2014 WHO VERBAL AUTOPSY

SAMPLE QUESTIONNAIRE

Death of a person aged 12 years and above

DK= answer means dont know

Ref= answer means refused to answer

WHOVA2014

NO.

QUESTIONS AND FILTERS

ANSWER

SKIP

0A100a

Is this a region of high HIV/AIDS prevalence?

0A100b

Is this a region of high malaria prevalence?

YES
NO
YES
NO

o
o
o
o

MALE
FEMALE
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
Ref

o
o
o
o
o
o
o
o
o
o
o
o
o

SECTION 1. INFORMATION ON THE DECEASED

1A100a

What was the first or given name(s) of the deceased?

___________________________________________________________

1A100b

What was the surname (or family name) of the deceased?

___________________________________________________________

1A110

What was the sex of the deceased?

1A400

Was this a woman who died more than 42 days but less than 1 year
after being pregnant or delivering a baby?

1A401

Was this a woman who died more than 42days after being pregnant
or delivering a baby?

1A200

Is the date of birth known?

1A210

When was the deceased born?

DAY
MONTH
YEAR

1A220

1A230

Is the date of death known?

When did (s)he die?

o
o
o

DAY

oo
oo
oo
oo

YEAR
AAAA

Put adult's age in years

1A500

What was her/his citizenship/nationality?

1A510

What was her/his ethnicity?

_______________________________________________________________

1A520

What was her/his place of birth?

_______________________________________________________________

1A530

What was her/his place of usual residence? (The place where the person lived most of the year)
_______________________________________________________________

1A540

What was her/his place of normal residence 1 to 5 years before death?

_______________________________________________________________
Where did death occur? (specify country, province, district, village)
_______________________________________________________________

1A550

WHOVA2014

YEARS
Citizen at birth
Naturalized citizen
Foreign national
DK

1A200

1A220
1A220

o
o
o

YES
NO
Ref.
MONTH

AAAA
AAAA

o
o
o
o

1A560

1A600

1A610

Where did the deceased die?

What was her/his marital status?

What was the date of marriage?

DAY
MONTH
YEAR

1A620

1A650

1A660

1A670

o
o
o
o
o
o
o
o

1A620

1A620

1A620

o
o

1A620
1A620

oo
oo
oo

______________________________________________________________

What was the name of the mother?

Surname ______________________________________________________________
Name

1A640

What was the name of the father?

Surname ______________________________________________________________
Name

1A630

o
o
o

Hospital
Other health facility
Home
On route to facility or
hospital
Other
DK
Ref.
Single
Married
Life partner
Divorced
Widowed
Too young to be
married
DK
Ref.

______________________________________________________________

What was her/his highest level of schooling?

No formal education
Primary school
Secondary school
Higher then secondary
school
DK
Ref.
Was (s)he able to read and write? (select 'yes' also if only one of either YES
reading or writing is know to the respondent)
NO
DK
Ref
What was her/his economic activity status in year prior to death?
Mainly
unemployed
Mainly employed
Home-maker
Pensioner
Student
Other
DK
Ref.
What was her/his occupation, that is, what kind of work does (s)he mainly do?
________________________________________________________________

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

SECTION 2. Vital Registration and Certification

WHOVA2014

1A700
1A710

Death registration number/certificate

____________________________________________________________
Date of registration

DAY
MONTH
YEAR

1A720

Place of registration
________________________________________________________________

1A730

National identification number of deceased

________________________________________________________________

oo
oo
oo

SECTION 3. Information on the respondent and background about interview

2A100
2A110

2A115

2A120
2A130
2A135
2A140

What is the name of VA respondent?

____________________________________________________________
What is the respondent's relationship to the deceased?
Parent
Child
Other family
member
Friend
Health worker
Public official
Another
relationship
Did the respondent live with the deceased in the period leading to YES
her/his death?
NO
DK
Ref
Name of VA interviewer
____________________________________________________________
Time at start of interview
hh:mm 24h
Time at end of interview
hh:mm 24h
Date of interview
DAY
MONTH
YEAR

2A150

Did the respondent give consent?

3A280

During which season did (s)he die?

3A300

For how many days was (s)he ill before (s)he died?

DAYS

3A310

Did (s)he die suddenly?

