BIBLIOGRAPHIC INPUT SHEET TEMPORARY Patterns of mortality ...

362 Patternsof Mortality in Childhood
INTERoAMERICAN INVESTIGATION OF MORTALITY IN CHILDHOOD
Confidential Death -page I
1. Name of child
2. Serial no.
3. Date of 4. Date of 5. Sex T6. Age at
birth
death
death -yrs. -mos. -days-hre.
7. Address
Sector or division
HOUSING
8. Neighbor, 9. Type of 10.Number of l.Water: Pipect water Other IiTollet: Flush Other None
hood - housing - rooms _ Inside r3Outside " 0 03E 0 13
13. HOUSEHOLD ROSTER
Education Length of residence
Relation Date of A
Ind. Nam Nad. toAe Date of e Maria Total Last In Last 5 years
head birth* sttus years..TypeTYear, rnity Urban Rural
z
3
4
5
6
9
10
Zl
*Enter date of birth for children under 6 years.
14. OCCUPATION
In.Currently
Time in
Ind. Name eply Occupation Kind of business
no. employed occupation
15. DEATHS IN HOUSEHOLD IN PAST YEAR
Name of deceased Age Sex Date Home Hosp. Name of hospital Other
16. PREGNANCY HISTORY OF MOTHER
O)rder Date
Live births
pregnancy Abortion? Stillbirth?
aend Name of child Sex Living now? Age at death
I
2
3
4
5
6
7
-8
9
to
17. Preanant now? Yes 0' No E3I Unknown 0]
19. Source of
Ind
information: Name. no. ­
18. Rn~marks:
Date
Interviewer