Instrument_NIST Mortality Study Hurricane Maria

HURRICANE MARIA NATIONAL CONSTRUCTION SAFETY TEAM INVESTIGATION: VERBAL AUTOPSY AND SOCIO-ENVIRONMENTAL SURVEY

FULL IMPLEMENTATION

OMB Control # 0693-0078

Expiration Date 7/31/2022

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0693-0078. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the National Institute of Standards and Technology at: 100 Bureau Drive, Gaithersburg, MD 20899, Attn: Dr. Maria Dillard, Associate Team Lead for the NIST Hurricane Maria Program, NIST Engineering Laboratory; or contact at maria.dillard@nist.gov.

Part 1: Introduction

Instruction: “Hello, I am part of an investigation of impacts from Hurricane María by the NIST/UPR/GWU. I am interested in hearing about the deceased’s experience leading up to Hurricane María’s landfall on Puerto Rico on September 20, 2017, particularly the 14 days after. I realize that the hurricane was a few years ago, and so I will ask questions related to the event to aid your memory.

The survey is expected to take 60 minutes. You will not receive compensation for participating in this survey, and your participation is completely voluntary. However, your feedback will help us to better understand the causes of death from Hurricane María and will lead to recommendations to improve codes, standards, and practices for Puerto Rico. In our reported findings, your responses will be kept anonymous and will not be associated with your name or other personally identifiable information.”

Part 2: Questionnaire

Q#	Question	Response
I. Informant Characterization
This section asks about the informant and relationship to the deceased.
1.1	What was the full name of the deceased? (INTERVIEWER: VERIFY THE NAME IS CONSISTENT WITH THE DECEASED PERSON THE INTERVIEW SHOULD REFER TO ACCORDING TO PRE-ENTERED INFORMATION)	_First name(s) _Last name(s) _Mother’s last name(s) _Refused to answer _Don’t know
1.2	What was your relationship to the deceased?	_Father _Mother _Sister _Brother _Son _Daughter _Aunt _Uncle _Grandmother _Grandfather _Non-relative (specify:___)

1.3	At the time of Hurricane María, did you live with the deceased?	_Yes _No _Refused to answer _Don’t know
1.4	How many years did you know the deceased?	_Integer _Months _Years _Refused to answer _Don’t know
II. Deceased Characterization
This section asks about characteristics of the deceased (him/her).
INTERVIEWER: FROM THIS POINT, REFER TO THE DECEASED AS HE/SHE AND HIM/HER.
2.1	How old was he/she when he/she died?	_Integer _Years _Refused to answer _Don’t know
2.2	Approximately how long did he/she lived in the last permanent residence?	_Integer _Years _Refused to answer _Don’t know
2.3	What was his/her ethnicity?	_Hispanic or Latino _Other (specify: _____) _Refused to answer _Don’t know
2.4	What was the main language spoken in his/her household?	_English _Spanish _Creole _French _Other (specify: _____) _Refused to answer _Don’t know
2.5	What was his/her marital status?	_Single _Married _Live together _Divorced _Widowed _Other (specify:___) _Refused to answer _Don't know

2.6	Was he/she able to read and/or write?	_Read only _Write only _Both _None _Refused to answer _Don’t know
2.7	What was his/her highest level of schooling?	_Did not attend school _Elementary school _Middle school _High school _Some college _Associate degree _Bachelor degree _Postgraduate _Other _Refused to answer _Don't know
2.8	During the 3 months prior to Hurricane María, what was his/her main occupation, that is, what kind of work did he/she mainly do?	_Management, Business and financial operations _Professional and related occupation _Service occupations _Sales and related occupations _Office and Administrative support occupations _Farming, fishing and forestry occupations _Construction and extraction occupations _Installation, maintenance and repair occupations _Production occupations _Transportation and material moving occupations _Student _Unemployed _Retired _Other (specify: _____) _Refused to answer _Don't know

2.9	What was the total annual household gross income during the time of Hurricane María? The total annual household gross income means income before taxes of the Head of Household plus all other incomes in the household.	_<$5,000 _$5,000 - $9,999 _$10,000 - $14,999 _$15,000 - $19,999 _$20,000 - $24,999 _$25,000 - $34,999 _$35,000 - $44,999 _$45,000 - $54,999 _$55,000 - $64,000 _$65,000 or more _Refused to answer _Don’t know
2.10	Did he/she have health insurance?	_Yes _No _Refused to answer _Don’t know
2.11	Was he/she a member of any community organization?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON´T KNOW, SKIP TO SECTION III.
2.12	What community organization was he/she a member?	_Volunteer at local organization _Member at local church group _ Other _Refused to answer _Don’t know
2.13	Did he/she ever work together with his/her community on preparation, mitigation, or other elements of potential disasters, to improve the community's resilience?	_Always _Often _Sometimes _Rarely _Never _Refused to answer _Don't know
2.14	Did he/she have family, friends and/or another network in the community, that could support him/her in case of an emergency (for example: help providing transportation; help to access medical care or medicines; help to provide food, water, other provisions; help providing shelter, etc)?	_Yes _No _Refused to answer _Don’t know

III. Household and Neighborhood Characteristics
This section asks about the permanent residence of the deceased, and surrounding neighborhood characteristics.
3.1	Was his/her permanent residence owned or rented?	_It was owned by him/her or others _It was rented by him/her or others _Other (specify:___) _Refused to answer _Don't know
3.2	What was the predominant material of the floor?	_Soil or dirt _Concrete _Tile _Wood _Other _Refused to answer _Don't know
3.3	What was the predominant material of the roof?	_Slate _Tile _Shingle _Concrete _Metal (Zinc Corrugated Panels) _Steel _Wood _Other _Refused to answer _Don’t know
3.4	What was the predominant material of the walls?	_Reinforced Concrete _Concrete blocks _Masonry _Wood panel _Other _Refused to answer _Don’t know
3.5	On a scale of 1 to 5, 1 represents "unlikely" and 5 represents a “certain”, what was the likelihood of the following hazards affecting the area of the residence? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Winds (_1 _2 _3 _4 _5) _Floods (_1 _2 _3 _4 _5) _Rains (_1 _2 _3 _4 _5) _Landslides (_1 _2 _3 _4 _5) _Coastal flooding (_1 _2 _3 _4 _5) _Coastal erosion (_1 _2 _3 _4 _5)
3.6	How many rooms did the residence have for sleeping?	_1 room _2 rooms _3 rooms _4 rooms _>5 rooms _Refused to answer _Don't know

3.7	What was the primary source of drinking water?	_Tap water _Bottled water _Spring/River _Water well _Cistern _Rain water _Cistern trucks _Other (specify:___) _Refused to answer _ Don't know
3.8	What was the primary type of fuel/energy used for cooking?	_Wood _Coal _Gas _Electricity _Other _Refused to answer _Don't know
3.9	Did the residence have an active electricity service connection?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON´T KNOW, SKIP TO QUESTION 3.11
3.10	Which was the source?	_Public electric/power grid _Power generators _Solar panels _Refused to answer _Don’t know
3.11	Before the landfall of Hurricane María, from the list of items, which of the following was in use and/or functioning? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Landline phone _Cellphone _Wi-Fi _Radio _TV _Car _Refused to answer _Don’t know
3.12	From this list of services, which of the following was of walking distance from the residence? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Supermarket _Pharmacy _Gas station _Health Center or ‘CDT’ _Hospital _Other _Refused to answer _Don’t know
3.13	How many people lived in the residence?	_Integer _Refused to answer _Don’t know
3.14	How many people in the residence were in the following age categories? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	__<1 year old __ 1-5 years old __6-12 years old __13-18 years old __19-64 years old __65+ years old _Refused to answer _Don’t know
3.15	Did the deceased or a household member suffer from any of the following? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_A hearing difficulty _A vision difficulty _A cognitive difficulty _An ambulatory difficulty _A self-care difficulty _Refused to answer _Don’t know
3.16	Were there pets and/or farm animals on the property?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER OR DON'T KNOW, SKIP TO NEXT SECTION IV
3.17	During the landfall of Hurricane María, did having a pet(s) or farm animal(s) affect the decision of whether go to a shelter?	_Yes _No _Refused to answer _Don’t know
IV. Circumstances and Location of the Deceased at Time of Hurricane María
This section asks about his/her location and circumstances during the time of Hurricane María and during the first 14 days after Hurricane María landfall.
4.1	Did he/she die days before, the day of, or days after landfall of Hurricane María?	_ The days before landfall (19th and prior) _The day of landfall (Sept. 20) _The days after landfall (21st onward) _Refused to answer _Don’t know
IF AFTER SKIP TO QUESTION 4.4, IF DURING SKIP TO QUESTION 4.5

