2006 PFU Results (Attachment)

DD-1301

3. CCM

MSN

MSN

4. CENSUS

10.
11.
12.

10.
11.

10.

11.

USCENSUSBUREAU

Reassignment reason

NOTICE

MSN

5. OTHER
ID

U.S. CENSUS BUREAU

Economics and Statistics Administration

U.S. DEPARTMENT OF COMMERCE

OMB No. 0000-0000: Approval Expires 00/00/0000

If found, please either call 1–301–763–3301 collect to arrange for pickup or mail to: Census Coverage Measurement,
U.S. Census Bureau, 4700 Silver Hill Rd, Washington, DC 20233-5780, Attn: CCM Field Staff.

9.

9.

9.

I code

8.

8.

8.

Interviewer name

7.

7.

7.

NOTES

6.

6.

6.

12.

5.

5.

5.

CL code

4.

4.

4.

Crew Leader name

3.

3.

12.

2.

2.

Telephone
b. Roster
1.

3.

ID

a. Address
Block

2.

Telephone
b. Roster – Census Day: April 1, 2006

a. Address
Block

1.

ID

2. LCO

CENSUS COVERAGE MEASUREMENT
2006 Census Test

PERSON FOLLOWUP QUESTIONNAIRE

1.

Telephone
b. Roster – PI interview day:

a. Address
Block

1. CLUSTER NO.

FORM
(5-11-2006)

D D

Y Y Y Y

Yes – Go to next person
No – Do not ask about this person,
go to the next person.

D D

Y Y Y Y

5

4

Yes – Go to next person
No – Do not ask about this person,
go to the next person.

If deceased, ask – Is it okay if I ask
questions about this person?

M M

Yes – Go to next person
No
Deceased – Specify date

5

4

If deceased, ask – Is it okay if I ask
questions about this person?

M M

Yes – Go to next person
No
Deceased – Specify date

9

8

7

6

1

9

8

7

6

FORM DD-1301 (5-11-2006)

Go
to
3

Go to
next
person

SKIP
to 4

SKIP
to 4

⎫
⎬
⎭

Must contact at least 3 knowledgeable
respondents.

R type

No – Specify R name and type

Former occupant
Neighbor
Landlord
Other – Specify

Yes – How?

R Name

5

2
3
4

Go to
next
person

SKIP
to 4

SKIP
to 4

Go
to
3

Must contact at least 3 knowledgeable
respondents.

R type

No – Specify R name and type

Landlord
Other – Specify

R Name

4
5

Ask Sections B and C for each person that R knows (Question 1 is "Yes"). For each person R doesn’t know, find
another R to complete those sections (must contact at least 3 knowledgeable respondents).

3

2

1

3

2

1

⎫
⎬
⎭
(

)

(

DK
REF

)

2

1

State

City

DK
REF

Number and street

2

1

State

City

Number and street

—

—

2

ZIP Code

Apt/Unit #

ZIP Code

Apt/Unit #

State

City

Number and street

Name

State

City

Number and street

Name

State

City

Number and street

Name

State

City

Number and street

Name

Go to next person.

ZIP Code

Apt/Unit #

ZIP Code

Apt/Unit #

Go to next person.

ZIP Code

Apt/Unit #

ZIP Code

Apt/Unit #

4. Is there someone else who might know
the people who lived around here/there
in 2006? Specify name and address.

3 = Relative/caregiver
4 = Neighbor
5 = Landlord (superintendent, rental office, owner, etc.)
6 = Other

3. What is his/her current phone
number and address?

RESPONDENT (R) TYPE CODE KEY
1 = Respondent’s name is on the front cover of form.
2 = Respondent lives at address on the front cover
of form, but is not listed on cover.

1. Do you know (name) well enough 2. Have you heard of (name)?
to answer questions about
1
Yes – How?
where he/she was living in 2006
2
Former occupant
and other places where he/she
Neighbor
3
stayed?

