Universal ID
Houshold #
Household member
DataFax Study Number
DataFax Plate Number
Visit Code
Interview Date(mm)
Interview Date(dd)
Interview Date(yy)
Interview Date
Staff ID
Team ID
1st Attempt: Date(mm)
1st Attempt: Date(dd)
1st Attempt: Date(yy)
1st Attempt: Date
1st attempt: time
1st Attempt: Staff ID
1st Attempt Result Code
2nd Attempt: Date(mm)
2nd Attempt: Date(dd)
2nd Attempt: Date(yy)
2nd Attempt: Date
2nd attempt: time
2nd Attemp Staff ID
2nd Attempt Result Code
3rd Attempt: Date(mm)
3rd Attempt: Date(dd)
3rd Attempt: Date(yy)
3rd Attempt: Date
3rd attempt: time
3rd Attempt Staff ID
3rd Attempt Result Code
Ppt refused venipuncture
Ppt is female-no data
7. Circumcision status
8. Circumcision status
9. When circumcised?
9.Date circumcised-REF
10.Med services location?
11. Name of site
11. Where circumcised-DK
10.Day of circum-HIV test
11.Result on surgery day
14. Completed RMI?
Final Comments