4.2	What was the exact day and time (before the landfall of the hurricane) in which the person died?	__/ _/__ Month/day/year _____: ___ Hours Minutes _Refused to answer _Don’t know
SKIP TO SECTION V
4.3	What was the exact day and time (after the landfall of the hurricane) in which the person died?	__/ _/__ Month/day/year _____: ___ Hours Minutes _Refused to answer _Don’t know
4.4	In the day of the landfall and the 14 days after Hurricane María’s landfall, where was he/she living? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Permanent residence _Family _Friend’s _Neighbor _Shelter _Health center or ‘CDT’ _Hospital _Vehicle _Other (specify:___) _Refused to answer _Don’t know
4.5	Had he/she evacuated his/her permanent residence at the time of Hurricane María?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON´T KNOW, SKIP TO QUESTION 4.9.
4.6	When did he/she and his/her family evacuate the residence?	_The day of landfall (Sept. 20) _The days before landfall (19th and prior) _The days after landfall (21st onward) _During Hurricane María _After Hurricane María _Refused to answer _Don't know
4.7	When evacuating the residence, where did he/she find shelter?	_At a relative's house _At a friend's house _Government shelter _NGO shelter _Faith-based organization shelter _Evacuated to mainland _Hospital _Hotel _Other (specify: __) _Refused to answer _Don’t know
4.8	Since first evacuating, did he/she move subsequently?	_Yes _No _Refused to answer _Don’t know
4.9	In the day of the landfall and the 14 days after Hurricane María’s landfall, how many places did the deceased live in?	_Integer _Refused to answer _Don’t know
4.10	Can you mention where the deceased person lived and/or found shelter?	Place 1: specify (________) Place 2: specify (________) Place 3: specify (________) Place 4: specify (________)
4.11	Can you mention how long the deceased person lived and/or found shelter in each one of these places?	Place 1: _ integer Place 2: _ integer Place 3: _ integer Place 4: _ integer
4.12	Can you confirm, at the time when he/she died, where was he/she living?	_Place 1 _Place 2 _Place 3 _Place 4 _Other (specify:_____) _Refused to answer _Don’t know
V. Environmental and Socio-Environmental Factors and Stressors
This section asks about the environmental and socio-environmental factors and stressors that may have affected him/her.
This part of the sections asks about what happened during Hurricane María, this includes the 1-4 days previous to the landfall.
5.1	In the previous section, you said that during Hurricane María he/she was living in (CONFIRM WITH QUESTION 4.4 RESPONSE).	_His/her permanent residence _Family _Friend’s _Neighbor _Shelter _Health center or ‘CDT’ _Hospital _Vehicle _Other (specify:___) _Refused to answer _Don’t know
5.2	During 1-4 days prior Hurricane María landfall, how many people were living with him/her?	_Integer _Refused to answer _Don’t know
5.3	During 1-4 days prior Hurricane María landfall, what was the primary source of drinking water?	_Tap water _Bottled water _Spring/River _Water well _Cistern _Rain water _Cistern trucks _Other (specify:___) _Refused to answer _ Don't know
5.4	During 1-4 days prior Hurricane María landfall, what was the primary type of energy used for cooking?	_Firewood _Coal _Gas _Electricity _Other _Refused to answer _Don't know
5.5	During 1-4 days prior Hurricane María landfall, was there an active electricity supply?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON´T KNOW, SKIP TO QUESTION 5.7
5.6	During 1-4 days prior Hurricane María landfall, what was the source?	_Public electric/power grid _Power generators _Solar panels _Refused to answer _Don’t know
5.7	During 1-4 days prior Hurricane María landfall, which of the following items were in use and/or functioning? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Landline phone _Cellphone _Wi-Fi _Radio _TV _Car _Refused to answer _Don’t know
5.8	During 1-4 days prior Hurricane María landfall, which of the following services were open, functioning and within walking distance? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Supermarket _Pharmacy _Gas station _Diagnostic and Treatment Center (CDT) _Health center _Hospital _Other _Refused to answer _Don’t know
5.9	During 1-4 days prior Hurricane María landfall, how many of the people living with him/her were in the following age categories? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	__<1 year old __ 1-5 years old __6-12 years old __13-18 years old __19-64 years old __65+ years old
5.10	During 1-4 days prior Hurricane María landfall, did the deceased or any of the people living with him/her, suffer from any of the following? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_A hearing difficulty _A vision difficulty _A cognitive difficulty _An ambulatory difficulty _A self-care difficulty _Refused to answer _Don’t know
Now, I will ask you about the day of the landfall and the 14 days after Hurricane María made landfall. If he/she lived in more than one place, think about the first place where he/she lived in that period. QUESTIONS 5.11 TO 5.33 WILL BE COMPLETED FOR EACH OF THE PLACES WHERE THE PERSON LIVED, REFERRING IN THE PROGRAMMING TO PLACE 1, PLACE 2, ETC. SKIP TO SECTION VI IF THE PERSON DIED BEFORE THE LANDFALL.
5.11	Was the residence affected by Hurricane María?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 5.14
5.12	How was the residence affected by Hurricane María? (INTERVIEWER: READ OPTIONS AND CHECK ALL THAT APPLY)	_Rain entered house _Flood waters entered house _Loss of power _Loss of water _Loss of telecommunications _Damage to windows, doors, walls _Minimal to moderate damage to roof; less than 50% impacted _Considerable damage to roof; more than 50% destroyed _Collapse of house, or completely destroyed
5.13	Based on your observations, was the residence damaged by one of the following? (INTERVIEWER: READ OPTIONS AND CHECK ALL THAT APPLY)	_Coastal floods _Floods _Wind _Rainfall _Flying objects _Landslide _Other
5.14	Was there running potable water where he/she was living?	_Yes _No _Refused to answer _Don’t know
IF YES, SKIP TO QUESTION 5.16
5.15	How many days was he/she living without running water?	OPEN _Refused to answer _Don’t know

5.16	What sources of water were used for cooking? (INTERVIEWER: SELECT ALL THAT APPLY)	_Bottled water _Spring/River _Water well _Cistern _Rain water _Cistern trucks _Other (specify:___) _Refused to answer _ Don't know
5.17	What sources of water were used for drinking? (INTERVIEWER: SELECT ALL THAT APPLY)	_Bottled water _Spring/River _Water well _Cistern _Tap water _Rain water _Cistern trucks _Other (specify:___) _Refused to answer _ Don't know
IF RESPONSE IS BOTTLED WATER, REFUSED TO ANSWER, OR DON’T KNOW, SKIP TO QUESTION 5.19
5.18	What kind of disinfection method(s) (if any) was used to make potable water? (INTERVIEWER: SELECT ALL THAT APPLY)	_Boiled the water _Chlorinated the water _Used water filters _Did not treat the water _Did not need to treat the water _Other (specify:___) _Refused to answer _Don't know
5.19	What sources of water were used for bathing? (INTERVIEWER: SELECT ALL THAT APPLY)	_Tap water _Bottled water _Spring/River _Water well _Cistern _Rain water _Cistern trucks _Other (specify:___) _Refused to answer _ Don't know
5.20	What was the primary type of fuel used for cooking?	_Firewood _Coal _Gas _Electricity _Other _Refused to answer _Don't know
5.21	Was there active electricity supply from their public electrical utility?	_Yes _No _Refused to answer _Don’t know
IF YES, SKIP TO QUESTION 5.30
5.22	How many days was he/she without an active electricity supply?	OPEN _Refused to answer _Don’t know
IF 0 DAYS, SKIP TO QUESTION 5.29
5.23	If 1 or more days without active electricity supply: Was there active electricity supply for some HOURS a day?	_Yes, (Integer) _None _Variable/unpredictable _Other (specify:___)
5.24	Was there a fully functioning electric portable generator to cover the electricity demand?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER OR DON’T KNOW, SKIP TO QUESTION 5.29
5.25	What fuel did the generator use?	_Gas (liquified petroleum gas) _Gasoline _Diesel _Other (specify:____) _Refused to answer _Don’t know
5.26	How many hours a day, on average, did the portable electric generator run?	_<3 hours _3-6 hours _6-9 hours _9-12 hours _12-15 hours _>15 hours _Refused to answer _Don’t know