Hello, I’m (name) from the U.S. Census Bureau. Here is my identification.
As part of the census, we are contacting households to make sure we
counted everyone correctly. Here is a letter explaining our interview.

Section A – INTRODUCTION

No, different people
DK – Go to Section C for person respondent knows
REF – Go to Section C

2

FORM DD-1301 (5-11-2006)

Notes

4

3

Yes, same person

1

and
the same person?

Are

1. We are trying to find out if the names we have refer to the same person.

Section B – POSSIBLE MATCH/DUPLICATE

6

5

4

3

2

1

REF

DK – Describe how R knows they are different people

Jr/Sr, Father/son, Mother/daughter
Twins
Neighbors
Other – Specify

2. What is the relationship between them?

3

No – SKIP to 1b
Go to next known person. If last
DK ⎫
⎬
REF ⎭ person, end interview.

2

Name’s location

All the time

2

Moved

3

2

1

Back and forth

Most of the time
Half of the time – At this place on April 1, 2006?
Less than half the time
Certain days of the week
Su
M
Tu
W
Th
Daytime only, didn’t spend nights

FORM DD-1301 (5-11-2006)

10

9

8

5

4

SKIP
to 1g

DK
REF

F

6

Sa

Yes
7

No

4

3

2

1

DK
REF

House/Apartment/Mobile home/
Condo/Townhouse
Other – Specify

SKIP to 1h at bottom of page.

Please provide as specific dates as possible.
FROM
TO

DK
REF

2

1

DK
REF

1f. What are the names of
neighbors who lived nearby?

SKIP 1
to 1g
2

Go to 1h at bottom of page.

Please provide as specific dates as possible.
FROM
TO

1e. What are the names of any 1g. Please look at the calendar. During
other people who lived with
2006, when did you/he/she live or
you/him/her at this address?
stay at that place?

Notes: Was there any other period of time at this address?

1c. What are the landmarks or cross
streets closest to that place?

How often did he/she stay at this place? Mark (X) all that apply.

1

ZIP Code

If more than one address – Record in notes

Same as

State

City

1b. At what address did you/he/she 1d. Is that place a house or
apartment or another type
live in 2006?
of place like those shown
Number and street
Apt/Unit #
on the card I gave you?

anytime in 2006?

1a. Please look at the calendar. During
2006, when did you/he/she live or
stay at

Hand respondent flashcard and calendar. I am going to be referring to these during the interview.

live or stay at

1h. Situation: Ask if necessary – Did he/she stay here all the time,
move, or go back and forth between 2 or more places?

4

3

Yes – Go to 1a

1

1. Did you/

Now, we’ll talk about

Section C – PERSON QUESTIONS

4

}

Yes – Go to 2a
No
DK
SKIP to 3
REF

Yes – Go to 3a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . .

FORM DD-1301 (5-11-2006)

5

4

3

2

1

}

SKIP to 4

live or stay part of the time with
another relative?

3. During 2006, did you/

4

3

2

1

2. Did you/
live anywhere else in 2006?

Same as

)

Name’s location

—

ZIP Code

Apt/Unit #

SKIP
to 2f

DK
REF
15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

DK
REF

}

Name’s location

ZIP Code

SKIP
to 3e

2

1

DK
REF

3b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

Same as

State

4

3

2

1

2d. What are the names of any
other people who lived with
you/him/her at that address?

DK
REF

House/Apartment/Mobile home
Condo/Townhouse
Other – Specify

2

1

DK
REF

3d. What is the name of the
relative you/he/she stayed
with?

House/Apartment/Mobile home/
Condo/Townhouse
College dorm/Residence hall
Sorority/Fraternity house
1
DK
Military barracks
2
REF
Nursing home
A 24-hour skilled nursing care unit
within an assisted living facility
Independent or assisted
2e. What are the names of
living facility
SKIP
neighbors who lived nearby?
to
Correctional facility
2f
Group home
Emergency shelter
Residential school for
people with disabilities
1
DK
Psychiatric facility
2
REF
Other – Specify

2c. Is that place a house or
apartment or another type
of place like those shown
on the card I gave you?

