Surveypoint

Q01

District Name

Q02

Block Name

Q03

Cluster Name

Q04

Interviewer ID

Q05

Mapper ID/Supervisor ID

Q06

Structure number

Q07

Structure type

Residential

Non-residential

Q08

Household ID

Q09

Date of visit

Q10

Result of 1st/ 2nd/3rd visit

Available for enumeration

Refused

HH migrated permanently

Not available for enumeration

HH temporarily away for a longer time

Others (specify)____

Q11

Type of respondent and name of the head of the household

Head of the household

Other than above

Q12

Name of the household head/respondent

Q13

What is the sex of the household head/respondent?

Male

Female

Transgender

Q14

What is the sex of the respondent?

Male

Female

Transgender

Q15

What is the religion of this household?

Hindu

Muslim

Christian

Sikh

Other (specify)

Refused

Q16

What is the caste of this household?

Scheduled caste

Scheduled tribe

Other backward caste

Forward/General

Other (specify)

Refused

Q17

How many members currently stay in this household?

A01

What is the total number of live births in the household between January 2019 to December 2020?

A01_1

Line number for livebirths

A01_2

Year of birth

A01_3

Month of birth

A01_4

Sex of the baby

Boy

Girl

A01_5

Place of delivery

Public facility

Private/NGO facility

Home

On the route

B01

Was there a stillbirth in this household between January 2018 to December 2020?

Yes

No

B02

What are the total number of stillbirth in this household during the above period?

B03_1

Line number for stillbirths

B03_2

Year of birth

B03_3

Month of birth

B03_4

Sex of the baby

Boy

Girl

B03_5

Place of delivery

Public facility

Private/NGO facility

Home

On the route

B03_6

How many months was the pregnancy at the time of delivery?

C01

Please let me know if there was a death of a household member of any age between January 2018 to December 2020? Please include deaths of small babies also. DO NOT INCLUDE STILLBIRTH HERE.

Yes

No

C02

How many deaths have occurred in this household?

C03_1

Line number

C03_2

Name of the deceased

C03_3

Sex of the deceased

C03_4

Age at death

C03_5

Year of death

C03_6

Month of death

C03_7

Place of death

Public facility

Private/NGO facility

Home

On the route

C03_8

Was the deceased residing in this household at the time of death?

Yes

No

D01

FOCAL LIVEBIRTHS: What is the total number of children born between January 2019 to December 2020?

D02

FOCAL STILLBIRTHS: What is the total number of stillbirths between January 2018 to December 2020?

D03

FOCAL DEATHS: What is the total number of deaths between January 2018 to December 2020?

D04

Enumeration Template -Form Fill

District Name

Block Name

Cluster Name

Interviewer ID

Mapper ID/Supervisor ID

Structure number

Structure type

Household ID

Date of visit

Result of 1st/ 2nd/3rd visit

Type of respondent and name of the head of the household

Name of the household head/respondent

What is the sex of the household head/respondent?

What is the sex of the respondent?

What is the religion of this household?

What is the caste of this household?

How many members currently stay in this household?

What is the total number of live births in the household between January 2019 to December 2020?

Line number for livebirths

Year of birth

Month of birth

Sex of the baby

Place of delivery

Was there a stillbirth in this household between January 2018 to December 2020?

What are the total number of stillbirth in this household during the above period?

Line number for stillbirths

Year of birth

Month of birth

Sex of the baby

Place of delivery

How many months was the pregnancy at the time of delivery?

Please let me know if there was a death of a household member of any age between January 2018 to December 2020? Please include deaths of small babies also. DO NOT INCLUDE STILLBIRTH HERE.

How many deaths have occurred in this household?

Line number

Name of the deceased

Sex of the deceased

Age at death

Year of death

Month of death

Place of death

Was the deceased residing in this household at the time of death?

FOCAL LIVEBIRTHS: What is the total number of children born between January 2019 to December 2020?

FOCAL STILLBIRTHS: What is the total number of stillbirths between January 2018 to December 2020?

FOCAL DEATHS: What is the total number of deaths between January 2018 to December 2020?

Total number of interviews to be conducted in this household.