5.27	Where was the portable electric generator located?	_Interior of the residence _Exterior of the residence _Carport/garage _Balcony _Back yard _Front yard _Other (specify:____) _Refused to answer _Don’t know
5.28	Was the portable electric generator located near a door or window?	_Yes _No _Refused to answer _Don’t know
5.29	Was there a working carbon monoxide detector at the residence?	_Yes _No _Refused to answer _Don’t know
5.30	To the best of your knowledge, which of the following additional hazardous conditions and elements was he/she exposed to? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Presence and abundance of mosquitoes _Extreme heat during the day _Extreme heat during the night _Molds _Air pollution (emissions associated with portable electric generators) _Noise pollution (noise associated with portable electric generators) _Debris _Rodents (mice, rats, others) _Garbage _Other _Refused to answer _Don’t know

5.31	Were there any of the following sources of toxic chemical and/or harmful pollutants nearby, if any? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Oil/fuel plants _Gas stations _Insecticides/pesticides _Paint shops _Hardware stores _Landfill _Factories _Toxic waste sites _Mechanical workshops _Other potential hazardous substances sites _No toxic chemicals identified _Refused to answer _Don’t know
5.32	How often did he/she sleep in temperatures that he/she considered uncomfortably hot? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Never _Rarely _Sometimes _Often _Always _Refused to answer _Don’t know
5.33	Did he/she use any of the following to stay cool inside the residence? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_AC _Ceiling or other fans _Open windows and doors _Other (specify:____) _Refused to answer _Don’t know
	INTERVIEWER: IF THE DECEASED ONLY LIVED IN ONE PLACE OVER THE LANDFALL AND 14 DAY PERIOD, GO TO THE NEXT SECTION. IF THE DECEASED LIVED IN >1 PLACE, RESTART FROM QUESTION 5.11, REFERRING TO THE SECOND PLACE. THE QUESTIONNAIRE PROGRAMMED IN THE TABLE WILL DIRECT YOU THERE. THE PROGRAM WILL MAKE AS MANY LOOPS NECESSARY TO MATCH THE NUMBER OF PLACES MENTIONED IN QUESTION 4.8.

VI. Preparedness Management Phases
This section asks about the measures taken in preparation, that is, an emergency plan, for Hurricane María.
6.1	To the best of your knowledge, had he/she lived through any other natural hazards before hurricanes María and Irma? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Earthquakes _Floods _Hurricanes _Tsunamis _Extreme heat episodes _Landslides _Other _Refused to answer _Don’t know
6.2	Did he/she have an emergency plan to face the hurricane impact?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, SKIP TO QUESTION 6.4
6.3	What actions were there taken as an emergency plan? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_Stock of food and water _Stock of medicines and other medical supplies _Had batteries and flashlights _Securing the envelope of the building: windows, or openings _Securing the roof with clip/straps _Identifying the shelter they had to attend _Other (specify:___) _Refused to answer _Don’t know
6.4	Did the household prepare for the hurricane with protective actions to the structure?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON´T KNOW, SKIP TO QUESTION 6.6

6.5	What protective actions to the structure did he/she prepare for the hurricane? (INTERVIEWER: SELECT ALL THAT APPLY)	_Protecting windows or openings with shutters _Protecting windows or opening with plywood _Pruning the trees _Disconnected the electrical appliances _Didn’t leave any garbage, debris or trash outside _Refused to answer _Don’t know
6.6	For how many days did he/she have enough food?	OPEN _Refused to answer _Don’t know
6.7	For how many days did he/she have enough water? (Assuming 1 person = 1 gallon/day)	OPEN _Refused to answer _Don’t know
VII. Verbal Autopsy: Injuries
This section asks about the occurrence of Injuries and other harm he/she suffered at the time of Hurricane María
7.1	Did he/she suffer from any injury before, or at the time of Hurricane María?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, SKIP TO NEXT SECTION: VIII
7.2	How was he/she injured? (INTERVIEWER: SELECT ALL THAT APPLY)	_Drowning _Asphyxia _Struck by a lightning _Hit by flying debris _Hit by collapsing tree _Hit by external structure _Hit by internal structure _Road traffic crash/injury _Fall _Poisoning _Bite or sting by venomous animal _Burn/fire _Cutting/bleeding _Self inflicted harm _Intentionally inflicted by other _Other (specify:____) _Refused to answer _Don’t know
7.3	If the response is yes for drowning, asphyxia, flying debris, hit by collapsing tree, hit by external structure or hit by internal structure were there any of the hazardous conditions present? (INTERVIEWER: SELECT ALL THAT APPLY)	_Coastal floods _Floods _Wind _Rainfall _Landslide _Other _Refused to answer _Don’t know
7.4	If the response is yes for road traffic crash/injury, were there any of the following hazardous conditions present? (INTERVIEWER: SELECT ALL THAT APPLY)	_ Hazardous conditions previous to landfall like flying debris _ Hazardous conditions previous to landfall like wind and rain _Hazardous conditions occurring during Hurricane María like flying debris _Hazardous conditions occurring during Hurricane María like wind and rain _Hazardous conditions after the hurricane, like fallen objects and trees, _Hazardous conditions after the hurricane, like flooding _Other (specify:____) _Refused to answer _Don’t know
7.5	If the response is yes for poisoning, what was the poisoning from?	_Carbon monoxide _Gas from the kitchen _Gas from another household appliance _Household cleaning products (bleach, disinfectants) _Inhalation of fumes/smoke _Other (specify:____) _Refused to answer _Don’t know
7.6	If the response is yes for carbon monoxide, what was the exposure from?	_Generator _Automobile/RV _Boat _Kerosene/Gas space heater _Gas powered tools _Other (specify:____) _Refused to answer _Don’t know
7.7	Was the injury self-inflicted?	_Yes _No _Refused to answer _Don’t know
7.8	Was the injury intentionally inflicted (e.g. an assault) by someone else?	_Yes _No _Refused to answer _Don’t know
VIII. Verbal Autopsy: Symptoms and/or Signs
FOR THE INTERVIEWER:	What age group does the deceased´s last known age fall into? (INTERVIEWER: VERIFY THAT THE RESPONSE TO THIS QUESTION MATCHES WITH THE MODULE OF THE VA WHERE YOU ARE DIRECTED)	_Adolescent/Adult _Child _Neonate
8.1. ADOLESCENT/ADULT SECTION TO BE ANSWERED IF THE DECEASED IS 12 YEARS OR OLDER. VERIFY WITH QUESTION 2.1 AND PREVIOUS INFORMATION ABOUT THE DECEASED.
8.1.1 Pre-Existing Medical Condition
To the best of your knowledge, was he/she ever told by a health professional that he or she ever suffered from one of the following?
8.1.1.1	Asthma	_Yes _No _Refused to answer _Don’t know
8.1.1.2	Cancer	_Yes _No _Refused to answer _Don’t know
8.1.1.3	COPD (Chronic Obstructive Pulmonary Disease)	_Yes _No _Refused to answer _Don’t know
8.1.1.4	Dementia/Alzheimer	_Yes _No _Refused to answer _Don’t know
8.1.1.5	Depression/mood changes	_Yes _No _Refused to answer _Don’t know
8.1.1.6	Epilepsy	_Yes _No _Refused to answer _Don’t know
8.1.1.7	Heart Disease	_Yes _No _Refused to answer _Don’t know
8.1.1.8	High Blood Pressure/Hypertension	_Yes _No _Refused to answer _Don’t know
8.1.1.9	Tuberculosis	_Yes _No _Refused to answer _Don’t know
8.1.1.10	Diabetes	_Yes _No _Refused to answer _Don’t know
8.1.1.11	Stroke	_Yes _No _Refused to answer _Don’t know
8.1.1.12	AIDS	_Yes _No _Refused to answer _Don’t know
8.1.2 Symptoms Checklist
Now I will ask you about some symptoms he/she may have experience around the time of death.
8.1.2.1	Did he/she have a fever?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.4
8.1.2. 2	If you could not measure the fever: How severe would you say the fever was?	_Mild _Moderate _Severe _Refused to answer _Don’t know
8.1.2. 3	What was the pattern of the fever?	_Continuous _On and off _Only at night _Refused to answer _Don’t know
8.1.2. 4	Did he/she have a rash?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.6
8.1.2. 5	Where was the rash located?	_Face _Trunk _Extremities _Everywhere _Refused to answer _Don’t know
8.1.2. 6	Did he/she have sores?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.8
8.1.2. 7	Did the sores have clear fluid or pus?	_Yes _No _Refused to answer _Don’t know
8.1.2. 8	Did he/she have an ulcer (pit) on the foot?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.11
8.1.2. 9	Did the ulcer ooze pus?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.11

