Surveypoint

Q01

District

Q02

Block

Q03

Village/UFS

Q04

Structure Type.

Residential

Non-residential

Q05

Structure No

Q06

Household No.

Q07

Unique Reference ID

Q08

Name of Household Head

Q09

Caste

Brahmin

Rajput/Thakur

Bhumihar

Kayasth/ Srivastava/Lala

Dalit

Chamar

Dusadh/Paswan

Musahar

Pasi

Dhobi

Bhuiya

Chaupal

Bantar

Rajwar

Yadav

Vaishya/Bania

Kurmi

Shah

Muslim

Other Caste Or Tribe (Specify)

Q10

Result of visit

Complete

Refused

HH Migrated

HH temporarily away

No female respondent of age present to respond

A01

Are there any women/girls in this household between the ages of 12 and 60 years?

Yes

No

A01A

Was there any other woman/girl who died during pregnancy, at the time of delivery or within 45 days of giving birth?

Yes

No

A02

Please tell me the name of each woman/girl in the household between the ages of 12 and 60 years and whether she was ever married.

A02_1

Name of woman/girl

A02_2

Age (in completed years)

A02_3

Whether ever married?

Yes

No

A02_4

whether woman alive now?

Yes

No

A02_5

Reason of death

A02_6

who gave woman information

A02_7

Identity of the respondent

Self

Other

A02_8

In the time since [MONTH]* last year, did [WOMAN] gave birth to a child (alive or dead) or had an abortion or miscarriage?

Gave birth to alive child

Gave birth to dead child

Had abortion

Had miscarriage

Not Applicable

A03

Name of woman who gave birth to a child (alive or dead) or had abortion or had miscarriage since [MONTH] last year, and line number of event

A03A

Name

A03B

Line Number

A04

For every birth alive or dead

A04A

Did the child/expulsed fetus cry at birth?

Yes

No

A05

Was the child/expulsed fetus breathing after birth?

Yes

No

A06

Did the child/expulsed fetus make any movement after birth?

Yes

No

A07A

If the response is YES to any of A04-A06, interpretation is that the child was born ALIVE

Child born ALIVE

Child born DEAD

Further information needed

A07B

If response is NO to ALL three A04-A06, interpretation is that the child was born DEAD

Child born ALIVE

Child born DEAD

Further information needed

A08

Did the doctor/nurse/dai/other health provider tell you that the child was alive or dead?

ALIVE

DEAD

Did not tell or Don’t know

A09

If response to A08 is 3, ask the respondent if the child was born alive or dead

ALIVE

DEAD

A10

When was the child born?

A11

If child was born alive, is the child alive now?

Yes

No

A12

What is the name of the child?

A13

What is the gender of the child?

Female

Male

Don’t know

A14

If answer to A11 is NO, for how long after birth was the child alive?

A15

What was the gender of the child?

Female

Male

Don’t know

A16

When did this abortion, miscarriage, or dead birth take place?

A17

If child was born dead or if there was an abortion or miscarriage, interviewer assess the completed gestational age in months using local event calendar.

A18

What was the gender of the child?

Female

Male

Don’t know

Household Listing Template 1 -Form Fill

District

Block

Village/UFS

Structure Type.

Structure No

Household No.

Unique Reference ID

Name of Household Head

Caste

Result of visit

Are there any women/girls in this household between the ages of 12 and 60 years?

Was there any other woman/girl who died during pregnancy, at the time of delivery or within 45 days of giving birth?

Please tell me the name of each woman/girl in the household between the ages of 12 and 60 years and whether she was ever married. var statement=document.write(localStorage.getItem('total'));

Name of woman/girl

Age (in completed years)

Whether ever married?

whether woman alive now?

Reason of death

who gave woman information

Identity of the respondent

In the time since [MONTH]* last year, did [WOMAN] gave birth to a child (alive or dead) or had an abortion or miscarriage?

Name of woman who gave birth to a child (alive or dead) or had abortion or had miscarriage since [MONTH] last year, and line number of event var statement=document.write(localStorage.getItem('total'));

Name

Line Number

For every birth alive or dead var statement=document.write(localStorage.getItem('total'));

Did the child/expulsed fetus cry at birth?

Was the child/expulsed fetus breathing after birth?

Did the child/expulsed fetus make any movement after birth?

If the response is YES to any of A04-A06, interpretation is that the child was born ALIVE

If response is NO to ALL three A04-A06, interpretation is that the child was born DEAD

Did the doctor/nurse/dai/other health provider tell you that the child was alive or dead?

If response to A08 is 3, ask the respondent if the child was born alive or dead

When was the child born?

If child was born alive, is the child alive now?

What is the name of the child?

What is the gender of the child?

If answer to A11 is NO, for how long after birth was the child alive?

What was the gender of the child?

When did this abortion, miscarriage, or dead birth take place?

If child was born dead or if there was an abortion or miscarriage, interviewer assess the completed gestational age in months using local event calendar.

What was the gender of the child?

Please tell me the name of each woman/girl in the household between the ages of 12 and 60 years and whether she was ever married.

Name of woman who gave birth to a child (alive or dead) or had abortion or had miscarriage since [MONTH] last year, and line number of event

For every birth alive or dead