Beruflich Dokumente
Kultur Dokumente
SAMPLE QUESTIONNAIRE
WHOVA2014
NO.
ANSWER
SKIP
0A100a
0A100b
YES
NO
YES
NO
o
o
o
o
MALE
FEMALE
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
Ref
o
o
o
o
o
o
o
o
o
o
o
o
o
1A100b
1A110
1A400
Was this a woman who died more than 42 days but less than 1 year
after being pregnant or delivering a baby?
1A401
Was this a woman who died more than 42days after being pregnant
or delivering a baby?
1A200
1A210
DAY
MONTH
YEAR
1A220
1A230
o
o
o
DAY
oo
oo
oo
oo
YEAR
AAAA
1A500
1A510
1A520
1A530
What was her/his place of usual residence? (The place where the person lived most of the year)
_______________________________________________________________
1A540
1A550
WHOVA2014
YEARS
Citizen at birth
Naturalized citizen
Foreign national
DK
1A200
1A220
1A220
o
o
o
YES
NO
Ref.
MONTH
AAAA
AAAA
o
o
o
o
1A560
1A600
1A610
DAY
MONTH
YEAR
1A620
1A650
1A660
1A670
o
o
o
o
o
o
o
o
1A620
1A620
1A620
o
o
1A620
1A620
oo
oo
oo
______________________________________________________________
1A640
1A630
o
o
o
Hospital
Other health facility
Home
On route to facility or
hospital
Other
DK
Ref.
Single
Married
Life partner
Divorced
Widowed
Too young to be
married
DK
Ref.
______________________________________________________________
No formal education
Primary school
Secondary school
Higher then secondary
school
DK
Ref.
Was (s)he able to read and write? (select 'yes' also if only one of either YES
reading or writing is know to the respondent)
NO
DK
Ref
What was her/his economic activity status in year prior to death?
Mainly
unemployed
Mainly employed
Home-maker
Pensioner
Student
Other
DK
Ref.
What was her/his occupation, that is, what kind of work does (s)he mainly do?
________________________________________________________________
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
WHOVA2014
1A700
1A710
DAY
MONTH
YEAR
1A720
Place of registration
________________________________________________________________
1A730
oo
oo
oo
2A115
2A120
2A130
2A135
2A140
2A150
3A280
3A300
For how many days was (s)he ill before (s)he died?
DAYS
3A310
YES
NO
DK
Ref.
WHOVA2014
YES
NO
WET
DRY
o
o
o
o
o
o
o
o
o
o
o
_____
_____
oo
oo
oo
o
o
o
o
oo
o
o
o
o
3A110
3A120
Did (s)he have a recent positive test by a physician or health worker for malaria?
3A130
Did (s)he have a recent negative test by a physician or health worker for malaria?
3A135
3A140
3A150
Was there any diagnosis by a physician or health worker of high blood pressure?
3A160
3A170
3A180
3A190
3A200
3A210
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3A220
3A230
3A240
3A250
Was there any diagnosis by a physician or health worker of sickle cell disease?
3A260
3A270
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
YES
NO
DK
Ref.
3B110
DAYS
3B115
3B120
3B130
Mild
Moderate
Severe
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B140
DAYS
3B150
3B155
3B160
3B180
3B190
During the illness that led to death, did (s)he have fast breathing?
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B200
DAYS
3B210
YES
NO
DK
Ref.
3B220
WEEKS
3B230
3B240
YES
NO
DK
Ref.
YES
NO
DK
Ref.
WHOVA2014
o
o
o
o
3B130
3B130
3B130
3B180
3B180
3B180
3B210
3B210
3B210
3B242
3B242
3B242
oo
o
o
o
o
o
o
o
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
oo
o
o
o
o
oo
o
o
o
o
o
o
o
o
3B242
During the illness that led to death, did (s)he have difficulty breathing?
3B246
3B260
During the illness that led to death did his/her breathing sound like any of
the following: Stridor, Grunting, Wheezing
3B270
YES
NO
DK
Ref.
Continuous
On and off
Stridor
Grunting
Wheezing
NO
DK
Ref.
YES
NO
DK
Ref.
3B272
How many days before death did (s)he have severe chest pain?
DAYS
3B274
MINUTES
3B280
YES
NO
DK
Ref.
3B290
DAYS
3B300
At any time during the final illness was there blood in the stools?
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B305
3B310
3B315
DAYS
3B320
3B325
3B330
3B340
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B350
For how many days before death did (s)he have severe abdominal pain?
WHOVA2014
DAYS
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3B260
3B260
3B260
3B280
3B280
3B280
3B310
3B310
3B310
3B310
3B310
3B310
3B330
3B330
3B330
3B360
3B360
3B360
oo
oo
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
oo
3B355
3B360
3B370
3B375
For how many days did (s)he have a more than usually protruding
abdomen?
How rapidly did (s)he develop the protruding abdomen?
3B380
Upper abdomen
Lower abdomen
YES
NO
DK
Ref.
o
o
o
o
DAYS
Rapidly
Slowly
YES
NO
DK
Ref.
