Cluster number
Household number
Line number of individual questionnaire
Region of residence
District
Type of place of residence
Type of questionnaire
Day of interview
Month of interview
Year of interview
Interviewer number
Result of individual interview
Total number of visits
Language of questionnaire
Language of interview
Language of respondent
Translator used
Supervisor number
Field editor number
Data entry clerk
Date of interview (CMC)
Date of interview Century Day Code (CDC)
Sample weight (6 decimals)
Line number
Sex
Age of respondent
Relationship to deceased
Highest education passed
Present when first fell ill
Present when taken to hospital
Present when died
Main respondent
Start of interview (hour)
Start of interview (minutes)
Day of death
Month of death
Year of death
Day of birth
Month of birth
Year of birth
Age at death
Was usual member or was here temporarily
Ever attended school
Highest class completed
Working for wages or salary when she died
Occupation
Mother tongue
Marital status
Age of husband at the time of her death
Husband ever attended school
Husband highest class completed
Husband's occupation
Death related to complications of pregnancy or childbirth
VA eligibility
Date of birth (CMC)
Date flag for Q204BC
Date of death (CMC)
Date flag for Q204C
Date of death Century Day Code (CDC)
Imputed day of death
Ever given birth
Live children she had
Living children still alive
Boys still alive
Girls still alive
Any abortion,miscarriage,stillbirth
Number of abortions
Number of stillbirths
Number of miscarriages
Number of pregnancy losses
Ever had a caesarean section operation
Number of caesarean sections
Had a pregnancy during last 3 years of her life
How long before her death the last pregnancy end (units)
How long before her death the last pregnancy end (number)
Outcome of last pregnancy
Last born still alive
Age of child
How old was the child when died (units)
How old was the child when died (number)
How long after last birth/delivery/miscarriage/abortion did she die (units)
How long after last birth/delivery/miscarriage/abortion did she die (number)
Was pregnant when she died
Months of pregnant when she died
Died before labour pains/before birth or during abortion or miscarriage
Died within 40 days of delivery, abortion or miscarriage
Place of death
Hospital name
Anyone at the hospital/clinic tell you why she died
Reason given by the hospital/clinic
Main cause of her death
High blood pressure
Sugar/diabetes
Epilepsy
TB
Hearth disease
Blood disease
Asthma
Severe anemia
Jaundice
Hepatitis
Hiv/Aids
Cancer
Other disease
Ever hospitalized
Reason of last hospitalization
Had any operation before she died
Operation type
Had fever
Fever duration (units)
Fever duration (number)
Was the fever continuous or on and off
Was she breathless doing light work
Was she breathless when was lying down
Had rapid heart beat (palpitations)
Had wheezing
Had cough
Duration of cough (units)
Duration of cough (number)
Cough produce sputum
Cough blood
Had chest pain
Duration of chest pain (units)
Duration of chest pain (number)
Chest pain severity
Chest pain started suddenly or gradually
Pain at or near the center of the chest
Had diarrhea (loose motions)
Times had loose motions
Had blood in the stools
Had poor appetite or loss of appetite
Duration of appetite lost (units)
Duration of appetite lost (number)
Had difficulty in swallowing
Had pain in swallowing
Had headache
Duration of headache (units)
Duration of headache (number)
Had blood in urine
Duration passed blood in urine (units)
Duration passed blood in urine (number)
Had pain while urinating
Duration of pain when urinating (units)
Duration of pain when urinating (number)
Unabled to pass urine
Urinated many times in a day
Had any type of pain anywhere in the body
Had abdominal pain
Duration of abdominal pain (units)
Duration of abdominal pain (number)
Abdominal pain severity
Abdominal pain location
Had abdominal distension
Duration of abdomen distended (units)
Duration of abdomen distended (number)
Distension come rapidly or slowly
Had mass in her abdomen
Had vomiting
Duration of vomiting (units)
Duration of vomiting (number)
Vomited blood
Became mentally confused
Lost consciousness
Duration of remained unconscious (units)
Duration of remained unconscious (number)
Became unconscious suddenly or gradually
Became paralyze
Duration of paralysis (units)
Duration of paralysis (number)
Paralysis on one side or both sides of body
Had stiffness in her whole body
Had neck pain
Had convulsions
Duration of convulsions (units)
Duration of convulsions (number)
Times a day had fits
Had ulcer or swelling/lump in the breast
Had vaginal bleeding
Duration of bleeding (units)
Duration of bleeding (number)
Bleeding persist until she died
Had abnormal vaginal discharge
Had swelling on her ankles
Had swelling or puffiness on her hands
Duration of had swelling on her hands and/or face (units)
Duration of had swelling on her hands and/or face (number)
Lost weight
Had sores in her mouth
Had skin disease
Looked pale
Had jaundice
Were eyes yellowish
Duration of had yellow eyes (units)
