDENTIFICATION

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

REGION

URBAN/RURAL

URBAN 1
RURAL 2

MALARIA ENDEMIC REGION

Hyperendemic (Cabinda, Uige, K. Norte, Malange, L. Norte, L. Sul) 1
Mesoendemic Stable (Zaire, Luanda, Bengo, Benguela, K. Sul, Huambo, Bié) 2
Mesoendemic Unstable (Moxico, K. Kubango, Kunene, Huila, Namibe) 3
INTERVIEWER VISITS

FIRST VISIT

DATE

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

DATE

TIME

FINAL VISIT

DAY

MONTH

YEAR

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

TOTAL NO. OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE


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Angola 2011
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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

NEXT VISIT

DATE

TIME

LAST VISIT

DAY

MONTH

YEAR: 2011

CODE

RESULT

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

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Angola 2015
Survey form view entire document:  text 
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

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Bangladesh 1994
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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


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Bangladesh 1997
Survey form view entire document:  text 
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


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Bangladesh 2000
Survey form view entire document:  text 
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____

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Bangladesh 2004
Survey form view entire document:  text 
NAME OF HOUSEHOLD HEAD:

IS HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

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Bangladesh 2007
Survey form view entire document:  text 
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

TOTAL NUMBER OF VISITS____


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Bangladesh 2011
Survey form view entire document:  text 
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

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Bangladesh 2014
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INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME ___________
RESULT* _____


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Bangladesh 2018
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INTERVIEWER 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. CODE______________
RESULT

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ____________

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Benin 1996
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INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME___
RESULT**


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Benin 2001
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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 2001
NAME___
RESULT ____


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Benin 2006
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
RESULT _____


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Benin 2011
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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 2011
INTERVIEWER CODE_______
RESULT _____


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Benin 2017
Survey form view entire document:  text 
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 __

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Burkina Faso 1993
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INTERVIEWER VISITS

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


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Burkina Faso 1998
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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

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Burkina Faso 2003
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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 _____


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Burkina Faso 2010
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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

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Burkina Faso 2014
Survey form view entire document:  text 
INTERVIEWER VISITS

(repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

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Burkina Faso 2018
Survey form view entire document:  text 
INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 2017
INTERVIEWER NUMBER ______
RESULT ______


TOTAL NUMBER OF VISITS ______

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Burundi 1987
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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
OTHER (SPECIFY) 6

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) 6

THIRD VISIT
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
INT. NUMBER
RESULT CODE


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Burundi 2010
Survey form view entire document:  text 
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____


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Burundi 2012
Survey form view entire document:  text 
INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 20______
INTERVIEWER NUMBER ______
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) ______

LANGUAGE OF QUESTIONNAIRE (FRENCH AND KIRUNDI = 1)
LANGUAGE OF INTERVIEW
INTERPRETER (YES = 1, NO = 2)

LANGUAGE CODES
1 KIRUNDI
2 FRENCH
6 OTHERS

LANGUAGE OF QUESTIONNAIRE 1
INTERVIEW LANGUAGE ______
INTERPRETER ______

TEAM LEADER
NAME ______

FIELD EDITOR
(NUMBER) ______

DATA ENTRY BY
(NUMBER) ______

[###translator's note: Throughout this survey, all questions or statements that are directly addressed to the respondent are given in Kirundi language as well as French]


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Burundi 2016
Survey form view entire document:  text 
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


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Cameroon 1991
Survey form view entire document:  text 
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__


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Cameroon 1998
Survey form view entire document:  text 
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

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Cameroon 2004
Survey form view entire document:  text 
INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____


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Cameroon 2011
Survey form view entire document:  text 
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

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Cameroon 2018
Survey form view entire document:  text 
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)_______

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Cameroon 2022
Survey form view entire document:  text 
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 2022
INT. NO.
RESULT*

TOTAL VISITS

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

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW**
NATIVE LANGUAGE OF RESPONDENT**
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES:
01 ENGLISH
02 FRENCH
03 FUFULDE
04 PIDGIN
96 OTHER (SPECIFY)

TEAM
NUMBER

TEAM SUPERVISOR
NAME
NUMBER


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Central African Republic 1995
Survey form view entire document:  text 
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


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Chad 1996

No questionnaire text is available for this sample.


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Chad 2004
Survey form view entire document:  text 
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_____

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Chad 2014
Survey form view entire document:  text 
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________

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Comoros 1996
Survey form view entire document:  text 
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


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Comoros 2012

No questionnaire text is available for this sample.