3a. What is the address of that place? 3c. Is that place a house or
apartment or another type
Apt/Unit #
Number and street
of place like those shown
on the card I gave you?
City

2

1

2b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

(

State

City

Number and street

2a. What is the address and phone
number of that place?

Section C – PERSON QUESTIONS – Continued

Yes

2

No

3

DK

4

REF

TO
Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
How often stayed at that place? Mark (X) all that apply.
3
Most of the time
4
Half of the time – At that place on April 1, 2006?
5
No
Yes 6
7
Less than half the time
8
Certain days of the week
M
Tu
W
Th
F
Sa
Su
9
Daytime only, didn’t spend nights
Notes

FROM

3e. During 2006, when did you/he/she
live or stay at that place?

1

2g. (Ask or verify) Were you/Was he/she
there on Saturday, April 1, 2006?

Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
How often stayed at that place? Mark (X) all that apply.
3
Most of the time
4
Half of the time
5
Less than half the time
Certain days of the week
6
M
Tu
W
Th
F
Sa
Su
7
Daytime only, didn’t spend nights
Notes

Please provide as specific dates as possible.
FROM
TO

2f. During 2006, when did you/he/she
live or stay at that place?

5

}

Yes – Go to 4a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . . .

attend college?

SKIP to 5

}

Yes – Go to 5a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . . .

FORM DD-1301 (5-11-2006)

5

4

3

2

1

SKIP to 6

away because of military
service?

5. During 2006, were you/was

5

4

3

2

1

4. During 2006, did you/

ZIP Code

Apt/Unit #

SKIP
to 4g

DK
REF

Name’s location

ZIP Code

Apt/Unit #

SKIP
to 5f

2

1

DK
REF

5b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

Same as

State

City

Number and street

5a. What was the address where
you/he/she stayed?

2

1

4c. What are the landmarks or cross
streets closest to that place?

Name’s location
Same as
If more than one address – Record in notes

State

City

Number and street

4b. What was the address where you/
he/she stayed while attending
college?

4a. What college or university did
you/he/she attend?

Section C – PERSON QUESTIONS – Continued

}

No, not college housing
DK
REF

Yes
No
SKIP to 4g
3
DK/REF
4
No, sorority/fraternity house
No, other college housing – Specify
2

Yes, dorm or residence hall – Ask: Is
that place owned, leased or
managed by the college or
university?

7

6

5

4

3

2

1

Military barracks
SKIP to 5f
Ship . . . . .
Other on-base housing
Off-base housing
Other non-military housing
DK
REF

}

5c. At what type of place did
you/he/she stay – a military
barracks, a ship, other
on-base housing, off-base
housing, or other
non-military housing?

9

8

7

6

5

1

4d. Is that place a dormitory
or residence hall?

DK
REF

Situation: What semesters or terms was he/she
there? – Mark (X) all that apply.
1
Spring semester 2006
2
Summer semester 2006
3
Fall semester 2006
4
Certain days of the week
Tu
W
Th
F
Sa
M
Su
5
Daytime only, didn’t spend nights

4g. During 2006, when did you/he/she
live or stay at that place?
FROM
TO

DK
REF

FROM

TO

5f. During 2006, when did you/he/she
live or stay at that place?

Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
1
DK
How often stayed at that place? Mark (X) all that apply.
2
REF
3
Most of the time
4
Half of the time – At that place on April 1, 2006?
5e. What are the names of
5
No
Yes 6
neighbors who lived nearby?
7
Less than half the time
8
Certain days of the week
M
Tu
W
Th
F
Sa
Su
9
Daytime only, didn’t spend nights
Notes
1
DK
2
REF

5d. What are the names of any
other people who lived with
you/him/her at that address?

2

1

4f. What are the names of
neighbors who lived nearby? Notes

2

1

4e. What are the names of any
other people who lived with
you/him/her at that address?

6

Yes – Go to 6a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . .

