IDENTIFICATION (1)

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________

(1) This section should be adapted for country-specific survey design.

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:

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES

SUPERVISOR
NAME ______
NUMBER __ __ __ __

FIELD EDITOR
NAME ______
NUMBER __ __ __ __

OFFICE EDITOR
NUMBER __ __

KEYED BY
NUMBER __ __

SECTION MM. ADULT AND MATERNAL MORTALITY MODULE

MM01. Now I would like to ask you some questions about your brothers and sisters born to your natural mother, including those who are living with you, those living elsewhere and those who have died. From our experience in prior surveys, we know it may sometimes be difficult to establish a complete list of all the children born to your natural mother. We will work together to draw the most complete list and work to recall all your siblings. Could you please now give me the names of all of your brothers and sisters born to your natural mother. DO NOT FILL IN THE ORDER NUMBER YET.

MM02. CHECK MM01:

MM03. READ THE NAMES OF THE BROTHERS AND SISTERS TO THE RESPONDENT AND AFTER THE LAST ONE ASK: Are there any other brothers and sisters from the same mother that you have not mentioned?

MM04. Sometimes people forget to mention children born to their natural mother because they do not live with them or they do not see them very often. Are there any brothers or sisters who do not live with you that you have not mentioned?

MM05. Sometimes people forget to mention children born to their natural mother because they have died. Are there any brothers or sisters who died that you have not mentioned?

MM06. Some people have brothers or sisters from the same mother but a different father. Are there any brothers or sisters born to your natural mother, but who have a different natural father, that you have not mentioned?

MM07. COUNT THE NUMBER OF BROTHERS AND SISTERS RECORDED IN MM01.

MM08. CHECK MM07:

Just to make sure that I have this right: Your mother had in TOTAL ________ births, excluding you, during her lifetime. Is that correct?

MM09. CHECK MM07:

MM10. Please tell me, which brother or sister was born first? And which was born next? RECORD '01' FOR THE ORDER NUMBER IN MM01 FOR THE FIRST BROTHER OR SISTER, '02' FOR THE SECOND, AND SO ON UNTIL YOU HAVE RECORDED THE ORDER NUMBER FOR ALL BROTHERS AND SISTERS.

MM11. How many births did your mother have before you were born?

MM12. LIST THE BROTHERS AND SISTERS ACCORDING TO THE ORDER NUMBER IN MM01. ASK MM13 TO MM24 FOR ONE BROTHER OR SISTER BEFORE ASKING ABOUT THE NEXT BROTHER OR SISTER. IF THERE ARE MORE THAN 12 BROTHERS AND SISTERS, USE AN ADDITIONAL QUESTIONNAIRE.

MM13. NAME OF BROTHER OR SISTER.

MM14. Is (NAME) male or female?

MM15. Is (NAME) still alive?

MM16. How old is (NAME)?

MM17. How many years ago did (NAME) die?

MM18. How old was (NAME) when (he/she) died? IF DON'T KNOW, PROBE AND ASK ADDITIONAL QUESTIONS TO GET AN ESTIMATE.

MM19. Was (NAME) pregnant when she died?

MM20. Did (NAME) die during childbirth?

MM21. Did (NAME) die within two months after the end of a pregnancy of childbirth?

MM22. How many days after the end of the pregnancy or childbirth did (NAME) die?

MM23. Was (NAME)'s death due to an act of violence?

MM24. Was (NAME)'s death due to an accident?

IF NO MORE BROTHERS OR SISTERS, GO TO NEXT SECTION.