YES
NO
DK
Ref.

WHOVA2014

YES
NO
WET
DRY

o
o
o
o
o
o
o
o
o
o
o

_____
_____

oo
oo
oo
o
o
o
o

oo
o
o
o
o

SECTION4 MEDICAL HISTORY ASSOCIATED WITH FINAL ILLNESS.

3A100

Was there any diagnosis by a physician or health worker of tuberculosis?

3A110

Was there any diagnosis by a physician or health worker of HIV/AIDS?

3A120

Did (s)he have a recent positive test by a physician or health worker for malaria?

3A130

Did (s)he have a recent negative test by a physician or health worker for malaria?

3A135

Was there any diagnosis by a physician or health worker of dengue fever?

3A140

Was there any diagnosis by a physician or health worker of measles?

3A150

Was there any diagnosis by a physician or health worker of high blood pressure?

3A160

Was there any diagnosis by a physician or health worker of heart disease??

3A170

Was there any diagnosis by a physician or health worker of diabetes?

3A180

Was there any diagnosis by a physician or health worker of asthma?

3A190

Was there any diagnosis by a physician or health worker of epilepsy?

3A200

Was there any diagnosis by a physician or health worker of cancer?

3A210

Was there any diagnosis by a physician or health worker of Chronic Obstructive

Pulmonary Disease (COPD)?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3A220

Was there any diagnosis by a physician or health worker of dementia?

3A230

Was there any diagnosis by a physician or health worker of depression?

3A240

Was there any diagnosis by a physician or health worker of stroke?

3A250

Was there any diagnosis by a physician or health worker of sickle cell disease?

3A260

Was there any diagnosis by a physician or health worker of kidney disease?

3A270

Was there any diagnosis by a physician or health worker of liver disease?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

SECTION5. GENERAL SIGNS AND SYMPTOMS ASSOCIATED WITH FINAL ILLNESS

3B100

Did (s)he have a fever?

YES
NO
DK
Ref.

3B110

How many days did the fever last?

DAYS

3B115

How severe was the fever?

3B120

Did (s)he have night sweats?

3B130

Did (s)he have a cough?

Mild
Moderate
Severe
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B140

For how many days did (s)he have a cough?

DAYS

3B150

Was the cough productive, with sputum?

3B155

Was the cough very severe?

3B160

Did (s)he cough up blood?

3B180

Did (s)he have any breathing problem?

3B190

During the illness that led to death, did (s)he have fast breathing?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B200

For how many days did the fast breathing last?

DAYS

3B210

Did (s)he have breathlessness?

YES
NO
DK
Ref.

3B220

For how many weeks did (s)he have breathlessness?

WEEKS

3B230

Was (s)he unable to carry out daily routines due to breathlessness?

3B240

Was (s)he breathless while lying flat?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

WHOVA2014

o
o
o
o

3B130
3B130
3B130

3B180
3B180
3B180

3B210
3B210
3B210

3B242
3B242
3B242

oo
o
o
o
o
o
o
o
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

oo
o
o
o
o

oo
o
o
o
o
o
o
o
o

3B242

During the illness that led to death, did (s)he have difficulty breathing?

3B246

Was the difficulty continuous or on and off?

3B260

During the illness that led to death did his/her breathing sound like any of
the following: Stridor, Grunting, Wheezing

3B270

Did (s)he have severe chest pain?

YES
NO
DK
Ref.
Continuous
On and off
Stridor
Grunting
Wheezing
NO
DK
Ref.
YES
NO
DK
Ref.

3B272

How many days before death did (s)he have severe chest pain?

DAYS

3B274

How many minutes did the pain last?

MINUTES

3B280

Did (s)he have diarrhoea?

YES
NO
DK
Ref.

3B290

For how many days did (s)he have diarrhoea?

DAYS

3B300

At any time during the final illness was there blood in the stools?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B305

Was there blood in the stool up until death?

3B310

Did (s)he vomit?

3B315

For how many days before death did (s)he vomit?

DAYS

3B320

Did (s)he vomit blood?

3B325

Was the vomit black?

3B330

Did (s)he have any abdominal problem?

3B340

Did (s)he have severe abdominal pain?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B350

For how many days before death did (s)he have severe abdominal pain?