Yes – Go to 7a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . .

FORM DD-1301 (5-11-2006)

5

4

3

2

1

}

SKIP to 7

}

SKIP to 8

have a seasonal or second
home?

7. During 2006, Did you/

5

4

3

2

1

have a job that involved living
or staying someplace else
(other than the military
service you just mentioned)?

6. During 2006, did you/

Same as

Name’s location

Short hotel stays only – SKIP to 7

ZIP Code

SKIP
to 6f

DK
REF

Name’s location

ZIP Code

Apt/Unit #

SKIP
to 7f

2

1

DK
REF

7b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

Same as

State

City

Number and street

7a. What was the address of that
place?

2

1

6b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

2

1

State

City

DK
REF

}

House/Apartment/Mobile home/
Condo/Townhouse
Hotel/Motel – Ask: Does he/she
have a residence there?
Yes . . . . . . . . . . . . . .
3
No . . . . . . . . . . . . . .
4
DK/REF . . . . . . . . . . .
5
Other – Specify
SKIP
to 6f

4

3

2

1

DK
REF

House/Apartment/Mobile home/
Condo/Townhouse
Other – Specify
SKIP
to 7f

7c. Is that place a house or
apartment or another type
of place like those shown
on the card I gave you?

8

7

6

2

1

6a. What was the address where you/ 6c. Is that place a house or
he/she stayed while working?
apartment, a hotel or
motel, or another type of
Number and street
Apt/Unit #
place?

Section C – PERSON QUESTIONS – Continued
FROM

TO

6f. During 2006, when did you/he/she
live or stay at that place?

DK
REF

FROM

TO

7f. During 2006, when did you/he/she
live or stay at that place?

Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
1
DK
How often stayed at that place? Mark (X) all that apply.
2
REF
3
Most of the time
7e. What are the names of
4
Half of the time – At that place on April 1, 2006?
neighbors who lived nearby?
5
No
Yes 6
7
Less than half the time
8
Certain days of the week
M
Tu
W
Th
F
Sa
Su
9
Didn’t stay there in 2006
1
DK
Notes
2
REF

7d. What are the names of any
other people who lived with
you/him/her at that address?

2

1

Notes

Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
1
DK
How often stayed at that place? Mark (X) all that apply.
REF
2
3
Most of the time
Half of the time – At that place on April 1, 2006?
4
Yes 6
5
No
7
Less than half the time
6e. What are the names of
Certain days of the week
neighbors who lived nearby? 8
M
Tu
W
Th
F
Sa
Su
9
Daytime only, didn’t spend nights

6d. What are the names of any
other people who lived with
you/him/her at that address?

7

Yes – Go to 8a
Yes, address already recorded
earlier for this person
No . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . .
REF . . . . . . . . . . . . . . .

}

SKIP to 9

FORM DD-1301 (5-11-2006)

5

4

3

2

1

Name’s location

ZIP Code

Apt/Unit #

SKIP
to 8f

DK
REF

9a. What is the name and address
of that place?

2

1

8b. What are the landmarks or cross
streets closest to that place?

If more than one address – Record in notes

Same as

State

City

Number and street

8a. What is the address of that
place?

DK
REF

House/Apartment/Mobile home/
Condo/Townhouse
Other – Specify
SKIP
to 8f

9c. What type of place was it?

4

3

2

1

8c. Is that place a house or
apartment or another type
of place like those shown
on the card I gave you?

}

College Housing
Name
Dormitory or residence hall
1
Sorority/Fraternity house
2
Apt/Unit #
did not live there, did you/he/she Number and street
Military Housing
spend even one night in any of
Military barracks
3
City
those types of places around
Military ship
4
April 1st ?
Other group facilities
ZIP Code
State
Yes – Go to 9a
Nursing home
5
Yes, address already recorded
A 24-hour skilled nursing care unit
6
earlier for this person
SKIP
within an assisted living facility
Name’s location
to 9c
No . . . . . . . . . . . . . . . .
SKIP to 10
Same as
Independent or assisted living facility
7
DK . . . . . . . . . . . . . . . .
9b. What are the landmarks or cross 8 Correctional facility
REF . . . . . . . . . . . . . . .
streets closest to that place?
Group home
9
Emergency shelter
10
11
Residential school for people with
disabilities
Psychiatric facility
12
1
DK
2
REF

9. Please look at the card again.
Even if you/

5

4

3

2

1

stayed often?