Duration of had yellow eyes (number)
Had blurred vision
Had difficulty in opening her mouth
Had difficulty in passing stools or constipation
Felt dizzy
Had general weakness or fatigue
Duration of had weakness (units)
Duration of had weakness (number)
Had light flashes before her eyes closed at night
Complained of double vision
Had any ulcers on her body
Other symptoms
People though had an evil eye or shadow
Faith healer called or amulets given
Spiritual healing details
How long before she died the fever start (units)
How long before she died the fever start (number)
When did the fever start
How long before/after childbirth, miscarriage or abortion the fever start (units)
How long before/after childbirth, miscarriage or abortion the fever start (number)
How long did it last (units)
How long did it last (number)
Fever high
Fever with chills
Prescribed antimalarial tablets for fever and chills
Colour changed during last illness
What was the color
Vomiting during last illness
How long before she died the vomiting start (units)
How long before she died the vomiting start (number)
Had severe body aches during fever
Ever vomited pure blood
Had any difficulty with urination
Unable to pass urine
Too frequent urination
Painful urination
Back pain with fever
Blood in urine
Other urination difficulty
Had convulsion with fever
How long before she died the cough start (units)
How long before she died the cough start (number)
Sputum when coughed
Blood in it
How much blood did the sputum contain
Lost weight during illness
Was she short of breath
How long was short of breath (units)
How long was short of breath (number)
Kind of pain
Pain location
How long before she died did the pain start (units)
How long before she died did the pain start (number)
How long did the pain last (units)
How long did the pain last (number)
Had pain in upper abdomen
When did the pain start
Pain in abdomen
Any pain in the lower abdomen
Pain was accompanied by fever
Fever severity
Pain was accompanied by vomiting
Had a history of convulsions
Had convulsions in her last illness
How long before death had convulsions (units)
How long before death had convulsions (number)
Had high blood pressure
Had severe headache
Had change in her vision
State of consciousness
Had history of convulsion or epilepsy
Times had convulsions
When did convulsions start
Duration of convulsions
Convulsions restricted to one part or the whole body
Swelling in abdomen
Swelling in face
Swelling in legs and feet
Swelling in whole body
How long before she died she have this swelling (units)
How long before she died she have this swelling (number)
When did the swelling start in relation to delivery of the baby or abortion or miscarriage (units)
When did the swelling start in relation to delivery of the baby or abortion or miscarriage (number)
Had yellowness of skin of face
Had any urinary problem
Other urinary problem
Did see anyone for antenatal care
Who did she see for antenatal care
Did she go because she had a problem or went for a check-up
What was the problem she went for
Month of pregnant at first health provider visit
Times saw a health provider
Referred to a specialist
Reason didn't sought care for ANC
During last pregnancy had an injection to prevent tetanus
During last pregnancy blood pressure was measured
Blood pressure
Prescribed medicines for blood pressure
Using family planning method before became pregnant
Wanted pregnancy
Tried to end the pregnancy
Action take to end the pregnancy
Went for help to end the pregnancy
Had a foul-smelling discharge after miscarriage/abortion
Had fever after miscarriage/abortion
Had abdominal distension after miscarriage/abortion
Had bleeding from vagina
Bleeding wet her clothes
Bleeding wet the bed
Was much blood as to wet the floor
Pain while bleeding
Bleeding contains clots
Examined internally during last pregnancy
Vaginal examination cause any bleeding
Bleeding persisted until she died
Bleeding started before or after the birth/delivery
Pain started before the labor pains
Place of delivery
Assistance at delivery
Any instrument used to assist delivery
Death reason confirmation
How was the delivery
Vagina was cut to make room
Tear in vagina after last delivery
Birth attendant examined vagina using hands or instruments
Water bag broken before the labor pains
Duration of labor
Given any drugs before or during labor
Drugs given
Had a lot of bleeding before delivery
Died before or after baby was born
Difficulty delivering the baby
Part of the baby came out first
Placenta came out
How long after the baby came the placenta came out (units)
How long after the baby came the placenta came out (number)
All the placenta came out
Had a lot of bleeding after delivery
Had a foul-smelling discharge after baby was born
Had a pain in legs after baby was born
Had fever after baby was born
How long after delivery the fever started (units)
How long after delivery the fever started (number)
Had any fits or rigors with the fever
Fits stopped after the baby was born
Had fever when she died
Color of eyes yellow after the baby was born