8.1.2. 10	For how many days did the ulcer ooze pus?	_ __ __ days Enter 99 if unknown _Refused to answer
8.1.2. 11	Did he/she have yellow discoloration of the eyes?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.13
8.1.2. 12	For how long did he/she have the yellow discoloration?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 13	Did he/she have puffiness on his/her face?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.15
8.1.2. 14	For how long did he/she have puffiness on his/her face?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 15	Did he/she have general puffiness all over his/her body?	_Yes _No _Refused to answer _Don’t know
8.1.2. 16	Did he/she have a lump in the neck?	_Yes _No _Refused to answer _Don’t know
8.1.2.17	Did he/she have a lump in the armpit?	_Yes _No _Refused to answer _Don’t know
8.1.2. 18	Did he/she have a lump in the groin?	_Yes _No _Refused to answer _Don’t know
8.1.2. 19	Did he/she have a cough?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.22
8.1.2. 20	Did the cough produce sputum?	_Yes _No _Refused to answer _Don’t know
8.1.2. 21	Did he/she cough blood?	_Yes _No _Refused to answer _Don’t know
8.1.2. 22	Did he/she have difficulty breathing?	_Yes _No _Refused to answer _Don’t know
8.1.2. 23	Did he/she experience pain in the chest in the month preceding death?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.25
8.1.2. 24	How long did the pain last?	_Less than 30 minutes _30 minutes to 24 hours _More than 24 hours _Refused to answer _Don’t know

8.1.2. 25	Did he/she have more frequent loose or liquid stools than usual?	_Yes _No _Refused to answer _Don’t know
8.1.2. 26	Was there blood in the stool?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.28
8.1.2. 27	Was there blood in the stool up until death?	_Yes _No _Refused to answer _Don’t know
8.1.2. 28	Did he/she stop urinating?	_Yes _No _Refused to answer _Don’t know
8.1.2. 29	Did he/she vomit in the week preceding the death?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.33
8.1.2. 30	Was there blood in the vomit?	_Yes _No _Refused to answer _Don’t know
8.1.2. 31	Was the vomit black?	_Yes _No _Refused to answer _Don’t know
8.1.2. 33	Did he/she have difficulty swallowing?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.35

8.1.2 33	For how long before death did he/she have difficulty swallowing?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 34	Was the difficulty with swallowing with solids, liquids, or both?	_Solids _Liquids _Both _Refused to answer _Don’t know
8.1.2. 35	Did he/she have pain upon swallowing?	_Yes _No _Refused to answer _Don’t know
8.1.2. 36	Did he/she have belly pain?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.39
8.1.2. 37	For how long before death, did he/she have belly pain?	_ __ __ hours Enter 99 if unknown _ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2.38	Was the pain in the upper or lower belly?	_Upper belly _Lower belly _Refused to answer _Don’t know
8.1.2.39	Did he/she have a more than usual protruding belly?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.42
8.1.2. 40	For how long before death, did he/she have a protruding belly?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 41	How rapidly did he/she develop the protruding belly?	_ Rapidly _ Slowly _Refused to answer _Don’t know
8.1.2.42	Did he/she have any mass in the belly?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.44
8.1.2.43	For how long before death did he/she have a mass in the belly?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 44	Did he/she have a stiff neck?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.46
8.1.2. 45	For how long before death, did he/she have stiff neck	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 46	Did he/she experience a period of loss of consciousness?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.49
8.1.2.47	Did the period of loss of consciousness start suddenly or slowly?	_Suddenly _Slowly _Refused to answer _Don’t know
8.1.2 48	Did it continue until death?	_Yes _No _Refused to answer _Don’t know
8.1.2. 49	Did he/she have convulsions?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.2.52
8.1.2. 50	For how long before death did the convulsions last?	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.1.2. 51	Did the person become unconscious immediately after the convulsions?	_Yes _No _Refused to answer _Don’t know
8.1.2. 52	Was he/she in any way paralyzed?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW: 1. IF THE DEACESED WAS FEMALE, THEN GO TO SECTION 8.1.3: QUESTIONS FOR WOMEN; 2. IF THE DEACESED WAS MALE, THEN GO TO SECTION 8.1.4: TOBACCO USE.
8.1.2. 53	Which were the limbs or body parts paralyzed? (INTERVIEWER: READ THROUGH THE LIST IN SEQUENCE AND MARK ALL THAT APPLY)	_Right side (arm and leg) _Left side (arm and leg) _Lower part of the body _Upper part of the body _One leg only _One arm only _Whole body _Other (specify:___) _Refused to answer _Don’t know
IF THE DECEASED WAS FEMALE, THEN CONTINUE TO SECTION 8.1.3: QUESTIONS FOR WOMEN. IF THE DECEASED WAS MALE, THEN GO TO SECTION 8.1.4: TOBACCO USE
8.1.3 Questions for Women
8.1.3.54	Did she have any swelling or lump in the breast?	_Yes _No _Refused to answer _Don’t know
8.1.3.55	Did she have any ulcers (pits) in the breast?	_Yes _No _Refused to answer _Don’t know
IF THE DECEDENT IS UNDER 18 YEARS OLD GO TO QUESTION 8.1.3.56 IF THE DECEDENT IS 18-39 YEARS OLD GO TO QUESTION 8.1.3.58 IF THE DECEDENT IS OVER 40 YEARS OLD GO TO QUESTION 8.1.3.57
8.1.3. 56	Did she ever have a period or menstruate?	_Yes _No _Refused to answer _Don’t know
IF YES, DON’T KNOW OR REFUSED TO ANSWER GO TO QUESTION8.1.3.59 IF NO SKIP TO SECTION 8.1.4: TOBACCO USE
8.1.3. 57	Had her periods stopped naturally because of menopause?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 8.1.3.59

8.1.3. 58	Did she have vaginal bleeding after cessation of menstruation? (post-menopausal)	_Yes _No _Refused to answer _Don’t know
8.1.3. 59	Did she have vaginal bleeding other than her period? (intermenstrual)	_Yes _No _Refused to answer _Don’t know
8.1.3. 60	Was there excessive vaginal bleeding in the week prior to death?	_Yes _No _Refused to answer _Don’t know
8.1.3. 61	At the time of death was her period overdue?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.3.63
8.1.3. 62	For how many weeks was her period overdue?	_ __ __ weeks Enter 99 if unknown _ Refused to answer _ Don’t know
8.1.3. 63	Did she have a sharp pain in the belly shortly before death?	_Yes _No _Refused to answer _Don’t know
8.1.3. 64	Was she pregnant at the time of death?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.1.3.71
8.1.3. 65	For how many months was she pregnant?	_ __ __ months Enter 99 if unknown _ Refused to answer _ Don’t know

8.1.3. 66	Did she die during an abortion?	_Yes _No _Refused to answer _Don’t know
IF YES, GO TO QUESTION 8.1.3.73
8.1.3. 67	Did bleeding occur while she was pregnant?	_Yes _No _Refused to answer _Don’t know
8.1.3. 68	Did she have excessive bleeding during labor or delivery? (“Labor” is the period of time by which contractions are less than 10 minutes apart.)	_Yes _No _Refused to answer _Don’t know
8.1.3. 69	Did she die during labor or delivery?	_Yes _No _Refused to answer _Don’t know
8.1.3. 70	For how long, was she in labor?	_ __ __ hours Enter 99 if unknown _Refused to answer _ Don’t know
IF ANSWER TO QUESTION 8.1.3.69 IS YES, SKIP TO SECTION 8.1.4: TOBACCO USE
8.1.3. 71	Did she die within 6 weeks of having an abortion?	_Yes _No _Refused to answer _Don’t know
IF YES, SKIP TO QUESTION 8.1.3.73
8.1.3. 72	Did she die within 6 weeks of childbirth?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, SKIP TO SECTION 8.1.4: TOBACCO USE
8.1.3. 73	Did she have excessive bleeding after delivery or abortion?	_Yes _No _Refused to answer _Don’t know
8.1.4 Tobacco Use
8.1.4.77	Did he/she use tobacco?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO SECTION 8.1.5: HEALTH RECORDS
8.1.4.78	What kind of tobacco did he/she use?	_Cigarettes _E-cigarettes _Pipe _Hookah _Chewing tobacco _Local form of tobacco _Other (specify:___) _Refused to answer _Don’t know
IF “YES” TO CIGARETTES, CONTINUE TO QUESTION 8.1.4.79. IF “NO” TO CIGARETTES, GO TO SECTION 8.1.5: HEALTH RECORDS
8.1.4.79	How many cigarettes did he/she smoke daily?	_Number ___ ___ _Refused to answer _Don’t know
8.1.5 Health Records
8.1.5.1	Do you have any health records that belonged to the deceased?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER OR DON’T KNOW, SKIP TO QUESTION 8.1.5.3
8.1.5.2	Can you read to me the health records?	_Yes _No _Refused to answer _Don’t know

