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Making Every Baby Count

9789241511223-eng

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SEQUENTIAL NUMBER<br />

<br />

SECTION 1. INTERVIEW AND DEMOGRAPHIC INFORMATION<br />

SECTION 1.1 INTERVIEWER VISITS<br />

1 2 3 FINAL VISIT<br />

DATE<br />

INTERVIEWER’S NAME<br />

RESULT*<br />

__________________<br />

__________________<br />

<br />

TAKE NOTES HERE IF FOLLOW-UP IS NEEDED<br />

(e.g. TELEPHONE, DIRECTIONS ETC)<br />

NEXT VISIT:<br />

DATE<br />

TIME<br />

__________________<br />

__________________<br />

GPS CODES:<br />

(of village)<br />

DECIMAL DEGREES<br />

__________________<br />

__________________<br />

<br />

__________________<br />

__________________<br />

__________________<br />

__________________<br />

<br />

DAY<br />

MONTH<br />

YEAR<br />

<br />

<br />

2 0 1<br />

<br />

INTERVIEWER<br />

# <br />

RESULT<br />

TOTAL NUMBER OF VISITS<br />

* RESULT CODES:<br />

1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED<br />

5 PARTLY COMPLETED 6 NO APPROPRIATE RESPONDENT FOUND 7 OTHER (SPECIFY) _________________________________<br />

SECTION 1.2 ADDITIONAL DEMOGRAPHIC INFORMATION<br />

(PLEASE USE CORRECT SPELLING FROM LIST)<br />

DISTRICT<br />

HEALTH SUBDISTRICT<br />

SUBCOUNTY<br />

PARISH<br />

VILLAGE/LOCALITY<br />

HOUSEHOLD NUMBER (HHN)<br />

NAME OF DECEASED BABY<br />

NAME OF THE BABY’S MOTHER<br />

NAME OF HOUSEHOLD HEAD<br />

LAT N<br />

S<br />

LONG<br />

<br />

<br />

+<br />

–<br />

E 3<br />

<br />

<br />

<br />

<br />

<br />

<br />

<br />

To be filled by data entry<br />

WHAT IS THE PRIMARY LANGUAGE OF THE INTERVIEW? ENGLISH........................................................................... 1<br />

OTHER (SPECIFY)________________________________ 2<br />

108 MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS

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