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Congo (Democratic Republic) 2007
Survey form view entire document:  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


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Congo (Democratic Republic) 2013
Survey form view entire document:  text 
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


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Congo Brazzaville 2005

No questionnaire text is available for this sample.


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Congo Brazzaville 2011

No questionnaire text is available for this sample.


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Cote d'Ivoire 1994
Survey form view entire document:  text 
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___


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Cote d'Ivoire 1998
Survey form view entire document:  text 
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 ____


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Cote d'Ivoire 2011
Survey form view entire document:  text 
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

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Egypt 1988
Survey form view entire document:  text 
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______
INTERVIEWER'S NAME____
RESULT____


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Egypt 1992
Survey form view entire document:  text 
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 ___


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Egypt 1995
Survey form view entire document:  text 
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 __


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Egypt 2000
Survey form view entire document:  text 
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_______


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Egypt 2003
Survey form view entire document:  text 
NEXT VISIT:

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


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Egypt 2005
Survey form view entire document:  text 
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 __


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Egypt 2008
Survey form view entire document:  text 
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 _____


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Egypt 2014
Survey form view entire document:  text 
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__


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Eswatini (Swaziland) 2006
Survey form view entire document:  text 
INTERVIEWER VISIT 1 (REPEAT FOR VISITS 2 AND 3)
DATE____
INTERVIEWER'S NAME____
RESULT____

NEXT VISIT:
DATE____
TIME_____

FINAL VISIT
DAY____
MONTH____
YEAR 2006
INT. NUMBER____
RESULT____

TOTAL NUMBER OF VISITS____

RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_______7

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Ethiopia 2000
Survey form view entire document:  text 
INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____


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Ethiopia 2005
Survey form view entire document:  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


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Gabon 2000
Survey form view entire document:  text 
INTERVIEWER VISITS

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

RESULT CODES

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)

FINAL VISIT
DAY_____
MONTH_____
YEAR 2000
NAME_____
RESULT_____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____

TOTAL NO. OF VISITS_____


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Gabon 2012
Survey form view entire document:  text 
INTERVIEWER VISITS
DATE_______
INTERVIEWER'S NAME_______
RESULT

1COMPLETED
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

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

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Gambia 2013

No questionnaire text is available for this sample.


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Gambia 2019
Survey form view entire document:  text 
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

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
LANGUAGE OF QUESTIONNAIRE
LANGUAGE OF INTERVIEW
NATIVE LANGUAGE OF RESPONDENT
TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE CODES

ENGLISH 01
MANDINKA 02
WOLLOF 03
FULA 04
JOLA 05
SARAHULE 06
SERERE 07
MANJANGO 08
CREOLE/AKU MARABOUT 09
BAMBARA 10
OTHER LANGUAGE (SPECIFY) 11

SUPERVISOR
NAME
CODE


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Ghana 1988
Survey form view entire document:  text 
INTERVIEW 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
MONTH____
YEAR ____
INTERVIEWER'S NAME ____


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Ghana 1993
Survey form view entire document:  text 
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 ___


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Ghana 1998
Survey form view entire document:  text 
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

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Ghana 2003
Survey form view entire document:  text 
INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____


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Ghana 2008
Survey form view entire document:  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


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Ghana 2014
Survey form view entire document:  text 
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

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Ghana 2016
Survey form view entire document:  text 
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

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Ghana 2019
Survey form view entire document:  text 
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 2019
INTERVIEWER'S NUMBER _____________
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER __________________(SPECIFY) 7

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Guinea 1999
Survey form view entire document:  text 
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 _____


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Guinea 2005
Survey form view entire document:  text 
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

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Guinea 2012
Survey form view entire document:  text 
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__________


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Guinea 2018
Survey form view entire document:  text 
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


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Guinea 2021
Survey form view entire document:  text 
INTERVIEWERS? VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 2020
RESPONDENT NUMBER______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:

1 COMPLETED
2 NOT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______

LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
INTERPRETER (YES = 1, NO = 2) ______
LANGUAGE OF QUESTIONNAIRE FRENCH

LANGUAGE CODES:

01 FRENCH
02 SUSU
03 PEUL
04 MALINKE
05 KISII
04 TOMA
07 KPELLE
08 OTHER (SPECIFY) ______

TEAM NUMBER ______

TEAM LEADER
NAME ______
NUMBER ______

CAPI SUPERVISOR
NAME ______
NUMBER ______


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India 1992
Survey form view entire document:  text 
INTERVIEW VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ______
RESULT ______


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India 1998
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE ______
INTERVIEWER'S NAME ________
RESULT _______


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India 2005
Survey form view entire document:  text 
FINAL VISIT
DATE ______
MONTH ______
YEAR ______
INT. NO. ______
RESULT CODE _____

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India 2015
Survey form view entire document:  text 
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 ________


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India 2019
Survey form view entire document:  text 
INTERVIEWER VISITS

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 __
INT. NO. __
RESULT CODE* __

TOTAL NUMBER OF VISITS __

SUPERVISOR'S NAME __
SUPERVISOR'S NUMBER __

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

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Jordan 1990
Survey form view entire document:  text 
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


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Jordan 1997
Survey form view entire document:  text 
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


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Jordan 2002
Survey form view entire document:  text 
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


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Jordan 2007
Survey form view entire document:  text 
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

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Jordan 2009
Survey form view entire document:  text 
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

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Jordan 2012
Survey form view entire document:  text 
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

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Jordan 2017
Survey form view entire document:  text 
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

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Kenya 1989
Survey form view entire document:  text 
INTERVIWERS VISITS
DATE_____
INTERVIEWER'S NAME_______
RESULT______

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___


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Kenya 1993
Survey form view entire document:  text 
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 ____


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Kenya 1998
Survey form view entire document:  text 
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


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Kenya 2003
Survey form view entire document:  text 
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 ___________


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Kenya 2008
Survey form view entire document:  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


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Kenya 2014
Survey form view entire document:  text 
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

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Kenya 2015
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT

DATE

INTERVIEWER'S NAME

RESULT

COMPLETED 1
NOT AT HOME 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 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE: 01 ENGLISH

LANGUAGE OF INTERVIEW

ENGLISH 01
KISWAHILI 02
BORANA 03
EMBU 04
KALENJIN 05
KAMBA 06
KIKUYU 07
KISII 08
LUHYA 09
MARAGOLI 10
LUO 11
MAASAI 12
MERU 13
MIJIKENDA 14
POKOT 15
SOMALI 16
TURKANA 17
OTHER 18

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Kenya 2020
Survey form view entire document:  text 
INTERVIEWER VISITS

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 _________________
INTERVIEWER NUMBER ____________________

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER __________________(SPECIFY) 7

TOTAL NUMBER OF VISITS _____________________


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Lesotho 2004
Survey form view entire document:  text 
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 _____


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Lesotho 2009
Survey form view entire document:  text 
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 ___ ___ ___


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Lesotho 2014
Survey form view entire document:  text 
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 ____


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Liberia 1986

No questionnaire text is available for this sample.


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Liberia 2007
Survey form view entire document:  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


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Liberia 2009
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE
INTERVIEWERS 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

SUPERVISOR
NAME
DATE
OFFICE EDITOR
KEYED BY


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Liberia 2011
Survey form view entire document:  text 
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

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

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Liberia 2013

No questionnaire text is available for this sample.


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Liberia 2016
Survey form view entire document:  text 
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

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


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Liberia 2019
Survey form view entire document:  text 
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

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

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Madagascar 1992
Survey form view entire document:  text 
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

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Madagascar 1997
Survey form view entire document:  text 
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

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Madagascar 2003
Survey form view entire document:  text 
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 ______


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Madagascar 2008
Survey form view entire document:  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


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Madagascar 2011
Survey form view entire document:  text 
(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______


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Madagascar 2013
Survey form view entire document:  text 
(Repeat for up to 3 visits)

DATE _____
NAME OF INTERVIEWER ______
RESULT ______


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Madagascar 2016
Survey form view entire document:  text 
INTERVIEWER VISITS:

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _______
INTERVIEWER'S NAME _________
RESULT* ____

NEXT VISIT

DATE ____
TIME ____

FINAL VISIT

DAY ____
MONTH ____
YEAR _____

TOTAL NUMBER OF VISITS ______

*RESULT CODES

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
UNABLE 6
OTHER (SPECIFY) ____ 7