WHOVA2014

DAYS

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3B260
3B260
3B260

3B280
3B280
3B280

3B310
3B310
3B310

3B310
3B310
3B310

3B330
3B330
3B330

3B360
3B360
3B360

oo
oo
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

oo

3B355

3B360

3B370

Was the pain in the upper or lower abdomen?

Did (s)he have a more than usually protruding abdomen?

3B375

For how many days did (s)he have a more than usually protruding
abdomen?
How rapidly did (s)he develop the protruding abdomen?

3B380

Did (s)he have any mass in the abdomen?

Upper abdomen

Lower abdomen

YES
NO
DK
Ref.

o
o
o
o

DAYS
Rapidly
Slowly
YES
NO
DK
Ref.

3B390

For how many days before death did (s)he have a mass in the abdomen?

DAYS

3B400

Did (s)he have a severe headache?

3B405

Did (s)he have a stiff neck during illness that led to death?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B407

For how many days before death did (s)he have stiff neck?

DAYS

3B409

Did (s)he have a painful neck during the illness that led to death?

YES
NO
DK
Ref.

3B410

For how many days before death did (s)he have a painful neck?

DAYS

3B420

Did (s)he have mental confusion?

YES
NO
DK
Ref.

3B430

For how many months did (s)he have mental confusion?

MONTHS

3B440

Was (s)he unconscious for more than 24 hours before death?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B450

Did the unconsciousness start suddenly, quickly (at least within a single
day)?

3B455

Did the unconsciousness continue until death?

3B460

Did (s)he have convulsions?

WHOVA2014

3B380
3B380
3B380

3B400
3B400
3B400

3B409
3B409
3B409

3B420
3B420
3B420

3B440
3B440
3B440

3B460
3B460
3B460

3B490
3B490
3B490

oo
o
o
o
o
o
o

oo
o
o
o
o
o
o
o
o

oo
o
o
o
o

oo
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3B465

Did (s)he experience any generalized convulsions or fits during the illness
that led to death?

YES
NO
DK
Ref.

3B470

For how many minutes did the convulsions last?

MINUTES

3B480

Did (s)he become unconscious immediately after the convulsion?

3B490

Did (s)he have any urine problems?

3B500

Did (s)he pass no urine at all?

3B510

Did (s)he go to urinate more often than usual?

3B520

During the final illness did (s)he ever pass blood in the urine?

3B530

Did (s)he have any skin problems?

3B535

Did (s)he have sores?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B537

Did the sores have clear fluid or pus?

3B540

Did (s)he have any ulcers, abscess or sores anywhere except on the feet?

3B542

Did (s)he have an ulcer (pit) on the foot?

3B544

Did the ulcer ooze pus?

3B546

For how many days did the ulcer ooze pus?

DAYS

3B550

Did (s)he have any ulcers, abscess or sores on the feet that were not also on
other parts of the body?

3B560

During the illness that led to death, did (s)he have any skin rash?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B570

For how many days did (s)he have the skin rash?

WHOVA2014

DAYS

o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3B540
3B540
3B540

3B560
3B560
3B560

3B550
3B550
3B550

o
o
o
o
o
o
o
o

3B596
3B596
3B596

oo

oo

10

3B575

Where was the rash?

3B580

Did (s)he have measles rash (use local term)?

3B590

Did (s)he ever have shingles or herpes zoster?

3B596

During the illness that led to death, did (s)he bleed from anywhere?

3B600

Did (s)he bleed from the nose, mouth or anus?

3B610

Did (s)he have noticeable weight loss?

3B620

Was (s)he severely thin or wasted?

3B630

During the illness that led to death, did s/he have a whitish rash inside the
mouth or on the tongue?

3B640

Did (s)he have stiffness of the whole body or was unable to open the
mouth?

3B650

Did (s)he have puffiness of the face?

Face
Trunk or abdomen
Extremities
Everywhere
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B652

For how many days did (s)he have puffiness of the face?

DAYS

3B654

During the illness that led to death, did (s)he have swelling in the armpits?

3B656

During the illness that led to death, did (s)he have swollen legs or feet?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B658

How many days did the swelling last?

DAYS

3B660

Did (s)he have both feet swollen?

