World Health Survey Template Page 21
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57.
If 2 or more births, continue here, starting
a. Sibling 1 b. Sibling 2
c. Sibling 3 d. Sibling 4
e. Sibling 5 f. Sibling 6
g. Sibling 7
h. Sibling 8
with eldest child
Q5104 Name
Q5105 Sex
F
M
F
M
F
M
F
M
F
M
F
M
F
M
F
M
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Q5106 Month/ Year of birth, e.g. Feb-02
Q5107 What is the age difference (in years) between
you and [NAME]?
Q5108 Is [NAME] still alive?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Q5109 How often are you in contact with [NAME] in
person, by phone, mail or other means of
communication?
1. Weekly
2. Monthly
3. Yearly
4. Every 2-3 years
5. Every 3 years or more
Q5110 If YES to 5108, how old is [NAME]?
Q5111 If NO to 5108, how old was [NAME] when
died?
Q5112 How many years ago did [NAME] die?
Q5113 Is [NAME] currently living / did [NAME]
before s/he died live in?
1. Private dwelling / house
2. Military establishment
3. Hospital
4. Nursing home
5. Other institution
8. DK
WORLD HEALTH SURVEY - MORTALITY
5.4
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