Christian Mission Aid CMA - Action Against Hunger

25.IX.3. Retrospective Mortality Survey QuestionnaireDATE:VILLAGE:CLUSTER No:TEAM No:FamilyN°.123456789101112131415161718192021222324252627282930TRIBE(1)Numberof < 5YearsalivetodayNumberof < 5yearsdead inlast 3monthsCAUSE(2)NUMBERof >= 5yearsalivetodayNumber ofdead >=5years inthe last 3monthsCAUSE(3)Number ofpeople alive inthe last 3months**(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarilyresident in village (cattle camp, water point, visiting family…).(2) Tribe: Nuer, Dinka, Shilluk. Murle.Cause: Diarrhoea (watery diarrhoea), 2=Bloody diarrhoea (Dysentery), 3=Measles, 4=Malaria, 5=TB, 6=Pneumonia, 7=Malnutrition, 8= Kala-Azar, 9=Accident (gunshot, snakebite…), 10=other(write presumed cause of death).