3B665

Did (s)he have general puffiness all over hi(s)her body?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

WHOVA2014

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3B610
3B610
3B610

3B630
3B630
3B630

3B654
3B654
3B654

o
o
o
o
o
o
o
o

3B660
3B660
3B660

oo

oo
o
o
o
o
o
o
o
o

11

3B670

Did (s)he have any lumps?

3B680

Did (s)he have any lumps or lesions in the mouth?

3B690

Did (s)he have any lumps on the neck?

3B700

Did (s)he have any lumps on the armpit?

3B710

Did (s)he have any lumps on the groin?

3B720

Did she have any swelling or lump in the breast?

3B722

Did she have any ulcers (pits) in the breast?

3B724

Was (s)he in any way paralysed?

3B730

Did s(he) have paralysis of only one side of the body?

3B731

Which were the limbs or body parts paralysed?

3B732

Did (s)he have difficulty swallowing?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Right side
Left side
Lower part of body
Upper part of body
One leg only
One arm only
Whole body
Other
YES
NO
DK
Ref.

3B734

For how many days before death did (s)he have difficulty swallowing?

DAYS

3B740

Was the difficulty with swallowing with solids, liquids, or both?

3B745

Did (s)he have pain upon swallowing?

3B750

Did (s)he have yellow discoloration of the eyes?

Solids
Liquids
Both
YES
NO
DK
Ref.
YES
NO
DK
Ref.

WHOVA2014

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3B732
3B732
3B732

3B745
3B745
3B745

o
o
o
o
o
o
o
o
o
o
o

3B760
3B760
3B760

oo

12

3B755

For how many days did (s)he have the yellow discoloration?

DAYS

3B760

Did her/his hair change in colour to a reddish or yellowish colour?

3B770

Did (s)he look pale (thinning/lack of blood) or have pale palms, eyes or nail
beds?

3B780

Did (s)he have sunken eyes?

3B790

Did (s)he drink a lot more water than usual?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

CHECK SEX OF THE DECEASED (QUESTION 1A110):

IF FEMALE

WHOVA2014

IF MALE

JUMP TO SECTION7, No. 3E100

13

SECTION 6. SIGNS AND SYMPTOMS ASSOCIATED WITH PREGNANCY AND WOMEN

3B798

Did she ever have a period or menstruate?

3B800

Did she have excessive vaginal bleeding in between menstrual periods?

3B810

Did her menstrual period stop naturally because of menopause?

3B820

Did she have vaginal bleeding after cessation of menstruation?

3B830

Was there excessive vaginal bleeding in the week prior to death?

3B840

At the time of death was her period overdue?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3B850

For how many weeks had her period been overdue?

WEEKS

3C105

Did she have a sharp pain in her abdomen shortly before death?

3C110

Was she pregnant at the time of death?

3C120

Did she die within 6 weeks of delivery, abortion or

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

miscarriage?

3C125

For how many months was she pregnant?

3C135

Please confirm: you said she was NOT pregnant and had NOT recently been YES
pregnant or delivered when she died is that right?
NO
DK
Ref.
Did she die within 24 hours after delivery?
YES
NO
DK
Ref.
Did she die during labour, and before delivery?
YES
NO
DK
Ref.
Did she die after delivering a baby?
YES
NO
DK
Ref.

3C200

3C210

3C212

WHOVA2014

MONTHS

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3C105
3C105
3C105

3C105
3C105
3C105

oo
o
o
o
o
o
o
o
o
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3C125

3C135

3C200
3E100

14

3C213

Did she give birth to a live baby within 6 weeks of death?

3C215

Did she die during or after a multiple pregnancy?

3C220

Was she breastfeeding the child in the days before death?

3C230

How many births, including stillbirths, did she/the mother have before this
baby?
Had she had any previous Caesarean section?

