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
LANGUAGE OF INTERVIEW
NATIVE LANGUAGE OF RESPONDENT
TRANSLATOR USED?
FIRST VISIT
DATE_________
DAY___
MONTH___
INTERVIEWER'S NAME_________
RESULT
NEXT VISIT:
DATE_________
TIME_________
SECOND VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
DAY____
MONTH____
INTERVIEWER'S NAME____
RESULT
FINAL VISIT
DAY_________
MONTH_________
YEAR_____
INT. NO._________
RESULT
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
***RESULT CODES
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
***RESULT CODES
RESULT ____
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
CODE
RESULT
TOTAL NUMBER OF VISITS:
FIRST VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:
NEXT VISIT:
DATE____
TIME____
SECOND VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:
NEXT VISIT:
DATE____
TIME____
THIRD VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:
FINAL VISIT:
DAY____
MONTH____
YEAR: 2007
INT. NUMBER____
RESULT:
TOTAL NUMBER OF VISITS____
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:
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
NEXT VISIT
DATE_______
TIME_______
FINAL VISIT
DAY_______
MONTH_______
YEAR __2018__
INT. NO. _______
RESULT*_______
TOTAL NUMBER OF VISITS________
*RESULT CODES:
*RESULT CODES:
1COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
LANGUAGE OF INTERVIEW**
INTERPRETER
**LANGUAGE CODES
01 FRENCH
02 CHADIAN ARABIC
03 SARA
04 GORANE
05 KANEMBOU
06 MABA (OUADDAIEN)
07 MOUDANG
08 MOUSSEYE
09 PEUL/FOULF/BODORE
10 LELE/MARBA
11 TOUPOURI
12 BOULALA
13 ZAGHAWA/BERI.BIDEYAT
96 OTHER CHADIAN LANGUAGES (SPECIFY)
SUPERVISOR
NAME___________
DATE____
FIELD EDITOR
NAME___________
DATE____
OFFICE EDITOR
KEYED BY
LANGUAGE OF INTERVIEW:_____
LANGUAGE:
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT* ___
NEXT VISIT
DATE___
TIME___
FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO.___
RESULT___
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT
RESULT CODES:
VISITS 1, 2, AND 3
NEXT VISIT:
FINAL VISIT
INTERVIEWER'S NAME
RESULT___
FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
TOTAL NUMBER OF VISITS
FIRST VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______
SECOND VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______
THIRD VISIT
DATE______
INTERVIEWER'S NAME_____
RESULT CODE______
NEXT VISIT
DATE_______
TIME_______
FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INT. NO ______
RESULT CODE ______
TOTAL NUMBER OF VISITS _______
SUPERVISOR'S NAME_______
SUPERVISOR NUMBER ________
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT***
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT***
FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR 1997
NAME
RESULT
TOTAL NUMBER OF VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR 2002
NAME
RESULT
TOTAL NUMBER OF VISITS
FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
NEXT VISIT:
DATE__
TIME__
SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
NEXT VISIT:
DATE__
TIME__
THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
FINAL VISIT
DAY__
MONTH__
YEAR 2007
INT. NUMBER__
RESULT:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
RESULT ____
INTERVIEWER'S NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR 2018
RESULT
NEXT VISIT
DATE
TIME
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT
NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
TOTAL NUMBER OF VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
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____
DATE
INTERVIEWER'S NAME ___________
INT. CODE ________
RESULT* ___
NEXT VISIT
LANGUAGE
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW
HOME LANGUAGE OF RESPONDENT
WAS A TRANSLATOR USED
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
TOTAL NUMBER OF VISITS
VISIT 1
DATE _____________
INTERVIEWER'S NAME _____________
RESULT _____________
NEXT VISIT:
DATE _____________
TIME _____________
VISIT 2
DATE _____________
INTERVIEWER'S NAME _____________
RESULT _____________
NEXT VISIT:
DATE _____________
TIME _____________
VISIT 3
DATE _____________
INTERVIEWER'S NAME _____________
RESULT _____________
NEXT VISIT:
DATE _____________
TIME _____________
FINAL VISIT
DAY_____________
MONTH _____________
YEAR _____________
INT. NUMBER _____________
RESULT_____________
TOTAL NUMBER OF VISITS
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW _____________
NATIVE LANGUAGE OF RESPONDENT _____________
VISIT 1
NEXT VISIT:
FINAL VISIT
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME: ______
DATE: ______
RESULT _____
NEXT VISIT:
DATE _____
TIME ______
FINAL VISIT:
DAY ____
MONTH ___
YEAR ____
NAME ____
RESULT ____
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NEXT VISIT
DATE
TIME
*RESULT CODES:
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
NAME_____
RESULT____
RESULT____
FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT ______
NEXT VISIT DATE _____
TIME ______
SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT ______
NEXT VISIT DATE _____
TIME ______
THIRD VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT ______
NEXT VISIT DATE _____
TIME ______
FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT. NO. _______
RESULT _______
TOTAL NUMBER OF VISITS _________
FIRST VISIT
DATE
NAME OF THE INTERVIWER
RESULT*
NEXT VISIT:
DATE
HOURS
SECOND VISIT
DATE
NAME OF THE INTERVIEWER
RESULT*
NEXT VISIT:
DATE
HOURS
THIRD VISIT
DATE
NAME OF THE INTERVIWER
RESULT*
FINAL VISIT
DAY
MONTH
YEAR
CODE
RESULT
TOTAL NUMBER OF VISITS
*RESULT CODES:
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE: _______
INTERVIEWER'S NAME _________
RESULT
FINAL VISIT
DAY ____
MONTH ____
YEAR _____
INT. NUMBER ____
RESULT _____
NEXT VISIT
DATE _____
TIME _____
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
FINAL VISIT
DAY____
MONTH____
YEAR 201__
INT. NUMBER____
RESULT
TOTAL NUMBER OF VISITS____
FIRST VISIT
DATE
INTERVIEWER NAME
RESUT
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
FINAL VISIT
DAY
MONTH
YEAR
INT. NU,
RESULT
TOTAL NUMBER OF VISITS
FIRST VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
RESULT
NEXT VISIT
DATE
TIME
SECOND VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEWER
RESULT
NEXT VISIT
DATE
TIME
FINAL VISIT
NAME OF INTERVIEWER
DATE OF VISIT
STARTING TIME
ENDING TIME
DURATION OF INTERVIEW
NEXT VISIT:
FINAL VISIT:
TOTAL NUMBER OF VISITS _____