QUESTIONNAIRE LANGUAGE** ____

QUESTIONNAIRE LANGUAGE** ____

LANGUAGE OF INTERVIEW** ____

NATIVE LANGUAGE OF RESPONDENT** ___

TRANSLATOR USED

YES 1
NO 2

**LANGUAGE CODES

FRENCH 01
MALGACHE 02
OTHER (SPECIFY) ____ 03

SUPERVISOR

NAME ____
NUMBER ___

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Madagascar 2021
Survey form view entire document:  text 
INTERVIEWER VISITS 1, 2, 3

DATE: ____
INTERVIEWER'S NAME ______
RESULT* ____

NEXT VISIT

DATE ____
TIME ____

FINAL VISIT

DAY ____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT* ____

TOTAL NUMBER OF VISITS _____

*RESULT CODES:

COMPLETED 1
NOT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
UNABLE 6
OTHER ____ (SPECIFY) 7

QUESTIONNAIRE LANGUAGE** ____ (LANGUAGE CODE)

QUESTIONNAIRE LANGUAGE** ____ (LANGUAGE NAME)

LANGUAGE OF INTERVIEW** ____

NATIVE LANGUAGE OF RESPONDENT** ___

TRANSLATOR USED

YES 1
NO 2

**LANGUAGE CODES

FRENCH 01
MALAGASY 02
LANGUAGE 03
LANGUAGE 04
LANGUAGE 05
LANGUAGE 06

TEAM SUPERVISOR

NAME ____
NUMBER ____


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Malawi 1992
Survey form view entire document:  text 
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWER'S NAME ___
RESULT* ___

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Malawi 2000
Survey form view entire document:  text 
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____

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Malawi 2004
Survey form view entire document:  text 
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____

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Malawi 2010
Survey form view entire document:  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


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Malawi 2012
Survey form view entire document:  text 
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 __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPICATATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE** ENGLISH
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (1 = NOT AT ALL; 2 = SOMETIME; 3 = ALL THE TIME) __

**LANGUAGE CODES:

CHICHEWA 1
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER 6 (SPECIFY) __

SUPERVISOR
NAME __

OFFICE EDITOR __

KEYED BY __


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Malawi 2014
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
TOTAL NUMBER OF VISITS
RESULT CODES

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7

LANGUAGE OF QUESTIONNAIRE
LANGUAGE OF INTERVIEW
NATIVE LANGUAGE OF RESPONDENT
TRANSLATOR USED

NOT AT ALL 1
SOMETIME 2
ALL THE TIME 3

LANGUAGE CODES

CHICHEWA 1
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER (SPECIFY) 6

SUPERVISOR
NAME__
OFFICE EDITOR__
KEYED BY__


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Malawi 2016
Survey form view entire document:  text 
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:


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Malawi 2017
Survey form view entire document:  text 
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

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
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW
NATIVE LANGUAGE OF RESPONDENT
TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE CODES

ENGLISH 01
CHICHEWA 02
TUMBUKA 03
OTHER (SPECIFY) 06

SUPERVISOR
NAME
NUMBER


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Mali 1987
Survey form view entire document:  text 
INTERVIWERS VISITS
DATE_____
INTERVIEWER'S NAME_______
RESULT______

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___


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Mali 1995
Survey form view entire document:  text 
INTERVIEWER VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR 1996
INTERVIEWER NAME____
RESULT ____


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Mali 2001
Survey form view entire document:  text 
INTERVIEWER VISITS:

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____


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Mali 2006
Survey form view entire document:  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


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Mali 2012
Survey form view entire document:  text 
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

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Mali 2015
Survey form view entire document:  text 
FINAL VISIT

DAY ______
MONTH ______
YEAR 2015
INTERVIEWER'S NUMBER______
RESULT CODE ______

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Mali 2018
Survey form view entire document:  text 
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


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Mali 2021
Survey form view entire document:  text 
INTERVIEWER'S VISITS

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 2021
INTERVIEWER'S NUMBER______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:

1 COMPLETED
2 NOT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______

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Morocco 1987
Survey form view entire document:  text 
VISITS:

DATE OF VISIT: ____

INTERVIEWER'S NAME: ____

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7 ____

NEXT VISIT INDICATED:

A) DATE: ____

B) TIME: ____

MONTH: ____

YEAR: ____

INTERVIEWER CODE: ____

FINAL RESULT: ____

TOTAL NO. OF VISITS: ____


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Morocco 1992
Survey form view entire document:  text 
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


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Morocco 2003
Survey form view entire document:  text 
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) __________

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Mozambique 1997
Survey form view entire document:  text 
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

