Houshold #
DataFax Study Number
DataFax Plate Number
Visit Code
Team ID
1.Routine/Extended Quest.
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
5. Total # in household
6. Total eligible
7. Total given PTID
8. Main source of water
8m. Other, specify text