World Health Survey Template Page 18
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575000. Mortality
Time Begin: __ __ : __ __
..
Section A - Birth History (Women only)
These questions are to be asked of all women respondents of reproductive (18-49) yrs age.
CHECK SEX: Female CONTINUE………………………Male GO TO SECTION 5100
CHECK AGE: Aged between 18 – 49 GO TO 5000…….Aged 50 or over GO TO SECTION 5100
.
Q5000 Now, I would like to ask you about all the births you have had during
1. Yes
5. No
If No: Go to
your life. Have you ever given birth?
Q5100
a. Child 1
b. Child 2
c. Child 3
d. Child 4
e. Child 5
f. Child 6
g. Child 7
h. Child 8
Q5001 Name
Q5002 Month / Year of Birth (eg. Feb –02)
AFTER RECORDING THE
INFORMATION ABOUT ALL BIRTHS,
UNDERLINE THE LAST BIRTH AND
THE NAME OF THE CHILD
Q5003 Sex
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
Q5004 Whether alive
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If No, Go to
Q5007
1
5
1
5
1
5
1
5
1
5
1
5
1
5
1
5
a) Current age in Years:
YY:
YY:
YY:
YY:
YY:
YY:
YY:
YY:
Q5005
Use Years for children older than 5 years and
adults
b) Current age in Months:
MM:
MM:
MM:
MM:
MM:
MM:
MM:
MM:
Use Months for children between 2 months
and 5 years of age
c) Current age in Days:
DD:
DD:
DD:
DD:
DD:
DD:
DD:
DD:
Use Days for infants below 2 months of age
WORLD HEALTH SURVEY - MORTALITY
5.1
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