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Mozambique 2003
Survey form view entire document:  text 
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______


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Mozambique 2011
Survey form view entire document:  text 
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_________


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Mozambique 2018
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE ____
INTERVIEWER'S NAME ____
NEXT VISIT: DATE ___
TIME: ____
NOTES ____
FINAL VISIT

DAY __ __
MONTH __ __
YEAR __ __ __ __

TOTAL NUMBER OF VISITS ___
TOTAL NUMBER OF ELIGIBLE CHILDREN ___
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW ___
NATIVE LANGUAGE OF RESPONDENT ___
TRANSLATOR USED (YES = 1, NO = 2) ___
LANGUAGE OF QUESTIONNAIRE: PORTUGUESE
LANGUAGE CODES:

01 PORTUGUESE
02 ENGLISH
03 EMAKHUWA 08 CINYANJA 09 CINDAU
04 XICHANGANA 10 XITSWA
05 CISENA 11 CINYUNGWE
06 ELOMWE 12 CIYAO
07 ECHUWABO
96 SHONA

SUPERVISOR
NAME
NUMBER __ __ __ __


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Myanmar 2015
Survey form view entire document:  text 

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____


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Namibia 1992
Survey form view entire document:  text 
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_____


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Namibia 2000
Survey form view entire document:  text 
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

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Namibia 2006
Survey form view entire document:  text 
INTERVIEWER VISIT 1
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 ____

INTERVIEWER VISIT 2
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 ____

INTERVIEWER VISIT 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 200__
INT.NUMBER ___
RESULT ___

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) ____ 7

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Namibia 2013
Survey form view entire document:  text 
INTERVIEW VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____


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Niger 1992
Survey form view entire document:  text 
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__


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Niger 1998
Survey form view entire document:  text 
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

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Niger 2006
Survey form view entire document:  text 
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

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Niger 2012
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE _____________
INTERVIEWER'S NAME ______________
RESULT* ____________

FINAL VISIT
DAY _______________
MONTH ______________
YEAR 2012 ____________
INTERVIEWER _____________
RESULT _____________

NEXT VISIT
DATE _________
TIME _________


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Niger 2021
Survey form view entire document:  text 
FINAL VISIT

DAY ______
MONTH ______
YEAR ______
RESPONDENT NUMBER______
RESULT ______

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Nigeria 1990
Survey form view entire document:  text 
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


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Nigeria 1999
Survey form view entire document:  text 
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 _____


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Nigeria 2003
Survey form view entire document:  text 
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) _________________

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Nigeria 2008
Survey form view entire document:  text 
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

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Nigeria 2010
Survey form view entire document:  text 
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 2010
INT. NUMBER __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE** ENGLISH
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (1 = NOT AT ALL, 2 = SOMETIME, 3 = ALL THE TIME) __
**LANGUAGE CODES

HAUSA 1
YORUBA 2
IGBO 3
ENGLISH 4
OTHER 6 (SPECIFY) __

SUPERVISOR/EDITOR
NAME __
DATE __

OFFICE EDITOR __
KEYED BY __


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Nigeria 2013
Survey form view entire document:  text 
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*


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Nigeria 2015
Survey form view entire document:  text 
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 2015
INT NO. __
RESULT* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE** ENGLISH
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (1 = NOT AT ALL, 2 = SOMETIME, 3 = ALL THE TIME) __

**LANGUAGE CODES

HAUSA 1
YORUBA 2
IGBO 3
ENGLISH 4
OTHER 6 (SPECIFY) __

SUPERVISOR/EDITOR
NAME __
DATE __

NUMBER __

OFFICE EDITOR __
KEYED BY __


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Nigeria 2018
Survey form view entire document:  text 
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

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Nigeria 2021
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NO.
RESULT
RESULT CODES:

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

TOTAL NUMBER OF VISITS
LANGUAGE OF QUESTIONNAIRE
LANGUAGE OF INTERVIEW
NATIVE LANGUAGE OF RESPONDENT
TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE CODES:

ENGLISH 01
HAUSA 02
YORUBA 03
IGBO 04
OTHER 06

TEAM NUMBER__
TEAM SUPERVISOR
NAME__
NUMBER__


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Pakistan 1991
Survey form view entire document:  text 
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


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Pakistan 2006
Survey form view entire document:  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


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Pakistan 2012
Survey form view entire document:  text 
INTERVIEW VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____


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Pakistan 2017
Survey form view entire document:  text 
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 _________


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Rwanda 1992
Survey form view entire document:  text 
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

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Rwanda 2000
Survey form view entire document:  text 
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

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Rwanda 2005
Survey form view entire document:  text 
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

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Rwanda 2008

No questionnaire text is available for this sample.