8.1.5.3	Are the dates known for the two most recent visits to a health care provider?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER OR DON’T KNOW, SKIP TO NEXT SECTION IX.
8.1.5.4	What is the date of most recent visit to a healthcare provider	_ _/_ _/_ _ _ _ dd mm yyyy
8.1.5.5	What is the date of second most recent visit a healthcare provider	_ _/_ _/_ _ _ _ dd mm yyyy
8.2. NEONATAL VA SECTION TO BE ANSWERED IF THE DECEASED IS UNDER 1 MONTH. CHECK WITH QUESTION 2.1 AND PREVIOUS INFORMATION ABOUT THE DECEASED.
8.2.1 Background
	IF MOTHER IS RESPONDENT, MARK 8.2.1.1 AS “YES”. IF MOTHER IS NOT RESPONDENT, GO TO QUESTION 8.2.1.1
8.2.1.1	Is the mother still alive?	_Yes _No _Refused to answer _Don’t know
8.2.1.2	What was the weight of the deceased at birth?	__Grams __Kilograms _Refused to answer _Don’t know
IF WEIGHT OF THE DECEASED AT BIRTH WAS KNOWN, GO TO QUESTION 8.2.1.4. IF REFUSED TO ANSWER OR DON’T KNOW, GO TO QUESTION 8.2.1.3
8.2.1.3	At the time of the delivery what was the size of the deceased: Read the question and slowly read the first 4 choices. (INTERVIEWER: RESPONDENT SHOULD HEAR ALL FOUR CHOICES AND THEN RESPOND.)	_Very small _Smaller than usual _About average _Larger than usual _Refused to answer _Don’t know
8.2.1.4	Was the baby born alive or dead?	_Alive _Dead _Refused to answer _Don’t know
8.2.1.5	Did the baby ever cry?	_Yes _No _Refused to answer _Don’t know
8.2.1.6	Did the baby ever move?	_Yes _No _Refused to answer _Don’t know
8.2.1.7	Did the baby ever breathe?	_Yes _No _Refused to answer _Don’t know
8.2.1.8	INTERVIEWER ONLY: REFER TO QUESTIONS 8.2.1.5, 8.2.1.6, AND 8.2.1.7. IF ALL THREE RESPONSES ARE “NO” THEN CHECK “YES”. OTHERWISE, CHECK “NO”.	_Yes _No
IF YOU ANSWERED “YES” TO QUESTION 8.2.1.8 (STILLBIRTH), THEN GO TO QUESTION 8.2.1.9 IN YOU ANSWERED “NO” TO QUESTION 8.2.1.8 (LIVEBIRTH), GO TO QUESTION 8.2.1.13
8.2.1.9	Were there any bruises or signs of injury on the baby’s body at birth?	_Yes _No _Refused to answer _Don’t know
8.2.1.10	Was the baby’s body (skin and tissue) pulpy?	_Yes _No _Refused to answer _Don’t know
8.2.1.11	Was any part of the baby physically abnormal at time of delivery? (INTERVIEWER: READ EXAMPLES: “body part too large or too small”, “additional growth on body”)	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO SECTION 8.2.2: MATERNAL HISTORY.
8.2.1.12	What were the abnormalities? (INTERVIEWER: MARK ALL THAT APPLY)	_Head size very small at time of birth _Head size very large at time of birth _Mass defect on the back of head _Other (specify:_____) _Refused to answer _Don't know
AFTER COMPLETING 8.2.1.12, CONTINUE TO SECTION 8.2.2: MATERNAL HISTORY.
8.2.1.13	How old was the baby/child when the fatal illness started? (INTERVIEWER: LESS THAN 24 HOURS = 00 DAYS. ENTER AGE IN DAYS UP TO 27 DAYS. ENTER 28 DAYS AS 1 MONTH. FROM 1-11 MONTHS ENTER AGE IN MONTHS.)	_Hours _Days _Months _Years _Refused to answer _Don’t know
8.2.1.14	How long did the illness last? (INTERVIEWER: LESS THAN 24 HOURS = 00 DAYS. ENTER AGE IN DAYS UP TO 27 DAYS. ENTER 28 DAYS AS 1 MONTH. FROM 1-11 MONTHS ENTER DURATION OF ILLNESS IN MONTHS. ENTER 12 MONTHS 1 YEAR. FROM 1-11 YEARS ENTER AGE IN YEARS.)	_Days _Months _Refused to answer _Don’t know
8.2.1.15	INTERVIEWER: MARK THE BABY’S AGE AT THE TIME OF DEATH	_Less than 28 days _28 days to 11 years
8.2.2 Maternal History
8.2.2.1	Was the late part of the pregnancy (defined as the last 3 months), labor, or delivery complicated by any of the following problems? (INTERVIEWER: READ EACH COMPLICATION AND MARK ALL THAT APPLY.) (READ “THE MOTHER” IF THE MOTHER IS NOT THE RESPONDENT.)	_You (the mother) had convulsions _You (the mother) had high blood _You (the mother) had severe anemia _You (the mother) had diabetes _Child delivered not head first _Cord delivered first _Cord around child's neck _Excessive bleeding _Fever during labor _Premature rupture of membranes (water breaks prematurely) _No complications _Refused to answer _Don't know
8.2.2.2	Was the baby moving in the last few days before the birth?	_Yes _No _Refused to answer _Don’t know

8.2.2.3	What was the color of the liquid when the water broke?	_Green or brown _Clear (normal) _Other (specify:___) _Refused to answer _Don't know
8.2.2.4	How much time did the labor and delivery take? (INTERVIEWER: LESS THAN 1 HOUR == “00”)	_Hours Enter 99 if unknown _Refused to answer _Don’t know
8.2.2.5	Who delivered the baby?	_Doctor _Nurse/midwife _Relative _Self (the mother) _Traditional birth attendant _Other (specify:_____) _Refused to answer _Don't know
8.2.2.6	How was the baby delivered? (INTERVIEWER: READ THE CHOICES AND MARK ONE.)	_Vaginal, with forceps _Vaginal, without forceps _Vaginal, don't know if forceps or not _C-Section _Refused to answer _Don't know
STOP. REFER BACK TO QUESTION 8.2.1.8. IF YOU ANSWERED “YES,” GO TO SECTION: 8.1.5 HEALTH RECORDS. IF YOU ANSWERED “NO,” AND CHILD IS LESS 28 DAYS OLD CONTINUE TO SECTION 8.2.3: NEONATAL DEATHS.
8.2.3 Neonatal Death
8.2.3.1	Was any part of the baby physically abnormal at time of delivery? (INTERVIEWER: FOR EXAMPLE: “BODY PART TO SMALL", “ADDITIONAL GROWTH ON BODY”)	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.2.3.3

8.2.3.2	What were the abnormalities? (INTERVIEWER: MARK ALL THAT APPLY)	_Head size very large at time of birth _Mass defect on the back of head _Other (specify:_____) _Refused to answer _Don't know
8.2.3.3	Did the baby breathe immediately after birth?	_Yes _No _Refused to answer _Don’t know
IF NO, GO TO QUESTION 8.2.3.5
8.2.3.4	Did the baby have difficulty breathing?	_Yes _No _Refused to answer _Don’t know
8.2.3.5	Was anything done to try to help the baby breathe at birth?	_Yes _No _Refused to answer _Don’t know
8.2.3.6	Did the baby cry immediately after birth?	_Yes _No _Refused to answer _Don’t know
IF YES, GO TO QUESTION 8.2.3.8
8.2.3.7	How long after birth did the baby first cry? (INTERVIEWER: MARK ONE)	_Within 5 minutes _Within 6-30 minutes _More than 30 minutes _Never _Refused to answer _Don't know
IF NEVER, GO TO QUESTION 8.2.3.9
8.2.3.8	Did the baby stop being able to cry?	_Yes _No _Refused to answer _Don’t know

