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Death Tool -Form Fill
Information
Q01
District Name
Q02
Block Name
Q03
Household ID
Q04
Date of visit
Q05
Focal deceased ID
Q06
Name of the deceased
Q07
Sex of the [deceased’s name]
Male
Female
Q08
Name of the respondent
Q09
Did respondent give consent for interview?
Yes
No
Q10
What is the relationship of the respondent with the deceased?
Mother
Father
Grand mother
Grand father
Son
Daughter
Daughter-In law
Spouse
Grand children
Other (specify)___________
Q11
Who else was present for this interview?
No one
Mother
Father
Grand mother
Other(specify)_____
Q12
In which month and year did [deceased’s name] die?
Q13
Age of the [deceased’s name] at the time of death (in completed years/months/days)
Q14
What was the marital status of the deceased?
Unmarried
Married
Separated
Divorced
Q15
What was the highest educational qualification attained by [deceased’s name]?
Never been to school
Class1-5
Class 6-7
Class 8-10
Class 11-12
College or more
Refused
Q16
Was [deceased’s name] employed/working at the time of death?
Yes
No
Q17
What was the occupation of [deceased’s name]?
Unemployed
Homemaker
Service/Salaried worker
Agricultural labour
Cultivator
Farmer other than cultivator
Business/self employed
Labour
Other (specify)__
Q18
Did [deceased’s name] have a life insurance cover?
Yes
No
Q19
Was the deceased receiving pension from any of these government schemes?
No
Atal Pension Yojana (APY)
National Pension scheme (NPS)
Indira Gandhi National Old Age Pension Scheme (IGNOAPS)
Varishtha Pension Bima Yojana (VPBY)
Pradhan Mantri Vaya Vandana Yojana (PMVVY)
Any other govt pension scheme
Retirement pension
Widow pension
Do not know
Refused to answer
Q20
Was the deceased a woman 15-49 years of age at the time of death?
Yes
No
Q21
Was [deceased’s name] pregnant at the time of death or had delivered a baby within 2 months before she died?
Not pregnant
Pregnant
Delivered a baby
Do not know
Q22
How long after the baby’s delivery did she die?
Q23
Where did [deceased’s name] gave birth?
Public facility
Private/NGO facility
Home
On route
Others (specify)
Q24
What was the cause of death of [deceased’s name]?
Old age
Birth trauma
Infection of the belly button
Spasm/convulsions
Breathing difficulty
Low birth weight
Preterm delivery
Blood loss during delivery
Delivery related
complications
Brain haemorrhage
Dengue
Diarrhoea
HIV/AIDS
Jaundice
Pneumonia/Fever
Tuberculosis
Asthma
Cancer
Kidney failure
Liver disease
Diabetes
Heart attack
High Blood pressure
Dog bite
Snake bite
Falls
Poisoning
Drowning
Burns
Road accident
Suicide
Violence
Homicide
Covid-19
Electrocution
Others (specify)
Do not know
Q25
Was a police case registered for this death?
Yes
No
Q26
Was [deceased’s NAME] admitted to a health facility for treatment of illness/injury just before his/her death?
Yes
No
Q27
In which type of health facility was the [deceased’s NAME] admitted in?
Public facility
Private facility
Other (specify)
Don’t know
Q28
Was [deceased’s NAME] discharged alive from this facility?
No, died at the facility
Yes, discharged alive
Q29
How many days after admission to the health facility did [deceased NAME] die?
Q30
Had [deceased NAME] recovered from the illness/injury at the time of discharge?
Not fully recovered
Yes, fully recovered
Do not know
Q31
What was the reason for discharge from the facility?
Doctor said nothing can be done
Lack of money
Wanted the deceased to die at home
Lack of transportation in case of death in the facility
Too many procedures in case of death at the facility
LAMA
Others (specify)
Don’t know
Q32
How many days after discharge from the health facility did [deceased NAME] die?
Q33
Where did the [deceased’s name] die?
MCH
DH/SDH/RH
CHC/PHC
UHC/UHP/UFWC
APHC/SHC
NGO hospital/clinic
Private hospital/clinic
RMP/quack
Home
On the route to hospital
Q34
How were the last rites done for the [DECEASED NAME]?
No last rites done
Buried at home
Dead body flown in water
Cremated at a crematorium
Cremated on the river bank
Buried at a graveyard
Buried in agricultural land
Buried in health facility premises
Don’t know
Other (specify)
Decline to respond
Q35
Was any document/slip required for cremation/burial?
Yes
No
Q36
What document/slip was required for cremation/burial of the [DECEASED NAME]?