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Rwanda 2010
Survey form view entire document:  text 
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

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Rwanda 2013
Survey form view entire document:  text 
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 __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

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 9 (SPECIFY) __

TOTAL PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

SUPERVISOR
NAME __

OFFICE EDITOR __

KEYED BY __


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Rwanda 2014
Survey form view entire document:  text 
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


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Rwanda 2017
Survey form view entire document:  text 
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. NO. __
RESULT* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES:

ENGLISH 01
KINYARWANDA 02

SUPERVISOR
NAME __
NUMBER __

OFFICE EDITOR
NUMBER __

KEYED BY
NUMBER __


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Rwanda 2019
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT
DATE __
INTERVIEWER'SNAME __
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* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW __
NATIVE LANGUAGE OF RESPONDENT __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE ENGLISH
LANGUAGE CODES:

ENGLISH 01
KINYARWANDA 02

TEAM LEADER
NAME __
NUMBER __
FIELD EDITOR
NAME __
NUMBER __
OFFICE EDITOR
NUMBER __
KEYED BY
NUMBER __


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Sao Tome 2008
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT
DAY____
MONTH___
YEAR 2008
INTERVIEWER'S NAME_________
AF.09- RESULT*_________

NEXT VISIT
DAY___
MONTH___
YEAR___
TIME___

SECOND VISIT
DAY____
MONTH ___
YEAR 2008
INTERVIEWER'S NAME_________
AF.09- RESULT*_________

NEXT VISIT
DAY___
MONTH___
YEAR___
TIME___

THIRD VISIT
DAY____
MONTH___
YEAR2008
INTERVIEWER'S NAME_________
AF.09- RESULT*_________

FINAL VISIT
DAY_________
MONTH_________
YEAR 2008
INTERVIEWER'S CODE ______
RESULT CODE*______

TOTAL NUMBER OF VISITS_________

*RESULT CODES:

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

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Senegal 1986
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____
INTERVIEWER NAME____
RESULT___

COMPLETED 1
NO MEMBER OF THE HOUSEHOLD AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY FILLED OUT 5
OTHER (SPECIFY) ____ 6

NEXT VISIT
DATE____
TIME____

FINAL VISIT
MONTH ____
YEAR 1986
RESPONDENT CODE ____
INTERVIEWER CODE ____


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Senegal 1992
Survey form view entire document:  text 
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

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Senegal 1997
Survey form view entire document:  text 
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

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Senegal 2005
Survey form view entire document:  text 
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

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Senegal 2006
Survey form view entire document:  text 
INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 2006
INTERVIEWER NUMBER______
RESULT ______

TOTAL NUMBER OF VISITS ______

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

LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______

LANGUAGE CODES:
1 FRENCH
2 WOLOF
3 PULAR
4 SERER
5 MANDINKA
6 DIOLA
8 OTHERS

INTERPRETER (YES = 1, NO = 2) ______

TEAM LEADER
NAME ______
DATE ______

SUPERVISOR
NAME ______
DATE ______

OFFICE EDITOR ______

KEYED BY ______


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Senegal 2008
Survey form view entire document:  text 
INTERVIEWER VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 200______
INTERVIEWER NUMBER______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

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

LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______

LANGUAGE CODES:
1 FRENCH
2 WOLOF
3 PULAR
4 SERER
5 MANDINKA
6 DIOLA
8 OTHER

INTERPRETER (YES = 1, NO = 2) ______

TEAM LEADER
NAME ______
DATE ______

SUPERVISOR
NAME ______
DATE ______

OFFICE EDITOR ______

KEYED BY ______


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Senegal 2010
Survey form view entire document:  text 
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

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Senegal 2012
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE _____________
INTERVIEWER'S NAME _____________
RESULT____

FINAL VISIT

DAY ______________
MONTH __________
YEAR 201__
INT. NUMBER__________
RESULT ____________

NEXT VISIT

DATE ___________
TIME ___________


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Senegal 2014
Survey form view entire document:  text 
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

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Senegal 2015
Survey form view entire document:  text 
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 __

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Senegal 2016
Survey form view entire document:  text 
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 __

