Page 245 - QAP Manual 2020

I-6 How many surveyors conducted the survey with this person? (This includes ‘shadow
surveyors’ or other silent observers. This does not include translators.)

□ 1. One
□ 2. Two
□ 3. Three
□ 4. Four or more

I-7 Date of face-to-face survey: (mm/dd/yyyy) _____/_____/__________
I-8 How was this survey administered?

Check ALL THAT APPLY.

1. Paper
2. Wi-fi connected device
3. Other:___________________________________________

I-9 If the person responded to all or part of the survey, how did he/she communicate with the
surveyor?
□ 1. Person answered independently

□ 2. Person answered with some verbal assistance
□ 3. Person answered using alternate/picture response format

• END OF IN-PERSON SURVEY •

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