Discharge slip
Deceased death claim receipt from the facility
Dead body carrying certificate
Death Certificate
Other (specify)
Q37
Did you receive any document after cremation/burial of the [DECEASED NAME]?
Yes
No
Q38
What docoument did you receive from the cremation/burial ground for the [DECEASED NAME]?
Receipt from cremation ground
Receipt from burial ground
Other (specify)
DEATHS IN PRIVATE FACILITY OR HOME
A01
Do you have the death certificate of [deceased’s name]?
No
Yes, shown
Yes, not shown
Don’t know
A01A
Can I take the picture of the death certificate of [DECEASED NAME]?
No, refused
Yes, picture taken
Picture not taken , (specify)
A02
Was the death of registered?
No
Yes
Applied but not received
Do not know
A03
How long after the death of [deceased’s name] did you obtain/apply for the death certificate?
A04
Where did you obtain/apply for the death certificate form for?
Did not go to any place
At the health facility
Village Panchayat office
Block development office
Sub divisional office
Nagar nigam/Nagar palika parishad/Nagar panchayat
Jan seva kendra
Other (specify)
Don’t know
A04A
How many times did you visit the concerned place to obtain/apply for the death certificate for [DECEASED’s NAME]?
A05
How much did you have to pay to get/apply the death certificate?
A05_1
Total cost incurred (Rs.)
A05_2
Money given to ASHA
A05_3
Money given to AWW
A05_4
Money given to ANM
A05_5
Money given to Data entry operator
A05_6
Money given to Jan seva Kendra
A05_7
Cannot say
A06
Did you contact ASHA or AWW or ANM or or Gram Pradhan/village Mukhiya/ ward member/councillor to arrange for the death certificate for?
No
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, Ward member/councillor
Don’t know
Not applicable
A07
Did the ASHA/AWW/ ANM// Gram Pradhan/village mukhiya/ ward member/councillor arrange for the death certificate?
Yes
No
A08
Why did the ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor did not facilitate the death registration?
Death at private facility/home
Asked money for registration
Registration process stopped dueto Covid-19 lockdown
Ask to come later, death report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
A09
Were you given any documentation from the health facility or facility where death was reported to register the death/to obtain death certificate of [deceased’s Name]?
Yes
No
A09A
Record if the documentation shown has “Death Certificate” written on it.
Yes, written on it
No
Other (specify)
A09B
Were you told anything by the health provider about the document given to you for the [DECEASED NAME]?
Nothing was told
Yes, told this is death certificate
Yes, told this receipt will help me in getting death certificate
Other (specify)
A10
Did you or a family member had to ask for this documentation for the death certificate or the facility provided on its own?
Had to ask for it
Facility provided on its own
Others (specify)
A11
Was the following information available on that document?
A11_1
Date of death
Yes
No
A11_2
Time of death
Yes
No
A11_3
Sex
Yes
No
A11_4
Age at death
Yes
No
A11_5
Cause of death
Yes
No
A11_6
Place of death
Yes
No
A11_7
Name of the deceased
Yes
No
A11_8
Name of the father
Yes
No
A11_9
Name of mother
Yes
No
A11_10
Name of the spouse
Yes
No
A11_11
Birth weight of the baby
Yes
No
A11_12
Place of delivery
Yes
No
A12
Why did you decide to register [deceased’s Name] death?
Useful government record
Useful for Bank/Postal settlements
Claim for property inheritance such as agricultural land
Claim for any business or share
Claim for insurance or any other policy benefits
Claim for pension
Removal of name from electoral rolls
Transfer of gas, telephone, electricity/ water meter
Other (specify)
Don’t know
A13
Why do you not have the death certificate for [deceased’s Name] currently?
Cannot find it right now
Do not know where it is kept
It is in my parent’s house
Waiting to get it from the government
Others (specify)
A14
Please rate your experience on ease of the process of registering death/obtaining the death certificate from the facility.
A15
Why was the death of [deceased’s Name] not registered?
Baby died immediately after birth
Child died too young
Died very old so not needed now
No need for it
Will get it if/when need arises
Did not think about it
No property so not needed
No one told us to register
No idea where to register
Went to register but staff was unavailable
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor did not register
No one at home during that time to register
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor refused to register due to home death
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor refused to register due to private hospital death
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor asked for money to register
No Aadhar card
Other (specify)
Don’t know
A16
Did you contact ASHA or AWW or ANM or Gram Pradhan/village mukhiya ward member/councillor to arrange for the death certificate for?
No
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member/councillor
A17
Why did the ASHA/AWW/ANM or Gram Pradhan/village mukhiya ward member/councillor did not facilitate the death registration?