3B390
For how many days before death did (s)he have a mass in the abdomen?
DAYS
3B400
3B405
Did (s)he have a stiff neck during illness that led to death?
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B407
For how many days before death did (s)he have stiff neck?
DAYS
3B409
Did (s)he have a painful neck during the illness that led to death?
YES
NO
DK
Ref.
3B410
For how many days before death did (s)he have a painful neck?
DAYS
3B420
YES
NO
DK
Ref.
3B430
MONTHS
3B440
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B450
Did the unconsciousness start suddenly, quickly (at least within a single
day)?
3B455
3B460
WHOVA2014
3B380
3B380
3B380
3B400
3B400
3B400
3B409
3B409
3B409
3B420
3B420
3B420
3B440
3B440
3B440
3B460
3B460
3B460
3B490
3B490
3B490
oo
o
o
o
o
o
o
oo
o
o
o
o
o
o
o
o
oo
o
o
o
o
oo
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3B465
Did (s)he experience any generalized convulsions or fits during the illness
that led to death?
YES
NO
DK
Ref.
3B470
MINUTES
3B480
3B490
3B500
3B510
3B520
During the final illness did (s)he ever pass blood in the urine?
3B530
3B535
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B537
3B540
Did (s)he have any ulcers, abscess or sores anywhere except on the feet?
3B542
3B544
3B546
DAYS
3B550
Did (s)he have any ulcers, abscess or sores on the feet that were not also on
other parts of the body?
3B560
During the illness that led to death, did (s)he have any skin rash?
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B570
For how many days did (s)he have the skin rash?
WHOVA2014
DAYS
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3B540
3B540
3B540
3B560
3B560
3B560
3B550
3B550
3B550
o
o
o
o
o
o
o
o
3B596
3B596
3B596
oo
oo
10
3B575
3B580
3B590
3B596
During the illness that led to death, did (s)he bleed from anywhere?
3B600
3B610
3B620
3B630
During the illness that led to death, did s/he have a whitish rash inside the
mouth or on the tongue?
3B640
Did (s)he have stiffness of the whole body or was unable to open the
mouth?
3B650
Face
Trunk or abdomen
Extremities
Everywhere
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B652
For how many days did (s)he have puffiness of the face?
DAYS
3B654
During the illness that led to death, did (s)he have swelling in the armpits?
3B656
During the illness that led to death, did (s)he have swollen legs or feet?
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B658
DAYS
3B660
3B665
YES
NO
DK
Ref.
YES
NO
DK
Ref.
WHOVA2014
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3B610
3B610
3B610
3B630
3B630
3B630
3B654
3B654
3B654
o
o
o
o
o
o
o
o
3B660
3B660
3B660
oo
oo
o
o
o
o
o
o
o
o
11
3B670
3B680
3B690
3B700
3B710
3B720
3B722
3B724
3B730
3B731
3B732
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Right side
Left side
Lower part of body
Upper part of body
One leg only
One arm only
Whole body
Other
YES
NO
DK
Ref.
3B734
For how many days before death did (s)he have difficulty swallowing?
DAYS
3B740
3B745
3B750
Solids
Liquids
Both
YES
NO
DK
Ref.
YES
NO
DK
Ref.
WHOVA2014
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3B732
3B732
3B732
3B745
3B745
3B745
o
o
o
o
o
o
o
o
o
o
o
3B760
3B760
3B760
oo
12
3B755
For how many days did (s)he have the yellow discoloration?
DAYS
3B760
3B770
Did (s)he look pale (thinning/lack of blood) or have pale palms, eyes or nail
beds?
3B780
3B790
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
WHOVA2014
IF MALE
13
3B800
3B810
3B820
3B830
3B840
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3B850
WEEKS
3C105
Did she have a sharp pain in her abdomen shortly before death?
3C110
3C120
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
miscarriage?
3C125
3C135
Please confirm: you said she was NOT pregnant and had NOT recently been YES
pregnant or delivered when she died is that right?
NO
DK
Ref.
Did she die within 24 hours after delivery?
YES
NO
DK
Ref.
Did she die during labour, and before delivery?
YES
NO
DK
Ref.
Did she die after delivering a baby?
YES
NO
DK
Ref.
3C200
3C210
3C212
WHOVA2014
MONTHS
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3C105
3C105
3C105
3C105
3C105
3C105
oo
o
o
o
o
o
o
o
o
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3C125
3C135
3C200
3E100
14
3C213
3C215
3C220
3C230
How many births, including stillbirths, did she/the mother have before this
baby?
Had she had any previous Caesarean section?
3C240
3C260
3C270
3C280
3C290
3C310
3C320
3C330
3C340
3C350
3C360
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Number
YES
NO
DK
Ref.
During pregnancy, did she suffer from high blood
pressure?
YES
NO
DK
Ref.
Did she have foul smelling vaginal discharge during pregnancy or after
YES
delivery?
NO
DK
Ref.
During the last 3 months of pregnancy, did she suffer from convulsions?
