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）
    ________________________________________________________________________________________________________
    ________________________________________________________________________________________________________
    ________________________________________________________________________________________________________
    ________________________________________________________________________________________________________