Received a blood transfusion
When got blood transfusion
Had serious accident or injury
Type of accident or injury
How long before she died the accident/injury happened (units)
How long before she died the accident/injury happened (number)
Hurt intentionally or was an accident
Was trying to commit suicide
Was the injury the main cause of death or contributed to the death
How long after having symptoms a serious problem was recognized (units)
How long after having symptoms a serious problem was recognized (number)
How serious the family perceived this complication or problem to be
Family thought she could have died because of her problem
Sought treatment for last illness
Reasons didn't seek for treatment
Who was involved in decision that should not go for treatment
From whom received treatment
Place of treatment
Who was involved in decision that should go for treatment
How long after the problem was recognized it was decided to go for treatment (units)
How long after the problem was recognized it was decided to go for treatment (number)
Tried to go immediately after decided to go for treatment
Reasons didn't go immediately
Time between first recognition of the seriousness of symptoms and taking to hospital (units)
Time between first recognition of the seriousness of symptoms and taking to hospital (number)
First place of treatment
Who went with her to the first place for treatment
Distance from home to health facility
How she went to the first place of treatment
Difficult to get transport to first place of treatment
Time to go to the first treatment place (units)
Time to go to the first treatment place (number)
Time waiting to be examined in the first hospital/clinic (units)
Time waiting to be examined in the first hospital/clinic (number)
Treatment: Injection in arm
Treatment: Injection in butt
Treatment: Drip
Treatment: Transfusion
Treatment: Operation
Treatment: Pills/Capsules
Treatment: Oxygen
Treatment: Other 1
Treatment: Other 2
Condition improved after treatment in first place
Time between she arrived in the hospital/clinic and the death (units)
Time between she arrived in the hospital/clinic and the death (number)
First hospital/clinic referred to other hospital
Referral place from first hospital/clinic
Time between she arrived in the hospital/clinic and was referred to the second hospital/clinic (units)
Time between she arrived in the hospital/clinic and was referred to the second hospital/clinic (number)
Reasons for referral to the second place
Went to the referred place
Reasons didn't go to the referred place
Went to anywhere else for treatment
Last place of treatment
Who went with her to the last place for treatment
How she went to the last place of treatment
Difficult to get transport for last place of treatment
Time waiting to be examined in the last hospital/clinic (units)
Time waiting to be examined in the last hospital/clinic (number)
Condition improved after treatment in last place
Time between she arrived in the last hospital/clinic and the death (units)
Time between she arrived in the last hospital/clinic and the death (number)
Last hospital/clinic referred to other hospital
Referral place from last hospital/clinic
Reasons for referral to another place
Cost of treatment
Funds source
Died in hospital
Time between she died and they removed the body from the hospital/clinic (units)
Time between she died and they removed the body from the hospital/clinic (number)
End of interview (hour)
End of interview (minutes)
Source of drinking water
Source of water for cooking/handwashing
Location of source for water
Time to water and back (minutes)
Water not available for at least a day
Do anything to water to make safe to drink
What do you usually do to make water safe to drink
Type of toilet facility
Share facility with other households
Number of households sharing toilet
Location of toilet facility
Type of cooking fuel
Location of cooking
Household has separate room used as kitchen
Number of rooms used for sleeping
Owns livestock, herds, farm animals, poultry
Cows/bulls
Other cattle (buffalo)
Horses/donkeys/mules
Goats
Sheep
Camels
Chickens/poultry
Electricity
Radio
Television
Non-mobile telephone
Refrigerator
Almirah/Cabinet
Chair
Room cooler
Airconditioner
Washing machine
Water pump
Bed
Clock
Sofa
Camera
Sewing machine
Computer
Internet connection
Watch
Mobile telephone
Bicycle
Motorcycle or scooter
Animal-drawn cart
Car or Truck
Tractor
Boat with a motor
Boat without motor
Rickshaw/chingchi
Main floor material
Main roof material
Main wall material
Reviewer's code
A ICD Code
B ICD Code
C ICD Code
D ICD Code
Was surgery performed within the last 4 weeks?
Was the deceased pregnant?
If Yes, than
Did the pregnancy contribute to the death?
Tentative underlying cause of death - Code
Final underlying cause of death - Code
Reviewer's decision on the category of death (see definition) Choose one:
Timing of death in relation to pregnancy, delivery or postpartum (choose one):
Delay in seeking treatment (address all three delays):FIRST DELAY
SECOND DELAY
THIRD DELAY