8.2.3.9	Was the baby able to suckle in a normal way during the first day of life?	_Yes _No _Refused to answer _Don’t know
IF YES, GO TO QUESTION 8.2.3.11
8.2.3.10	Did the baby ever suckle in a normal way?	_Yes _No _Refused to answer _Don’t know
8.2.3.11	During the illness that led to death, did the baby have difficult breathing?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.2.3.13
8.2.3.12	For how many days did the difficult breathing last?	_Days _Refused to answer _Don’t know
8.2.3.13	During the illness that led to death, did the baby have fast breathing?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.2.3.15
8.2.3.14	For how many days did the fast breathing last?	_Days _Refused to answer _Don’t know
8.2.3.15	During the illness that led to death, did the baby have indrawing of the chest?	_Yes _No _Refused to answer _Don’t know
8.2.3.16	During the illness that led to death, did the baby become cold to touch?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.2.3.18

8.2.3.17	At what age did the baby start feeling cold to touch?	_Days _Refused to answer _Don’t know
8.2.3.18	During the illness that led to death, did the baby become lethargic, after a period of normal activity?	_Yes _No _Refused to answer _Don’t know
8.2.3.19	During the illness that led to death, did the baby become unresponsive or unconscious?	_Yes _No _Refused to answer _Don’t know
8.2.3.20	During the illness that led to death, did the baby have pus drainage from the umbilical cord stump?	_Yes _No _Refused to answer _Don’t know
8.2.3.21	During the illness that led to death, did the baby have an area(s) of skin with redness and swelling?	_Yes _No _Refused to answer _Don’t know
8.2.3.22	During the illness that led to death, did the baby have yellow skin?	_Yes _No _Refused to answer _Don’t know
8.2.3.23	Did the infant appear to be healthy and then just die suddenly?	_Yes _No _Refused to answer _Don’t know
8.3. CHILD VA SECTION TO BE ANSWERED IF THE DECEASED IS BETWEEN 1 MONTH AND 12 YEARS OLD. CHECK WITH QUESTION 2.1 AND PREVIOUS INFORMATION ABOUT THE DECEASED.
8.3.1.1	Did he/she suffer an injury or accident that led to death?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO SECTION 8.3.2: BACKGROUND

8.3.2. BACKGROUND
8.3.2.1	Is the mother still alive?	_Yes _No _Refused to answer _Don’t know
IF YES, GO TO QUESTION 8.3.2.4
8.3.2.2	Did the mother die during or after the delivery?	_During _After _Refused to answer _Don’t know
IF DURING DELIVERY, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.2.4
8.3.2.3	How long after the delivery did the mother die? (INTERVIEWER: LESS THAN 24 HOURS == 00 DAYS. ENTER AGE IN DAYS UP TO 27 DAYS. ENTER 28 DAYS AS 1 MONTH. FROM 1-11 MONTHS ENTER AGE IN MONTHS.)	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _Refused to answer
8.3.2.4	Where was the deceased born?	_Hospital _Other health facility _On route to hospital or other health facility _Home _Other (specify:_____) _Refused to answer _Don’t know
8.3.2.5	At the time of the delivery what was the size of the deceased: (INTERVIEWER: READ THE QUESTION AND SLOWLY READ THE FIRST 4 CHOICES. RESPONDENT SHOULD HEAR ALL FOUR CHOICES AND THEN RESPOND.)	_Very small _Smaller than usual _About average _Larger than usual _Refused to answer _Don’t know
8.3.2.6	How old was the baby/child when the fatal illness started? (INTERVIEWER: LESS THAN 24 HOURS == 00 DAYS. ENTER AGE IN DAYS UP TO 27 DAYS. ENTER 28 DAYS AS 1 MONTH. FROM 1-11 MONTHS ENTER AGE IN MONTHS.)	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _ __ __ years Enter 99 if unknown _Refused to answer
8.3.2.7	How long did the illness last? (INTERVIEWER: LESS THAN 24 HOURS = 00 DAYS. USE 1 MONTH = 28 DAYS TO DETERMINE THE NUMBER OF MONTHS.)	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _ Refused to answer
8.3.2.8	How old was the deceased at the time of death? (INTERVIEWER: USE ONE MONTH = 28 DAYS TO DETERMINE THE NUMBER OF MONTHS.)	_ __ __ days Enter 99 if unknown _ __ __ months Enter 99 if unknown _ __ __ years Enter 99 if unknown _Refused to answer
8.3.2.9	Has the deceased's (biological) mother ever been tested for HIV?	_Yes _No _Refused to answer _Don’t know
8.3.2.10	Was the HIV test ever positive?	_Yes _No _Refused to answer _Don’t know

8.3.2.10	Has the deceased's (biological) mother ever been told she had AIDS by a health worker?	_Yes _No _Refused to answer _Don’t know
8.3.3. Infant and Child Deaths
8.3.3.1	During the illness that led to death, did he/she have a fever?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.5
8.3.3.2	How many days did the fever last?	_ Less than 24 hours _ __ __ days Enter 99 if unknown _Refused to answer _Don’t know
8.3.3.3	Did the fever continue until death?	_ Yes _ No _ Refused to answer _ Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.5
8.3.3.4	How severe was the fever?	_ Mild _ Moderate _ Severe _ Refused to answer _ Don’t know
8.3.3.5	During the illness that led to death, did he/she have more frequent loose or liquid stools than usual?	_ Yes _ No _ Refused to answer _ Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.8
8.3.3.6	How many stools did he/she have on the day that loose or liquid stools were most frequent?	_ __ __ stools Enter 99 if unknown _Refused to answer _Don’t know
8.3.3.7	Did the frequent loose or liquid stools continue until death?	_Yes _No _Refused to answer _Don’t know
8.3.3.8	During the illness that led to death, did the child have a cough?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.11
8.3.3.9	For how many days did the cough last?	_ __ __ days Enter 99 if unknown _Refused to answer _Don’t know
8.3.3.10	Was the cough very severe?	_Yes _No _Refused to answer _Don’t know
8.3.3.11	During the illness that led to death, did he/she have difficult breathing?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.13
8.3.3.12	For how many days did the difficult breathing last?	_ __ __ days Enter 99 if unknown _Refused to answer _Don’t know
8.3.3.13	During the illness that led to death, did he/she have fast breathing?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.15

8.3.3.14	For how many days did the fast breathing last?	_ __ __ days Enter 99 if unknown _Refused to answer _Don’t know
If BOTH 8.3.3.11 AND 8.3.3.13 ARE “NO” GO TO QUESTION 8.3.3.17
8.3.3.15	During the illness that led to death, did he/she have indrawing of the chest?	_Yes _No _Refused to answer _Don’t know
8.3.3.16	During the illness that led to death, did his/her breathing sound like grunting?	_Yes _No _Refused to answer _Don’t know
8.3.3.17	Did he/she experience any generalized convulsions or fits during the illness that led to death?	_Yes _No _Refused to answer _Don’t know
8.3.3.18	Was he/she unconscious during the illness that led to death?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.20
8.3.3.19	How long before death did unconsciousness start?	_Less than 6 hours _6-23 hours _24 hours or more _Refused to answer _Don’t know
8.3.3.20	Did he/she have a stiff neck during the illness that led to death? INTERVIEWER: (Demonstrate)	_Yes _No _Refused to answer _Don’t know
8.3.3.21	Did he/she have a bulging fontanelle during the illness that led to death? INTERVIEWER: (Show photo)	_Yes _No _Refused to answer _Don’t know

8.3.3.22	During the month before he/she died, did he/she have a skin rash?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 8.3.3.24
8.3.3.23	How many days did the rash last?	_ __ __ days Enter 99 if unknown _ Refused to answer _ Don’t know
8.3.3.24	During the illness that led to death, did he/she skin flake off in patches?	_ Yes _ No _ Refused to answer _ Don’t know
8.3.3.25	Did his/her hair change in color to a reddish or yellowish color?	_Yes _No _Refused to answer _Don’t know
8.3.3.26	Did he/she have a protruding belly?	_Yes _No _Refused to answer _Don’t know
8.3.3.27	During the illness that led to death, did he/she suffer from “lack of blood” or “pallor”?	_Yes _No _Refused to answer _Don’t know
8.3.3.28	During the illness that led to death, did he/she have swelling in the armpits?	_Yes _No _Refused to answer _Don’t know
8.3.3.29	During the illness that led to death, did he/she bleed from anywhere?	_Yes _No _Refused to answer _Don’t know

8.3.3.30

During the illness that led to death, did he/she have areas of the skin that turned black?

