Cause of Death using verbal autopsy in Tiruvallur district,Tamilnadu,India 2015-16

National Institute of Epidemiology, Chennai

Indian Council of Medical research, Govt. of India

Deaths ( > 1 year ) form

Deceased name and address

1.

2.

Deceased ID
(First 2 digits- district code, Middle 2 digitscluster code, Last 2 digits deceased serial
number)
District code
Tiruvallur

3.

Name of the cluster and Cluster code

4.

Date of interview

.
DD/MM/YY

Details of the respondent

Respondent name

5.

Relationship of the respondent with

deceased

Wife/Husband...1
Brother/Sister2
Son/daughter.3
Mother/Father...4
Grandchild5
Son-in-law/Daughter-in-law.6
Brother-in-law/Sister-in-law.7
Parent-in-law.8
Grandfather/Grand mother9
Other relative10
Neighbour/no relation...11
Unknown..99

6.

Age in completed years

7.

Sex

Male...........1
Female ...2

8.

Education

9.

Did the respondent live with the deceased

during the events that led to death?

Illiterate and never attended school...1

Literate and never attended school2
Standard (1to5)......3
Standard (6to8)..4
Standard (9to10)....5
Standard (11 to 12)6
Dip, Degree, technical, College & others .7
Yes...1
No.....2

Details of the Deceased

10.

Date of death
DD/MM/YY

11.

Date of Birth of deceased

DD/MM/YY

12.

Age in completed years (at the time of

death)

13.

Sex

14.

How many years did he/she live at this

address?

Male...........1
Female ...2
Transgender3
Yrs

15.

Marital status of deceased

Married..1
Unmarried......2
Widow/widower....3
Divorcee/separated4

16.

Education level of deceased

17.

Religion of deceased

Illiterate and never attended school...1

Literate and never attended school2
Standard (1to5)......3
Standard (6to8)..4
Standard (9to10)....5
Standard (11 to 12)6
Dip, Degree, technical, College & others .7
Hindu..1
Muslim...2
Christian.3
Tribal religion (specify).....4

18.

Community

19.

If ST, mention the name of the tribe

20.

Does the family of deceased have BPL

card?

21.

Ask about any other cards that indicate

socio-economic status.
Mention the name of card and benefits.
What is type of the house of deceased?
(Observe the house and fill the details)

22.
23.

What was the occupation of deceased?

Sikh....5
Buddhist.6
Jain.7
Others.8
General1
OBC.2
SC3
ST4

Yes....1
No.....2
Do not know.3

Kaccha(NOT made with bricks/stones)..1

Pucca (Made with bricks/stones)2
Retired....1
Non agricultural unskilled wage Labour2
Skilled wage Labour...3
Agriculture wage Labour............4
Landlord/farmer..5
Self Employed.....6
Government employee....7
Private employee.........8
Professional/Executive....9
Home maker...10
Student..11
Unemployed......12
Others....13

24.

Where did the death happen?

25.

What do you think that he/she died of?

Home.....1
On the way to health facility.2
PHC/CHC/Rural hospital..3
District Hospital4
Private hospital..5
Medical college/ Cancer hospital..6
Other (Specify)..7
Unknown...9

Did the doctor ever state that he/she had any of the following diseases?
Hypertension
Yes...1
26.
No.....2
Do not know.3
Diabetes
Yes...1
27.
No.....2
Do not know.3
Heart Disease
Yes...1
28.
No.....2
Do not know.3
Yes...1
29. Stroke
No.....2
Do not know.3
Yes...1
30. Chronic Respiratory Disease/Asthma
No.....2
Do not know.3
Yes...1
31. Cholesterol problem
No.....2
Do not know..3
Cancer
Yes...1
32.
No.....2
Do not know..3
Yes...1
33. Tuberculosis
No.....2
Do not know..3
Yes...1
34. HIV/AIDS
No.....2
Do not know.3
Any other chronic disease (specify)
35.

36.

Was he/she taking any medications

regularly during the past 5 years?

List of medicines
1.
2.
3.
4.
5.

History of Injury/accident

37.
38.

Did he/she suffer from injury/accident that Yes...1

led to the death?
No.....2
Do not know..3
What kind of injury/accident did he/she
Road Traffic accident1
suffer?
Fall.2
Drowning...3
Poisoning...4
Burns..5
Violence.6
Assault...7
Others (Specify)

39.