3C240

3C260

3C270

3C280

3C290

3C310

3C320

3C330

3C340

3C350

3C360

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Number

YES
NO
DK
Ref.
During pregnancy, did she suffer from high blood
pressure?
YES
NO
DK
Ref.
Did she have foul smelling vaginal discharge during pregnancy or after
YES
delivery?
NO
DK
Ref.
During the last 3 months of pregnancy, did she suffer from convulsions?
YES
NO
DK
Ref.
During the last 3 months of pregnancy did she suffer from blurred vision?
YES
NO
DK
Ref.
Did she have excessive bleeding during pregnancy
before labour started? YES
NO
DK
Ref.
Was there vaginal bleeding during the first 6 months of pregnancy?
YES
NO
DK
Ref.
Was there vaginal bleeding during the last 3 months of pregnancy but
YES
before labour started?
NO
DK
Ref.
Did she have excessive bleeding during labour or delivery?
YES
NO
DK
Ref.
Did she have excessive bleeding after delivery or abortion?
YES
NO
DK
Ref.
Was the placenta completely delivered?
YES
NO
DK
Ref.

WHOVA2014

o
o
o
o
o
o
o
o
o
o
o
o

oo
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3C340
3C340
3C340

15

o
o
o
o

3C365

Did she deliver or try to deliver an abnormally positioned baby?

YES
NO
DK
Ref.

3C370

For how many hours was she in labour?

HOURS

3C380

Did she attempt to terminate the pregnancy?

3C390

Did she recently have a pregnancy that ended in an abortion (spontaneous

or induced)?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Hospital

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Other
health
facility

Home

On route to
hospital or
facility

Other

YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES

o
o
o
o
o
o
o
o
o

NO

DK
Ref.

o
o

3C393

Did she die during an abortion?

3C395

Did she die within 6 weeks of having an abortion?

3C400

Where did she give birth?

3C430

Did she receive professional assistance during the delivery?

3C440

Did she have an operation to remove her uterus shortly before death?

oo

3C400
3C400
3C400

How did the mother deliver her baby?

3C450

Was the delivery normal vaginal, without forceps or vacuum?

3C460

Was the delivery vaginal, with forceps or vacuum?

3C470

Was the delivery a Caesarean section?

WHOVA2014

3C480

3C480

16

3C480

Was the baby born more than one month early?

WHOVA2014

YES
NO
DK
Ref.

o
o
o
o

17

SECTION 7. HISTORY OF INJURIES/ACCIDENTS

3E100

3E102

Did (s)he suffer from any injury or accident that led to her/his
death?

Was the injury intentionally inflicted by someone else?

3E104

Was (s)he injured by a firearm?

3E106

Was (s)he stabbed, cut or pierced?

3E108

Was (s)he strangled?

3E111

Was (s)he injured by a blunt force?

3E112

Was (s)he injured by burns?

3E113

Do you think (s)he committed suicide?

3E115

Was it a road traffic accident?

3E120

3E170

What was her/his role in the road traffic accident?

What was the counterpart that was hit during the road traffic
accident?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Pedestrian
Driver or passenger in car
or light vehicle
Driver or passenger in
bus or heavy vehicle
Driver or passenger on a
motorcycle
Driver or passenger on a
pedal cycle
Pedestrian
Stationary object
Car or light vehicle
Bus or heavy vehicle
Motorcycle
Pedal cycle
Other

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3F100
3F100
3F100

3E113
3E113
3E113

3E310
3E310
3E310

o
o
o
o
o
o
o
o
o
o
o

18

3E310

Was (s)he injured in a fall?

3E320

Did (s)he die of drowning?

3E330

Was (s)he suffering from burns?

3E335

Was (s)he injured by a blunt force?

3E340

Was (s)he injured by a plant/ animal/insect that led to her/his

death?

3E400

What was the plant/animal/insect?

3E500

Was (s)he injured by a force of nature?

3E510

Was there any poisoning?

3E520

Was (s)he subject to violence/assault?

3E530

Was it electrocution?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
Dog
Snake
Insect or Scorpion
Others
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

3E500
3E500
3E500

19

SECTION 8. RISK FACTORS

3F100

Did (s)he drink alcohol?

3F110

Did (s)he smoke tobacco (cigarette, cigar, pipe, etc.)?

3F120

What kind of tobacco did (s)he use?

3F130

How many cigarettes did (s)he smoke daily?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
Cigarettes
Pipe
Chewing tobacco
Local form of tobacco
Other
NUMBER

o
o
o
o
o
o
o
o
o
o
o
o
o

3G110
3G110
3G110

3H130
3H130
3H130

3G190
3G190
3G190

oo

SECTION 9. HEALTH SERVICE UTILISATION

3G110

Did (s)he receive any treatment for the illness that led to
death?

