It's modified from an Australian Bureau of Statistics format circulated 2 or 3 years ago, with a couple of additional questions added: one for the visitor's origin (local or overseas) as this is of interest to local tourism bodies. The other is an option for follow-up contact.
Barrie is happy for other EVRNN members, particularly those from small regional museums who may not be currently collecting any visitor data, to modify this template for their own uses.
Any comments or queries? Please add to the comments section of this blog post.