8. During 2006, was there any
other place you/

Section C – PERSON QUESTIONS – Continued
FROM

TO

8f. During 2006, when did you/he/she
live or stay at that place?

22

21

20

19

18

17

16

15

14

13

2

1

DK
REF

Residential treatment center
Hospital with patients who have no
usual home elsewhere
In-patient hospice facility
Transitional shelter for people
experiencing homelessness
Living quarters for victims of natural
disasters
Religious group quarters
Workers’ group living quarters and Job
Corps Centers
Other – Specify

DK
REF

Yes
No
DK
REF
Notes

4

3

2

1

9e. (Ask or verify) Were you/was he/she
there on Saturday, April 1, 2006?

Please provide as specific dates as possible.
FROM
TO

9d. During 2006, when did you/he/she
live or stay at that place?

Notes

Situation: Did he/she move or go back and forth between
2 or more places?
1
Moved 2
Back and forth
1
DK
How often stayed at that place? Mark (X) all that apply.
2
REF
3
Most of the time
Half of the time – At that place on April 1, 2006?
4
Yes 6
5
No
7
Less than half the time
8e. What are the names of
Certain days of the week
neighbors who lived nearby? 8
M
Tu
W
Th
F
Sa
Su
9
Daytime only, didn’t spend nights

8d. What are the names of any
other people who lived with
you/him/her at that address?

8

Yes – SKIP to 13a
No – Record other addresses in NOTES

Just to confirm, you/

1 only – Go to 11
2 or more – SKIP to 12a

DO NOT ASK
How many addresses did

DK
REF

3

DK
REF

Someplace else – Specify

4

Go to next

No
DK
REF

2
3

Yes – What is it?

1

section
Respondent is
Respondent’s name is on front cover of form
Respondent lives at address on front cover of form, but his/her name is not on cover
Relative/Caregiver
Neighbor
Landlord (superintendent, rental office, owner, etc., for places with fewer than 10 units)
Other – Specify

FORM DD-1301 (5-11-2006)

7

6

5

4

3

2

1

4

3

2

1

11

10

9

8

1

DK
REF

DK
REF

D D

Y Y Y Y

2

1

Same as previous – Go to next section

3

2

1

State

City

Number and street

ZIP Code

Apt/Unit #

(

Before or on April 1, 2006
After April 1, 2006

14b. (Ask or Verify) What is your name? 14c. What is your address and phone number?

2

1

M M

)

—

13d. If respondent tells you (name) was born in
2006, find out if he/she was born before, on,
or after April 1, 2006.

Moved
Was that before, after, or on April 1, 2006?
2
Before 3
After 4
On
Was that before, after, or on
5
Before 6
After 7
On
Back and forth
Other – Specify

12c. Did you/he/she move from one address to the other,
or did you/he/she go back and forth between places?

13c. What is your/his/her date of birth?

12b. Around
where did you/he/she live and sleep most of
the time?

NOTES

lived or stayed at only one address during 2006. Is that correct?

have in 2006?

13b. Is there any other name that people
know you/him/her by?

14a. DO NOT ASK
Which one of the following best describes the respondent?

13a. Can you make sure I have your/this
person’s full name, including middle
initial, and that it is spelled correctly?
Read and spell name to respondent.

4

Someplace else – Specify

2

1

live and sleep most of the time?

12a. Around April 1, 2006, where did you/

2

1

11.

2

1

10.

Section C – PERSON QUESTIONS – Continued

?

