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Afghanistan Mortality Survey 2010 - Measure DHS

Afghanistan Mortality Survey 2010 - Measure DHS

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THE MINISTRY OF PUBLIC HEALTHAFGHANISTAN MORTALITY SURVEYVERBAL AUTOPSY [FORM 3]DEATH OF AN ADULT AGED 12 YEARS AND ABOVEIDENTIFICATIONApril 14 <strong>2010</strong>VILLAGE / NEIGHBORHOOD [MUQATAA / MAHALAH]NAME OF HOUSEHOLD HEADCLUSTER NUMBER [SAHA SHOMOR]STRUCTURE NUMBERHOUSEHOLD NUMBERNAME, LINE NUMBER OF RESPONDENT FROM Q.101 AND Q.102 IN HQNAME, COLUMN NUMBER OF DECEASED FROM Q.303 AND Q.304 IN HQINTERVIEWER VISITS1 2 3FINAL VISITDATEDAYMONTHYEARINTERVIEWER'S NAMERESULT*INT. NUMBERRESULTNEXT VISIT:DATETIMETOTAL NUMBEROF VISITS*RESULT CODES:1 COMPLETED2 NOT AT HOME3 POSTPONED4 REFUSED5 PARTLY COMPLETED7 INCAPACITATED6 OTHER(SPECIFY)LANGUAGE OF INTERVIEWLANGUAGE OF QUESTIONNAIRE: LANGUAGE OF INTERVIEW: LANGUAGE OF RESPONDENTLANGUAGE CODES: PASHTU = 1, DARI = 2, OTHER = 3, OTHER = 4TRANSLATOR USED: (YES = 1, NO = 2)SUPERVISORFIELD EDITOROFFICEEDITORKEYED BYNAMENAMEAppendix F |265

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