Literal question
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
TOTAL NUMBER OF VISITS