9

lived
’s permanent address was
stayed at
was the landlord of

4

5

6

7

FINAL PERSON-LEVEL OUTCOME CODE

FORM DD-1301 (5-11-2006)

1

Complete
2

Complete (valid skip)

3

months at

, but usually slept at

and

Complete (fictitious)

4

Partial

5

Refusal

, but lived someplace else.

⎫
⎬ Please describe situation in Notes section below.
had another living situation. ⎭
had no usual home.

NOTES – Use this space to record detailed notes about this person’s living situation.

9

8

stayed at 2 or more places and spent most of the time at

3

on

/

/2006.

6

Other

because of illness (his/her own or someone else’s), but his/her usual residence was

to

moved from

2

months at

during 2006.

lived only at

1

SUMMARY AND NOTES
DO NOT READ THIS TO RESPONDENT

Section C – PERSON QUESTIONS – Continued To be completed by the interviewer

Crew Leader initials

10

Only PI household lived at
on April 1, 2006

Only Census household lived at
on April 1, 2006

Neither household listed above lived at
on April 1, 2006

Both PI and Census households lived at
in separate housing units (i.e., different living spaces with separate entrances) on April 1, 2006

Both PI and Census households lived at
and shared a housing unit (i.e., shared living space) on April 1, 2006
Other – Explain in NOTES section

3

4

5

6

7

FORM DD-1301 (5-11-2006)

8

2

PI household is unknown
Census household is unknown

NOTES

DO NOT READ THIS TO RESPONDENT
Two earlier interviews have reported two different households living at this address. Based on what you
have learned, what do you think the true situation is? Mark (X) as many boxes as you think apply AND
write detailed notes in the NOTES section.

1

Census Household

To be completed by the interviewer

PI Household

Section D – APRIL 1 OCCUPANCY

11

Month

Day

(a)

Date

Year

(b)

Time

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

a.m.
p.m.

(c)

Respondent name, address, and telephone number
(d)

Interviewer
code

FORM DD-1301 (5-11-2006)

Crew Leader
signature

Interviewer
signature

CL code

I code

Personal visit
Telephone
Personal visit
Telephone
Personal visit
Telephone
Personal visit
Telephone
Personal visit
Telephone
Personal visit
Telephone

1

1

1

1

1

Day

D D

M M

D D

M M
Month

Day

2

2

2

2

2

2

201 Complete
203 Partial
216 No one home
218 Refusal
219 Other

3

2

1

3

2

1

3

2

1

3

2

1

3

2

1

3

2

1

3

2

1

Complete
Partial
No one home

Complete
Partial
No one home

Complete
Partial
No one home

Complete
Partial
No one home

Complete
Partial
No one home

Complete
Partial
No one home

Complete
Partial
No one home

6

5

4

6

5

4

6

5

4

6

5

4

6

5

4

6

5

4

6

5

4

6

5

4

6

5

4

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Refusal
Callback
Other

Non-proxy (single respondent)
Proxy (single respondent)
Multiple respondents

CL/QI
initials

3

2

1

Respondent classification

Non-proxy
Proxy

Non-proxy
Proxy

Non-proxy
Proxy

Non-proxy
Proxy

Non-proxy
Proxy

Non-proxy
Proxy

Final outcome

4

3

4

3

4

3

4

3

4

3

4

3

Non-proxy
Proxy

3

2

1

3

Complete
Partial
No one home

1

4

3

4

Non-proxy
Proxy

Personal visit
Telephone

2

2

3

2

1

1

Personal visit
Telephone

4

1

2

Complete
Partial
No one home

Non-proxy
Proxy

Personal visit
Telephone

1

Visit
outcome
(f)

3

Attempt type
(e)

Month

CERTIFICATION
I certify that the entries I have made on this questionnaire are true and correct to the best of my knowledge.

9

8

7

6

5

4

3

2

1

Line
No.

RECORD OF VISITS

3

2

1

Selected
Not selected
Not eligible

7

6

5

4

Pass
Fail/N
Fail/D
Noninterview/Unresolved

QA USE ONLY

(g)

Comments

12