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 * __________