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Senegal 2017
Survey form view entire document:  text 
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 _____


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Senegal 2021
Survey form view entire document:  text 
INTERVIEWERS VISITS

(Repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 202______
RESPONDENT NUMBER______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

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

LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______
NATIVE LANGUAGE OF RESPONDENT ______
INTERPRETER (YES = 1, NO = 2) ______
LANGUAGE OF QUESTIONNAIRE FRENCH

LANGUAGE CODES:
01 FRENCH
02 WOLOF
03 PULAR
04 SERER
05 MANDINKA
06 DIOLA
07 OTHERS

TEAM LEADER
NAME ______
NUMBER ______
DATE ______


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Sierra Leone 2008

No questionnaire text is available for this sample.


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Sierra Leone 2013

No questionnaire text is available for this sample.


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Sierra Leone 2016
Survey form view entire document:  text 
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 2016
INT. NO. __
RESULT* __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY) __

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __
NATIVE LANGUAGE OF RESPONDENT** __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES:

ENGLISH 01
KRIO 02
MENDE 03
TEMNE 04
MADINGO 05
LOKO 06
SHERBRO 07
LIMBO 08
KISSI 09
KONO 10
SUSU 11
FULLAH 12
KRIM 13
YALUNKA 14
KORANKO 15
VAI 16
OTHER 96

SUPERVISOR
NAME __
NUMBER __


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Sierra Leone 2019
Survey form view entire document:  text 
INTERVIEWER VISITS

DATE___
INTERVIEWER'S NAME___
RESULTS___

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 DWELLING 6

NEXT VISITATION ___
TIME___

FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO___

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 DWELLING 6

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South Africa 1998
Survey form view entire document:  text 
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

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South Africa 2016
Survey form view entire document:  text 
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____


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Sri Lanka 1987

No questionnaire text is available for this sample.


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Sudan 1989
Survey form view entire document:  text 
INTERVIEWER VISITS

INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) ______ 6

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) ______ 6

THIRD VISIT
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
MONTH
YEAR

TOTAL NUMBER OF VISITS


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Tanzania 1991
Survey form view entire document:  text 
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 __


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Tanzania 1996
Survey form view entire document:  text 
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

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Tanzania 1999
Survey form view entire document:  text 
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

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Tanzania 2004
Survey form view entire document:  text 
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

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Tanzania 2010
Survey form view entire document:  text 
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


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Tanzania 2015
Survey form view entire document:  text 
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 _____


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Tanzania 2017
Survey form view entire document:  text 
FINAL VISIT

DAY_
MONTH_
YEAR_
INT. NO._
RESULT*_
TOTAL NUMBER OF VISITS_

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Togo 1988

No questionnaire text is available for this sample.


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Togo 1998

No questionnaire text is available for this sample.


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Togo 2013

No questionnaire text is available for this sample.


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Togo 2017
Survey form view entire document:  text 
INTERVIEWER VISITS

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 2017
INTERVIEWER NUMBER _________
RESULT ____*

*RESULT CODES

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPLETED 5
UNABLE 6
OTHER _____ (SPECIFY) 7

NEXT VISIT:
DATE ___________
HOUR ____________

TOTAL NUMBER OF VISITS _______________

QUESTIONNAIRE LANGUAGE (LANGUAGE CODE) **: ____

QUESTIONNAIRE LANGUAGE (NAME OF LANGUAGE): ____

LANGUAGE OF INTERVIEW: ____

**LANGUAGE CODES

FRENCH 01
EWE/MINA 02
KABYE 03
KOTOKOLI/TEM 04
AKPOSSO/AKEBOU 05
IFE/ANA 06
MOBA-GOURMA 07
TCHOKOSSI 08
BASSAR/KONKOMBA 09
OTHER NATIONAL LANGUAGE ________________(SPECIFY) 96
OTHER FOREIGN LANGUAGE _______________(SPECIFY) 97

NATIVE LANGUAGE OF RESPONDENT: ____

FRENCH 01
EWE/MINA 02
KABYE 03
KOTOKOLI/TEM 04
AKPOSSO/AKEBOU 05
IFE/ANA 06
MOBA-GOURMA 07
TCHOKOSSI 08
BASSAR/KONKOMBA 09
OTHER NATIONAL LANGUAGE ________________(SPECIFY) 96
OTHER FOREIGN LANGUAGE _______________(SPECIFY) 97

TRANSLATOR USED?