Do you think he/she committed suicide?

40.

Did he/she suffer from insect/animal bite

that led to death?

41.

If yes, mention the name of animal/insect.

(Probe for snake, dog, scorpion, etc.)

Yes...1
No.....2
Do not know.3
Yes...1
No.....2
Do not know.3

Tobacco, alcohol, diet

42.
43.

Did he/she smoke bidi/cigarettes/any other Yes...1

form of tobacco within past 5 years?
No.....2
Do not know.3
If yes, how many cigarettes per day?

44.

If yes, how many bidis per day?

45.

If yes, how many leaf rolled tobacco

joints (add any local forms of smoked
tobacco)?
Did he/she chew tobacco or consumed any Yes...1
form of smokeless tobacco (gutka etc)?
No.....2
Do not know.3
Did he/she drink alcohol at least once a
Yes...1
week during most weeks in past 5 years?
No.....2
Do not know.3
If yes, what was the average number of
Number of days
days per week he/she drank alcohol?

46.
47.
48.
49.

If yes, what type of alcohol was most

commonly consumed?

Locally made liquor..1

Indian made foreign liquor....2
Toddy3
Beer...4
Wine..5
Others (specify).6

Was he/she a pure vegetarian for the last 5 Yes....1

years?
No.....2
Do not know.3
For female deaths aged 15-49 years, else skip to 52

50.

Was she either known or suspected to be

Yes....1
pregnant OR within 42 days of delivery or No.....2
abortion?
Do not know.3
If yes, stop the interview here, Fill the maternal death form

51.

Did the Deceased have any of the following symptoms prior to death?
Yes....1
52. Fever
No.....2
Do not know.3
Yes....1
53. Breathlessness
No.....2
Do not know.3

54.

Cough

55.

Diarrhoea/Dysentry

56.

Weight loss

57. A Chest pain

57. B Paralysis/stroke
58.

Oedema

59.

Urinary problems

60.

GI tract problem

61.

Jaundice

62.

Seizures/Fits

63.

Difficulty in swallowing liquids

64.

Headache

65.

Confusion

66.

Unconsciousness

67.

Skin rash

68.

Lumps

69.

Did the deceased undergo any surgery for

any disease prior to the death?

70.

Did the deceased receive any blood

transfusions for any disease prior to the
death?

Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
Yes....1
No.....2
Do not know.3
If yes (specify the name of surgery)

Yes....1
No.....2
Do not know.3
If yes, explain how many and how frequently transfusions were
given

71.

Did anybody in the family (sisters, brothers, Yes....1

mother, father) of deceased suffer from the No.....2
similar disease or died of similar disease? Do not know.3
If yes, explain in detail

72.

Did the deceased receive any treatment

Local doctor..1
days/months before death? If yes, where the Tribal healer..2
treatment was given?
PHC/CHC/Rural hospital..3
District Hospital4
Private hospital..5
Medical college/ Cancer hospital..6
Other (Specify)..7
No treatment..8
Give details of treatment in the narrative section.

Only for females

73.
74.
75.
76.

Did she have ulcer or swelling in the breast? Yes....1

No.....2
Do not know.3
Did she have excessive vaginal bleeding
Yes....1
during menstrual periods?
No.....2
Do not know.3
Did she have excessive vaginal bleeding in Yes....1
between the periods?
No.....2
Do not know.3
Did she have abnormal vaginal discharge? Yes....1
No.....2
Do not know.3

Please describe the symptoms in order of appearance, doctors consulted, hospitalizations,

history of similar episodes, enter the results from reports of the investigations if available.
(Use attached symptoms list) Use additional sheets if necessary

Interviewer name and signature

Summarize the key findings from questionnaire/narrative in the following format

Order of appearance
(Symptom that appeared
first should be numbered
1. Give S. No)*

Symptoms

Duration (days/months/yrs)

* If multiple symptoms appear at the same time, they can be given same s.no.
Diagnosis treatment
Doctor/hospital visited
(write in the order in which
doctors visited give s. no.)

Name of disease/Diagnosis as
told by doctor

Cause of death (to be written by PI):

Days/months/yrs
before death
Treatment given if any