DEMOGRAPHIC AND HEALTH SURVEYS
ACCIDENT AND INJURY MODULE
MODEL HOUSEHOLD QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
HOUSEHOLD SELECTED FOR MAN'S SURVEY (1=YES, 2=NO)
INTERVIEWER VISITS
FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __
TOTAL NUMBER OF VISITS: __
*RESULT CODES:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AND HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) __________
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
Note: Brackets [] indicate items that should be adapted on a country-specific basis.
A01. Now I would like to ask you about road traffic accidents that anyone in your household may have been involved in during the last 12 months.
Was anyone in your household killed in a road traffic accident in the past 12 months or injured in a road traffic accident with injuries severe enough that for at least one day they could not carry out their normal daily activities?
NO 2 (GO TO A14)
A02. What is the name of the persons injured or killed?
ENTER THE NAME OF EACH PERSON INJURED OR KILLED IN A03. IF THERE ARE MORE THAN TWO PERSONS, USE ADDITIONAL QUESTIONNAIRE(S).
A03. ENTER THE NAME OF EACH PERSON INJURED OR KILLED
A04. Was (NAME) in a car, truck, bus, motorcycle, bicycle, another kind of vehicle, or a pedestrian? IF A PERSON HAD MORE THAN ONE ROAD TRAFFIC ACCIDENT, ASK QUESTIONS ABOUT THE MOST RECENT ACCIDENT ONLY.
TRUCK 02
BUS 03
MOTORCYCLE 04
BICYCLE 05
PEDESTRIAN 06
OTHER (SPECIFY) __________ 96
DON'T KNOW 98
NO 2
DON'T KNOW 8 (GO TO A09)
A06. Was (NAME)'s death related to the road traffic accident?
NO 2
A07. Was (NAME) male or female?
FEMALE 2
A08. What was (NAME)'s age when (NAME) died? IF LESS THAN ONE YEAR, RECORD '00'.
DON'T KNOW 98
(GO TO A13)
A09. RECORD HOUSEHOLD LINE NUMBER FROM COLUMN 1. CIRCLE '00' IF PERSON NOT LISTED IN HOUSEHOLD.
NOT IN HOUSEHOLD 00
A10. Is (NAME) male or female?
FEMALE 2
A11. How old is (NAME)? IF LESS THAN ONE YEAR, RECORD '00'.
DON'T KNOW 98
A12. What kind of injuries did (NAME) have as a result of the accident? RECORD ALL MENTIONED.
BRAIN DAMAGE B
DISFIGUREMENT C
LOSS OF LIMB D
LOSS OF LIMB FUNCTION E
LOSS OF EYE SIGHT F
CHRONIC PAIN G
BURN H
CUTS I
BROKEN BONE J
EMOTIONAL TRAUMA K
OTHER (SPECIFY) __________ X
A13. GO BACK TO A04 IN NEXT COLUMN, OR IF NO MORE PERSONS WITH ACCIDENTS, GO TO A14.
A14. Now I would like to ask you about other incidents that anyone in your household may have been involved in during the last 12 months.
Was anyone in your household killed in the last 12 months or injured in any other incident such as a fire, violent attack, animal bite, fall, drowning or anything else with injuries severe enough that for at least one day they could not carry out their normal daily activities?
NO 2 (END)
A15. What is the name of the person(s) injured or killed?
ENTER THE NAME OF EACH PERSON INJURED OR KILLED IN A16. IF THERE ARE MORE THAN TWO PERSONS, USE ADDITIONAL QUESTIONNAIRE(S).
A16. ENTER THE NAME OF EACH PERSON INJURED OR KILLED:
A17. In what type of incident was (NAME) injured or killed? IF A PERSON HAD MORE THAN ONE INCIDENT, ASK QUESTIONS ABOUT THE MOST RECENT INCIDENT ONLY.
FIRE/BURNING 02
ANIMAL BITE 03
ACCIDENTAL FALL 04
DROWNING 05
POISONING 06
OTHER (SPECIFY) __________ 96
DON'T KNOW 98
NO 2
DON'T KNOW 8 (GO TO A22)
A19. Was (NAME)'s death related to this incident?
NO 2
A20. Was (NAME) male or female?
FEMALE 2
A21. What as (NAME)'s age when (NAME) died? IF LESS THAN ONE YEAR, RECORD '00'.
DON'T KNOW 98
(GO TO A26)
A22. RECORD HOUSEHOLD LINE NUMBER FROM COLUMN 1. CIRCLE '00' IF PERSON NOT LISTED IN HOUSEHOLD.
NOT IN HOUSEHOLD 00
A23. Is (NAME) male or female?
FEMALE 2
A24. How old is (NAME)? IF LESS THAN ONE YEAR, RECORD '00'.
DON'T KNOW 98
A25. What kind of injuries did (NAME) have as a result of the accident? RECORD ALL MENTIONED.
BRAIN DAMAGE B
DISFIGUREMENT C
LOSS OF LIMB D
LOSS OF LIMB FUNCTION E
LOSS OF EYE SIGHT F
CHRONIC PAIN G
BURN H
CUTS I
BROKEN BONE J
EMOTIONAL TRAUMA K
OTHER (SPECIFY) __________ X
A26. GO BACK TO A17 IN NEXT COLUMN, OR IF NO MORE PERSONS WITH INJURIES, END.