YES 1
NO 2

FIELD EDITOR

NAME _______________
NUMBER _____________


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Tunisia 1988
Survey form view entire document:  text 
Visits

FIRST VISIT
5) DATE OF VISIT____

6) NAME OF INTERVIEWER____

7) RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPETED 5
OTHER (SPECIFY) 6

8) NEXT VISIT

DATE ____
TIME ____

SECOND VISIT
5) DATE OF VISIT____

6) NAME OF INTERVIEWER____

7) RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPETED 5
OTHER (SPECIFY) 6

8) NEXT VISIT

DATE ____
TIME ____

THIRD VISIT
5) DATE OF VISIT____

6) NAME OF INTERVIEWER____

7) RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTIALLY COMPETED 5
OTHER (SPECIFY) 6

8) NEXT VISIT

DATE ____
TIME ____

MONTH ____
YEAR 88

INTERVIEWER CODE
RESULT

NUMBER OF VISITS

NAME ____

DATE ____

FIELD EDITED BY ____

OFFICE EDITED BY ____

KEYED BY ____

CODE KEYED ____


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Uganda 1988
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT
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

SECOND VISIT
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

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) ___________ 6

FINAL VISIT
MONTH
YEAR

TOTAL NUMBER OF VISITS


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Uganda 1995
Survey form view entire document:  text 
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


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Uganda 2001
Survey form view entire document:  text 
INTERVIEWER VISITS
DATE _____
INTERVIEWER'S NAME __________
*RESULT

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT


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Uganda 2006
Survey form view entire document:  text 
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


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Uganda 2009
Survey form view entire document:  text 
SECTION 1B: INTERVIEWER VISITS

FIRST VISIT

1. DATE_
2. INTERVIEWER'S NAME_
3. RESULT*
4. NEXT VISIT: DATE_
5. TIME_

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Uganda 2011
Survey form view entire document:  text 

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 __


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Uganda 2014
Survey form view entire document:  text 
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*___

TOTAL NUMBER OF VISITS ___

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPCITATED 6
OTHER (SPECIFY) 7

LANGUAGE OF THE QUESTIONNAIRE 7
LANGUAGE USED IN THE INTERVIEW ___
NATIVE LANGUAGE OF RESPONDENT ___
TRANSLATOR USED (NOT AT ALL =1, SOMETIMES = 2, ALL THE TIME = 3)
LANGUAGE OF QUESTIONNAIRE ENGLISH

LANGUAGE USED:

ATESO-KARAMOJONG 1
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKORE-RUKIGA 5
RINYORO-RUTORO 6
ENGLISH 7
OTHER 8 (SPECIFY)

SUPERVISOR
NAME ___

OFFICE EDITOR ___

KEYED BY ___


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Uganda 2016
Survey form view entire document:  text 
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


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Uganda 2018
Survey form view entire document:  text 
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. NO.
RESULT*

TOTAL NUMBER OF VISITS__

*RESULT CODES

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)

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Yemen 1991
Survey form view entire document:  text 
INTERVIEWER VISITS

FIRST VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW

HOURS____
MINUTES____

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY)____ 6

NEXT VISIT
DATE
TIME

SECOND VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEWER

HOURS____
MINUTES____

RESULT

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY)____ 6

NEXT VISIT
DATE
TIME

FINAL VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW

HOURS____
MINUTES____

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Yemen 2013
Survey form view entire document:  text 
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

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Zambia 1992
Survey form view entire document:  text 
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 ____


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Zambia 1996
Survey form view entire document:  text 
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

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Zambia 2001
Survey form view entire document:  text 
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

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Zambia 2007
Survey form view entire document:  text 
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

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Zambia 2013
Survey form view entire document:  text 
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) ___________________

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Zambia 2018
Survey form view entire document:  text 
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 _____


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Zimbabwe 1988
Survey form view entire document:  text 
INTERVIWERS VISITS
DATE_____
INTERVIEWER'S NAME_______
RESULT______

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___


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Zimbabwe 1994
Survey form view entire document:  text 
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


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Zimbabwe 1999
Survey form view entire document:  text 
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__
INTERVIEWER'S NAME___
RESULT ____

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Zimbabwe 2005
Survey form view entire document:  text 
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) _________

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Zimbabwe 2010
Survey form view entire document:  text 
INTERVIEW VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____


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Zimbabwe 2015
Survey form view entire document:  text 
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 __ __