_Yes _No _Refused to answer _Don’t know

IX. Response of Health Care System
This section asks about the medical care and health care system response to his/her needs at the time of Hurricane María and the first 14 days after landfall. IF THE PERSON DIED BEFORE THE LANDFALL OF THE HURRICANE, SKIP TO SECTION X
9.1 PERMANENT LIFE SUPPORT NEEDS
9.1.1	Did he/she have a permanent need of in-home treatment support, or care for critical medical conditions, or need of essential medicines?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 9.1.3
9.1.2	What was the permanent need of in-home or essential care? (INTERVIEWER: READ OPTIONS AND SELECT ALL THAT APPLY)	_ Medical equipment for oxygen support _Medical equipment for enteric nutrition/ feeding _Medical equipment for permanent intravenous treatment _Medical equipment for dialysis _Essential medicines for diabetes (insulin) _Essential medicine for heart disease (example nitroglycerin) _Essential medicine for asthma or other respiratory chronic condition _Essential medicine for epilepsy status, esquizofrenia, depression, or another mental health chronic condition _Essential medicine for ulcer treatment or another severe gastrointestinal chronic illness _Essential medicine for liver problems _Essential medicine for renal problems _Other _Refused to answer _Don’t know

9.1.3	Was he/she affected by lack of needed medication?	_Yes _No _Other (specify:____) _Refused to answer _Don’t know
9.1.4	Was he/she affected by lack of needed access to dialysis?	_Yes _No _Refused to answer _Don’t know
9.2. FIRST RESPONSE EMERGENCY
This section asks about the emergency services that he/she (or any other person living with him/her) tried to seek for medical help. This includes 911, another ground ambulance, a health department, the Red Cross, Police Department, Fire Department, or another emergency system.
9.2.1	When he/she was injured or suffered the illness, did he/she seek medical care?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER, OR DON’T KNOW, GO TO QUESTION 9.3.3
9.2.2	To the best of your knowledge, was he/she in a life-threatening emergency when care was sought?	_Yes _No _Refused to answer _Don’t know
9.2.3	Did he/she or anyone living with him/her call 911? Or any equivalent emergency agency for immediate help?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 9.3.1
9.2.4	Did the 911 or other ambulance arrive?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 9.3.2
9.2.5	Was he/she taken to a health care facility?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 9.3.2

9.2.6	Where was he/she taken?	_Urgent care services _Emergency room _Hospitalization services/hospital _Primary health care center/health center _Pharmacy _Community center _Red Cross _Other _Refused to answer _Don’t know
9.2.7	In what municipality is this place/facility located?	_Adjuntas _Aguada _Aguadilla _Aguas Buenas _Aibonito _Arecibo _Arroyo _Añasco _Barceloneta _Barranquitas _Bayamón _Cabo Rojo _Caguas _Camuy _Canóvanas _Carolina _Cataño _Cayey _Ceiba _Ciales _Cidra _Coamo _Comerío _Corozal _Culebra _Dorado _Fajardo _Florida _Guayama _Guayanilla _Guaynabo _Gurabo _Guánica _Hatillo _Hormigueros _Humacao _Isabela _Jayuya _Juana Díaz _Juncos _Lajas _Lares _Las Marías _Las Piedras _Loiza _Luquillo _Manatí _Maricao _Maunabo _Mayagüez _Moca _Morovis _Naguabo _Naranjito _Orocovis _Patillas _Peñuelas _Ponce _Quebradillas _Rincón _Rio Grande _Sabana Grande _Salinas _San Germán _San Juan _San Lorenzo _San Sebastián _Santa Isabel _Toa Alta _Toa Baja _Trujillo Alto _Utuado _Vega Alta _Vega Baja _Vieques _Villalba _Yabucoa _Yauco
9.2.8	What was the name of the place/facility visited?	OPEN _Refused to answer _Don’t know

9.2.9

How long did it take to get there?

_Integer _Minutes _Hours _Days _Refused to answer _Don’t know

9.2.10	Did he/she receive care at the healthcare facility?	_Yes _No _Refused to answer _Don’t know
9.2.11	Was he/she hospitalized in the ER/hospital?	_Yes _No _Other (specify:____) _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 9.2.14
9.2.12	During the time he/she was in the hospital/ healthcare facility, were there noticeable disruptions of critical services?	_No _Yes, interruption of the electricity _Yes, A/C (ventilation) not functioning _Yes, interruption of the water supply _Yes, not enough personnel available _Yes, not enough medical supplies _Yes, not enough medical gases available (oxygen) _Other (specify:____) _Refused to answer _Don't know
9.2.13	Did he/she die in the hospital (medical services)?	_Yes _No _Other (specify:____) _Refused to answer _Don’t know
IF YES, SKIP TO SECTION X

9.2.14	Was he/she discharged during the first 14 days?	_Yes _No _Other (specify:____) _Refused to answer _Don’t know
9.2.15	Was he/she transferred to another healthcare facility?	_Yes _No _Refused to answer _Don’t know
9.2.16	Why did he/she need to be transferred? (INTERVIEWER: SELECT ALL THAT APPLY)	_Healthcare facility was damaged _Healthcare facility was closed _There wasn’t enough personnel available _The hospital did not have the required personnel/equipment for treatment of the condition _Other (specify:____) _Refused to answer _Don’t know
9.2.17	Where was he/she referred to?	_Different hospital emergency room _Different hospital non-emergency sector _Emergency military hospital _Different health clinic _Medical shelter _Red Cross health post/shelter _Pharmacy for medication _Community health center _Other (specify:____) _Refused to answer _Don't know
9.3. EMERGENCY MEDICINE NETWORK
This section asks about the emergency units/hospitals where he/she (or anyone living with him/her) tried to seek medical assistance.

9.3.1	Why was 911 not called? (INTERVIEWER: SELECT ALL THAT APPLY)	_Cell phone battery died _Couldn’t charge cell phone _Didn’t have signal _Didn’t have landline telephone _Landline was interrupted _911 not available _Refused to answer _Don’t know
9.3.2	Did he/she or anyone close to or living with him/her seek medical care elsewhere?	_Yes _No _Refused to answer _Don’t know
IF YES, SKIP TO QUESTION 9.3.4

9.3.3	What was the reason for not seeking care? (INTERVIEWER: SELECT ALL THAT APPLY)	_He/she was too ill to leave the house _It wasn't considered necessary _The roads were damaged _There was no means of transport _Unable to afford care _Other (specify:___) _Refused to answer _Don’t know
SKIP TO SECTION X.

9.3.4.	In total, how many places, did he/she or anyone close to the deceased, look for medical care?	_Integer _Refused to answer _Don’t know
Now, I will ask you about the first place.
9.3.5	Where was medical care sought? (INTERVIEWER: SELECT ALL THAT APPLY)	_Hospital emergency room _Hospital non-emergency sector _Emergency military hospital _Different health clinic _Medical shelter _Red Cross health post/shelter _Pharmacy for medication _Community health center _Other (specify:____) _Refused to answer _Don't know
9.3.6	Which means of transportation was used to get there? (INTERVIEWER: SELECT ALL THAT APPLY)	_Own car _Relative, friend or neighbor's car _Taxi or Uber _Public service transportation _Walking _Biking _Other _Refused to answer _Don’t know

9.3.7	How long did it take to get there?	_Integer _Minutes _Hours _Days _Refused to answer _Don’t know
9.3.8	Did it take longer than usual to get there?	_Yes _No _Refused to answer _Don’t know
IF NO, REFUSED TO ANSWER OR DON´T KNOW SKIP TO QUESTION 9.3.10
9.3.9	How much time longer than usual, did it take to get there?	_Integer _Minutes _Hours _Days _Refused to answer _Don’t know
9.3.10	In what municipality is this place/facility located?	Adjuntas _Aguada _Aguadilla _Aguas Buenas _Aibonito _Arecibo _Arroyo _Añasco _Barceloneta _Barranquitas _Bayamón _Cabo Rojo _Caguas _Camuy _Canóvanas _Carolina _Cataño _Cayey _Ceiba _Ciales _Cidra _Coamo _Comerío _Corozal _Culebra _Dorado _Fajardo _Florida _Guayama _Guayanilla _Guaynabo _Gurabo _Guánica _Hatillo _Hormigueros _Humacao _Isabela _Jayuya _Juana Díaz _Juncos _Lajas _Lares _Las Marías _Las Piedras _Loiza _Luquillo _Manatí _Maricao _Maunabo _Mayagüez _Moca _Morovis _Naguabo _Naranjito _Orocovis _Patillas _Peñuelas _Ponce _Quebradillas _Rincón _Rio Grande _Sabana Grande _Salinas _San Germán _San Juan _San Lorenzo _San Sebastián _Santa Isabel _Toa Alta _Toa Baja _Trujillo Alto _Utuado _Vega Alta _Vega Baja _Vieques _Villalba _Yabucoa _Yauco

