World Health Survey Template Page 20
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57a. Child 1
b. Child 2
c. Child 3
d. Child 4
e. Child 5
f. Child 6
g. Child 7
h. Child 8
Q5016 If yes, was it (1) dry, (2) productive, (3) with
blood, (4) or unknown ?
Q5017 Did s/he have fast breathing?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Q5018 Did s/he have in drawing of the chest while
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
breathing?
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Q5019 Did s/he have diarrhea?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Q5020 Was there visible blood in the stools?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Complete columns for all children.
Section B: Assessment of Adult Mortality
..
B 1 : Sibling Survivorship To be asked of primary respondent. See explanatory notes in training manual.
.
Q5100 Please write line number from Household roster, using numbers
between 0400 and 0413. Line number
_____________________
Q5101 How many children did your mother give birth to, including you ? No. of
births to natural mother:
_____________________
Q5102 How many births did your mother have before you were born? No. of
preceding births:
_____________________
Q5103 How many births did your mother have after you were born? No. of
succeeding births:
_____________________
.
Interviewer: Include all siblings (e. g. step siblings, born to the same mother). Check sum of Q5102 and Q5103 and ensure equality with (Q5101 minus 1).
INTERVIEWER: IN THE FOLLOWING QUESTION MARK RESPONDENT BY PUTTING IN Q5107 THE VALUE OF ZERO
Now I would like you to list for me details of all your siblings form oldest to youngest (including yourself)
Complete columns for all siblings.
WORLD HEALTH SURVEY - MORTALITY
5.3
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