时间：______年_____月_____日______时_____分_____至_____时_____分
　　地点：_________________________________________________________
　　调查人：_______________________________________________________
　　记录人：_______________________________________________________
　　被调查人：________________________(姓名、性别、住址等基本情况)
　　________________________________________________________________________________________________________
　　________________________________________________________________________________________________________
　　________________________________________________________________________________________________________
　　_______________________________________________________________________________________