9.3.11	What was the name of the place/facility visited?	OPEN _Refused to answer _Don’t know
9.3.12	Did he/she receive care in the healthcare facility?	_Yes _No _Refused to answer _Don’t know

IF NO, SKIP TO QUESTION 9.3.18

9.3.13	During the time he/she was in the health care facility, were there noticeable disruptions of medical services of the hospital? (INTERVIEWER, SELECT ALL THAT APPLY)	_No _Healthcare facility was closed _Yes, interruption of the electricity _Yes, A/C (ventilation) not functioning Yes, damage to building components (including roof, walls, windows, doors, or foundation) _Yes, damage to interior finishes and contents (equipment, furniture, appliances, computers, supplies, documents, etc.) _Yes, physical hazards that penetrated buildings (such as floodwater, wind-borne debris, or falling debris) _Yes, Damage to electrical and mechanical systems (HVAC, electrical and lighting, elevators, communications, plumbing, medical gas storage and distribution) _ Shortage of oxygen _Yes, interruption of the water supply _Yes, not enough personnel available _Yes, no enough medical supplies _Yes, no medical gases available (oxygen) _Other (specify:____) _Refused to answer _Don’t know
9.3.14	Was he/she hospitalized in the health care facility?	_Yes _No _Refused to answer _Don’t know
IF NO, SKIP TO QUESTION 9.3.17
9.3.15	How long was he/she hospitalized?	_Integer _Days _Refused to answer _Don’t know
9.3.16	Was he/she discharged during the first 14 days? (INTERVIEWER: READ OPTIONS)	_Yes _No _Died before _Refused to answer _Don’t know
IF NO, SKIP TO NEXT SECTION X
9.3.17	When discharged, where was he/she sent?	_Permanent residence _Place where he/she had been living prior to the hospitalization _Hospice _Referred to another health care facility _Other (specify:____) _Refused to answer _Don’t know
IF THE RESPONSE IS REFERRED TO ANOTHER HEALTH CARE FACILITY, CONTINUE TO QUESTION 9.3.18 FOR ANY OTHER RESPONSE SKIP TO SECTION X
9.3.18	Why was he/she referred to another place? (INTERVIEWER: SELECT ALL THAT APPLY)	_Healthcare facility was closed _Healthcare facility was damaged _Not enough personnel available _Unavailable equipment for treatment _Other _Refused to answer _Don’t know
IF THE DECEASED ONLY SOUGHT CARE IN ONE PLACE, GO TO SECTION X. IF THE DECEASED SOUGHT CARE IN MORE THAN ONE PLACE, GO BACK TO QUESTIO 9.3.5. THE QUESTIONNAIRE PROGRAMMED IN THE TABLET WILL DO AS MANY LOOPS NECESSARY TO CAPTURE THE INFORMATION FOR ALL THE PLACES WHERE THE DECEASED SOUGHT CARE, AS INDICATED IN QUESTION 9.3.4.

X. Section: Place of Death
This section asks about the death of (name of deceased).
10.1	Where did he/she die?	_In the trajectory, vehicle/other means of transportation _At his/her permanent residence _At a friend/family’s residence _At a community shelter _At a governmental shelter _At a Red Cross facility _At a hospital _Other (specify:____) _Refused to answer _Don’t know
IF RESPONSE IS NOT HOSPITAL OR HEALTH CARE FACILITY, GO TO SECTION XI
10.2	Were there disruptions of critical services or other failures in the hospital?	_Unable to continue dialysis _Disruption of breathing support treatment or other life support that requires electricity (CPAP, BiPAP, or nebulizer) Damage to building components (including roof, walls, windows, doors, or foundation) _Damage to interior finishes and contents (equipment, furniture, appliances, computers, supplies, documents, etc.) _Physical hazards that penetrated buildings (such as floodwater, wind-borne debris, or falling debris) _Damage to electrical and mechanical systems (HVAC, electrical and lighting, elevators, communications, plumbing, medical gas storage and distribution) _Shortage of oxygen _Disruption in the operating theater _Unable to get medicine because of supply chain problems _Direct injury by structural collapse in the building _Other (specify:____) _Refused to answer _Don’t know

XI. Open Ended Question and Interviewer Comments/Observations

INTERVIEWER (SAY TO THE RESPONDENT): "THANK YOU FOR THE PATIENT RESPONSES TO THIS EXHAUSTIVE SET OF QUESTIONS. COULD YOU PLEASE SUMMARIZE, OR TELL US IN YOUR OWN WORDS HOW THE DEATH HAPPENED AND ANY ADDITIONAL INFORMATION ABOUT THE ILLNESS AND/OR DEATH?"

FOR THE INTERVIEWER: LISTEN TO WHAT THE RESPONDENT TELLS YOU IN HIS/HER OWN WORDS.

PROMPT TO MAKE SURE:

1. IF THE DEATH WAS RELATED TO AN INJURY VS. A NATURAL CAUSE

2. THE TIME OF DEATH (BEFORE, DURING, OR AFTER THE DISASTER, AND HOW LONG AFTER)

VERIFY THAT THE RIGHT SECTIONS OF THE VA WERE USED IF THE DEATH WAS RELATED TO AN INJURY VS. A NATURAL CAUSE.

DO NOT PROMPT FOR ANYTHING ELSE EXCEPT FOR ASKING WHETHER THERE WAS ANYTHING ELSE AFTER THE RESPONDENT FINISHES. IF THE RESPONDENT MENTIONS KEY WORDS REFERRING TO THE PRESENCE OF ANY OF THESE CONDITIONS, MARK "MENTIONED" ON THE CHECKLISTS.

Adult Checklist

	Key Words	Mentioned
	Chronic kidney disease	
	Dialysis	
	Diabetes	
	Dengue fever	
	Epilepsy	
	Fever	
	Heart attack (AMI)	
	Heart problems	
	Hypertension	
	Influenza	
	Leptospirosis	
	Jaundice	
	Liver failure	
	Malaria	
	Pneumonia	
	Renal (kidney) failure	
	Sepsis	
	Stress/Anxiety	
	Stroke	
	Suicide	
	Death Scene Investigation
	Power outage	
	Road Closure	
	Heat illness	
	Extreme heat	
	Homeless	
	Heat-related warnings	
	Storm clean up	
	Response/Recovery efforts	
	State of emergency	
	Storm preparation	
	Position of safety	
	Recreational activities	

Child Checklist

	Key Words	Mentioned
	Abdomen	
	Cancer	
	Dehydration	
	Dengue fever	
	Diabetes	
	Diarrhea	
	Epilepsy	
	Fever	
	Heart problems	
	Influenza	
	Jaundice (yellow skin or eyes)	
	Leptospirosis	
	Pneumonia	
	Rash	
	Renal failure	
	Sepsis	
	Stress/Anxiety	
	Death Scene Investigation
	Power outage	
	Heat illness	
	Extreme heat	
	Homeless	
	Heat-related warnings	
	Storm clean up	
	Response/Recovery efforts	
	State of emergency	
	Storm preparation	
	Position of safety	
	Recreational activities	

Neonatal Checklist

	Key Words	Mentioned
	Asphyxia (lack of oxygen)	
	Incubator	
	Lung problems	
	Pneumonia	
	Preterm delivery	
	Respiratory distress	
	Death Scene Investigation
	Power outage	
	Heat illness	
	Extreme heat	
	Homeless	
	Heat-related warnings	
	Storm clean up	
	Response/Recovery efforts	
	State of emergency	
	Storm preparation	
	Position of safety	
	Recreational activities	

Confirm that no words of interest were used during the open response.

1. No word was mentioned 9. Don’t know

 

END OF INTERVIEW

INTERVIEWER (THANK RESPONDENT FOR PARTICIPATION): “This is the end of the interview. We are deeply sorry for the death of (name). We appreciate all your help and may come back to you with any clarification on this information only if it is strictly necessary.

Are we able to contact you in the future if there are further questions?  Yes  No

Finally, do you have any questions or comments?”

FOR THE INTERVIEWER: CLARIFY ANY QUESTION AND INCLUDE BELOW ANY COMMENTS YOU HAVE ABOUT THE INTERVIEW. PLEASE INCLUDE ANYTHING THAT SOUNDED UNUSUAL TO YOU AND THAT MAY BE OUT OF THE NORM OR HELPFUL TO UNDERSTAND THE INFORMATION PROVIDED IN THE INTERVIEW.

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