3G120

Did (s)he receive oral rehydration salts?

3G130

Did (s)he receive (or need) intravenous fluids (drip)

treatment?

3G140

Did (s)he receive (or need) a blood transfusion?

3G150

Did s/he receive (or need) treatment/food through a tube

passed through the nose?

3G160

Did (s)he receive (or need) injectable antibiotics?

3G165

Did (s)he receive (or need) antiretroviral therapy (ART)?

3G170

Did (s)he have (or need) an operation for the illness?

3G180

Did (s)he have the operation within 1 month before death?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

20

3G190

Was (s)he discharged from hospital very ill?

3H130

Was care sought outside the home while (s)he had this
illness?

3H140

Where or from whom did you seek care?

3H150

Record the name and address of any hospital, health centre

or clinic where care was sought

3H160

Did a health care worker tell you the cause of death?

YES
NO
DK
Ref.
YES
NO
DK
Ref.
Traditional healer
Homeopath
Religious leader
Government hospital
Government health
centre or clinic
Private hospital
Community-based
practitioner associated
with health system
Trained birth attendant
Private physician
Pharmacy
YES
NO
DK
Ref.
YES
NO
DK
Ref.

3H170

What did the health care worker say?

__________________________________________________________________________

3H180

Do you have any health records that belonged to the

deceased?

3H190

3H200

Can I see the health records?

Record the date of the most recent (last) visit

YES
NO
DK
Ref.
YES
NO
DK
Ref.
DAY

Record the date of the last but one (second last) visit

YEAR
3H220

Record the date of the last note on the health records

DAY
MONTH
YEAR

3H230
3H240

Record the weight (in kilograms) written at the most recent

(last) visit
Record the weight (in kilograms) written at the last but one
(second last) visit

WHOVA2014

o
o
o
o
o
o
o
o
o
o
o

o
o
o
o
o
o
o
o

ooo.o

MONTH

3H180
3H180
3H180

4A100
4A100
4A100

4A100
4A100
4A100

[KG]

DAY

3H160
3H160
3H160

[KG]

YEAR

oo
oo
oo
oo
oo
oo
oo
oo
oo
ooo.o

MONTH

3H210

o
o
o
o
o
o
o
o
o
o
o
o

21

3H250

Transcribe the last note on the health records

DAY
MONTH
YEAR

oo
oo
oo

SECTION 10. Background and context

4A100

In the final days before death, did s/he travel to a hospital or

health facility?

4A110

Did (s)he use motorised transport to get to the hospital or

health facility?

4A120

Were there any problems during admission to the hospital or

health facility?

4A130

Were there any problems with the way (s)he was treated
(medical treatment, procedures, interpersonal attitudes,
respect, dignity) in the hospital or health facility?

4A140

Were there any problems getting medications, or diagnostic

tests in the hospital or health facility?

4A150

Does it take more than 2 hours to get to the nearest hospital

or health facility from the deceased's household?

4A160

In the final days before death, were there any doubts about
whether medical care was needed?

4A170

In the final days before death, was traditional medicine used?

4A180

In the final days before death, did anyone use a telephone or

cell phone to call for help?

4A190

Over the course of illness, did the total costs of care and
treatment prohibit other household payments?

WHOVA2014

YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

4A150
4A150
4A150

22

SECTION 11. OPTIONAL OPEN NARRATIVE

5A100

Narrative Description
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

SECTION 12. DEATH CERTIFICATE

6H260

6H270

Was a death certificate issued?

Can I see the death certificate?

YES
NO
DK
Ref.
YES
NO
DK
Ref.

o
o
o
o
o
o
o
o

END
END
END

6H280

Record the immediate cause of death from the certificate (line 1a) *

END

END

END
Duration 1(a)

6H290

____________________________________________________________
Record the first antecedent cause of death from the certificate (line 1b)

Duration 1(b)

6H300

____________________________________________________________
Record the second antecedent cause of death from the certificate (line 1c)

Duration 1(c)

6H310

____________________________________________________________
Record the third antecedent cause of death from the certificate (line 1d)

Duration 1(d)

6H320

____________________________________________________________
Record the contributing cause(s) of death from the certificate (part 2)
____________________________________________________________

WHOVA2014

23