Death at private facility/home
Asked money for registration
Registration process stopped due to Covid-19 lockdown
Ask to come later, death report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
A18
Did you/family try to get the death certificate yourself?
Yes
No
A19
Were you given any documentation from the health facility or facility where death was reported, to register the death/to obtain death certificate of [deceased’s Name]?
Yes
No
A19A
Record if the documentation shown has “Death Certificate” written on it.
Yes
No
A19B
Were you told anything by the health provider about the document given to you for the [DECEASED NAME]?
Nothing was told
Yes, told this is death certificate
Yes, told this receipt will help me in getting death certificate
Other (specify)
A20
Did you or a family member had to ask for this documentation for the death certificate or the facility provided on its own?
Had to ask for it
Facility provided on its own
Frontline health worker provided
Others (specify)
A21
Was the following information available on that document?
A21_1
Date of death
Yes
No
A21_2
Time of death
Yes
No
A21_3
Sex
Yes
No
A21_4
Age at death
Yes
No
A21_5
Cause of death
Yes
No
A21_6
Place of death
Yes
No
A21_7
Name of the deceased
Yes
No
A21_8
Name of the father
Yes
No
A21_9
Name of mother
Yes
No
A21_10
Name of the spouse
Yes
No
A21_11
Birth weight of the baby
Yes
No
A21_12
Place of delivery
Yes
No
DEATHS IN PUBLIC HEALTH FACILITY
B01
Do you have the death certificate of [deceased’s name]?
No
Yes, shown
Yes, not shown
Don’t know
B02
Was the death of registered?
No
Yes, shown
Yes, not shown
Don’t know
B03
Where did you obtain/apply the death certificate from?
Did not go to any place
At the health facility
Village Panchayat office
Block development office
Sub divisional office
Nagar nigam/Nagar palika parishad/Nagar panchayat
Jan seva kendra
Other (specify)
Don’t know
B04
Were you given the death certificate before leaving the facility after death or you had to come later to get it?
No
At the time of discharge
Later, family member got it
Later, ASA/AWW got it
Not received yet
Do not recall
B05
Did you or a family member had to ask for the death certificate or the facility provided on its own?
Had to ask for it
Facility provided on its own
Others (specify)
B06
How long after the death of [deceased’s name] did you obtain/apply for the death certificate?
B07
How much did you have to pay to get/apply the death certificate?
B08
Did ASHA or AWW or ANM or Gram Pradhan/village mukhiya ward member/councillor accompany/guide to obtain/apply the certificate?
None
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, Ward member/councillor
Don’t know
Not applicable
B09
Why did you decide to register the death of [deceased’s Name]?
It was registered automatically by the facility
Useful government record
Useful for Bank/Postal settlements
Claim for property inheritance such as agricultural land
Claim for any business or share
Claim for insurance or any other policy benefits
Claim for pension
Removal of name from electoral rolls
Transfer of gas, telephone, electricity/ water meter
Other (specify)
Don’t know
B10
Please rate your experience on ease of the process of registering the death/obtaining death certificate.
B11
Why do you not have the death certificate for [deceased’s Name] when the death was registered?
Cannot find it right now
Do not know where it is kept
Waiting to get it from the government
Other (specify)
Don’t know
B12
Why was the death of [deceased’s Name] not registered?
Baby died immediately after birth
Child died too young
Died very old so not needed now
No need for it
Will get it if/when need arises
Did not think about it
No property so not needed
No one told us to register
No idea where to register
Went to register but staff was unavailable
Due to Covid-19 lockdown office are closed
ASHA or AWW or ANM or Gram Pradhan/village Mukhiya/ ward member/councillor /not responding the request to register/not supportive to register
Registration period is over
Registration process stopped due to election
Registration process stopped due to flood
Other (specify)
Don’t know
B13
Did you contact ASHA or AWW or ANM or Gram Pradhan/village Mukhiya/ ward member/councillor arrange for the death certificate for?
No
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, or Gram Pradhan/village mukhiya
Yes, ward member/councilor
B14
Why did the ASHA/AWW/ANM Gram Pradhan/village mukhiya ward member/councillor did not facilitate the death registration?
Asked money for registration
Registration process stopped due to Covid-19 lockdown
Ask to come later, death report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
B15
Did you/family try get the death certificate yourself?
Yes
No
B16
Do you know if the death of [deceased’s Name] was automatically registered by the facility where the death occurred?
Yes
No
B17
Is the verbal autopsy questionnaire filled for the (deceased name)?
Incomplete
Yes, completed
Refused to answer
Other (specify)_____
B18
Is this the only/last death in the household for interview?
Yes
No
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