YES
NO
DK
Ref.
During the last 3 months of pregnancy did she suffer from blurred vision?
YES
NO
DK
Ref.
Did she have excessive bleeding during pregnancy
before labour started? YES
NO
DK
Ref.
Was there vaginal bleeding during the first 6 months of pregnancy?
YES
NO
DK
Ref.
Was there vaginal bleeding during the last 3 months of pregnancy but
YES
before labour started?
NO
DK
Ref.
Did she have excessive bleeding during labour or delivery?
YES
NO
DK
Ref.
Did she have excessive bleeding after delivery or abortion?
YES
NO
DK
Ref.
Was the placenta completely delivered?
YES
NO
DK
Ref.
WHOVA2014
o
o
o
o
o
o
o
o
o
o
o
o
oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3C340
3C340
3C340
15
o
o
o
o
3C365
YES
NO
DK
Ref.
3C370
HOURS
3C380
3C390
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Hospital
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Other
health
facility
Home
On route to
hospital or
facility
Other
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
o
o
o
o
o
o
o
o
o
NO
DK
Ref.
o
o
3C393
3C395
3C400
3C430
3C440
Did she have an operation to remove her uterus shortly before death?
oo
3C400
3C400
3C400
3C460
3C470
WHOVA2014
3C480
3C480
16
3C480
WHOVA2014
YES
NO
DK
Ref.
o
o
o
o
17
3E102
Did (s)he suffer from any injury or accident that led to her/his
death?
3E104
3E106
3E108
3E111
3E112
3E113
3E115
3E120
3E170
What was the counterpart that was hit during the road traffic
accident?
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Pedestrian
Driver or passenger in car
or light vehicle
Driver or passenger in
bus or heavy vehicle
Driver or passenger on a
motorcycle
Driver or passenger on a
pedal cycle
Pedestrian
Stationary object
Car or light vehicle
Bus or heavy vehicle
Motorcycle
Pedal cycle
Other
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3F100
3F100
3F100
3E113
3E113
3E113
3E310
3E310
3E310
o
o
o
o
o
o
o
o
o
o
o
18
3E310
3E320
3E330
3E335
3E340
3E400
3E500
3E510
3E520
3E530
Was it electrocution?
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Dog
Snake
Insect or Scorpion
Others
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3E500
3E500
3E500
19
3F110
3F120
3F130
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Cigarettes
Pipe
Chewing tobacco
Local form of tobacco
Other
NUMBER
o
o
o
o
o
o
o
o
o
o
o
o
o
3G110
3G110
3G110
3H130
3H130
3H130
3G190
3G190
3G190
oo
Did (s)he receive any treatment for the illness that led to
death?
3G120
3G130
3G140
3G150
3G160
3G165
3G170
3G180
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
20
3G190
3H130
Was care sought outside the home while (s)he had this
illness?
3H140
3H150
3H160
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Traditional healer
Homeopath
Religious leader
Government hospital
Government health
centre or clinic
Private hospital
Community-based
practitioner associated
with health system
Trained birth attendant
Private physician
Pharmacy
YES
NO
DK
Ref.
YES
NO
DK
Ref.
3H170
3H180
3H190
3H200
YES
NO
DK
Ref.
YES
NO
DK
Ref.
DAY
Record the date of the last but one (second last) visit
YEAR
3H220
DAY
MONTH
YEAR
3H230
3H240
WHOVA2014
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
ooo.o
MONTH
3H180
3H180
3H180
4A100
4A100
4A100
4A100
4A100
4A100
[KG]
DAY
3H160
3H160
3H160
[KG]
YEAR
oo
oo
oo
oo
oo
oo
oo
oo
oo
ooo.o
MONTH
3H210
o
o
o
o
o
o
o
o
o
o
o
o
21
3H250
DAY
MONTH
YEAR
oo
oo
oo
4A110
4A120
4A130
Were there any problems with the way (s)he was treated
(medical treatment, procedures, interpersonal attitudes,
respect, dignity) in the hospital or health facility?
4A140
4A150
4A160
In the final days before death, were there any doubts about
whether medical care was needed?
4A170
4A180
4A190
Over the course of illness, did the total costs of care and
treatment prohibit other household payments?
WHOVA2014
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
4A150
4A150
4A150
22
Narrative Description
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
6H270
YES
NO
DK
Ref.
YES
NO
DK
Ref.
o
o
o
o
o
o
o
o
END
END
END
6H280
Record the immediate cause of death from the certificate (line 1a) *
END
END
END
Duration 1(a)
6H290
____________________________________________________________
Record the first antecedent cause of death from the certificate (line 1b)
Duration 1(b)
6H300
____________________________________________________________
Record the second antecedent cause of death from the certificate (line 1c)
Duration 1(c)
6H310
____________________________________________________________
Record the third antecedent cause of death from the certificate (line 1d)
Duration 1(d)
6H320
____________________________________________________________
Record the contributing cause(s) of death from the certificate (part 2)
____________________________________________________________
WHOVA2014
23