FORM 3a

VERBAL AUTOPSY FORM: NEONATAL DEATHS

Instructions
1. NOTE: This form must be completed for all neonatal deaths (0-28 days)
2. Write in capital letters
3. Circle the appropriate response (or) place a (tick) wherever applicable

District: …………………………... Block: ……………………………... Village: ……………………………

PHC: ……………………………... Sub-Centre: …………………………………………………………………
MCTS / RCH Number.………………………………. Date: …../……/…………….
Name of Head of the Household:

Full Name of the deceased:

Name of mother of deceased:

Section A: Details for Respondent and Deceased

Details of the Respondent:
1.
Name of the Respondent:

2. Relationship of the respondent with the deceased:

a. Brother/ Sister b. Mother/ Father c. Neighbor/ No relation d. Grandfather/Grandmother e. Other relative
3. Did the respondent live with the deceased during the events that led to death?
a. Yes b. No
4. What is the highest standard of education the respondent has completed?
a. Illiterate and literate with no formal education
b. Literate, Primary or below c. Literate, Middle d. Literate, Matric (Class-X)
e. Literate, Class XII f. Graduate & Above
5. Category: a. SC/ST b. OBC c. General
6. Religion of the head of the household
a. Hindu b. Muslim c. Christian d. Sikh
e. Buddhist f. Jain g. No religion h. Others, Specify…………
Details of deceased
7. Deceased's Sex : a. Male b. Female
8. Age in Completed days: a. Less than 1 day b. 01-28 days
9. Date of birth : ___/___/______
10. Date of death : ___/___/______
11A House address of the deceased

11B PIN :
12. Place of death:
a. Home b. On way to health facility/in transit c. Sub Center
d. PHC/CHC/Rural Hospital e. District Hospital f. Medical college
g. Private Hospital h. Other, Specify ………….. i. DNK
Section B: Neonatal Death
13A Did the child met with an accident
a. Yes b. No (if No, go to Q 14A)
13B If yes, what kind of injury or accident?
a. Road traffic injury b. Falls c. Fall of objects
d. Burns e. Drowning f. Poisoning

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g. Bite/sting h. Natural disaster i. Homicide/ assault
x. Other, Specify …………………………………………………………..
13C Do you think the child died from an injury or accident
a. Yes (if Yes, go to SectionC) b. No c. DNK
Details of pregnancy and delivery
14A How many months long was the pregnancy? (in completed months)
14B Mother's age: ___/___/______
15 Did the mother receive 2 doses of tetanus toxoid during pregnancy?
a. Yes b No c. DNK
16A Were there any complications during the pregnancy, or during labour?
a. Yes b. No c. DNK (go to Q 17)

16B If yes, what complications occurred? (Check all that apply)

a. Mother had fits
b. Excessive (more than normal) bleeding before/ during delivery
c. Water broke one or more days before contractions started
d. Prolonged/ difficult labour (12 hours or more)
e. Operative delivery (c-Section)
f. Mother had fever
g. Baby had cord around neck
h. Instrumental delivery/ Assisted
i. DNK
17. Was the child a single or multiple birth?
a. Single b. Multiple c. DNK
18. Where was she/ he born?
a. Home b. On way to health facility/ in transit c. Sub Centre
d. PHC/CHC/Rural Hospital e. District Hospital f. Medical College
g. Private Hospital h. Other, Specify…………………….. i. DNK
19. Who attended the delivery?
a. Untrained traditional birth attendant b. Trained traditional birth attendant
c. ANM/Nurse d. Allopathic Doctor e. Other, Specify……..
f. None g. DNK
20. Was a disinfected or new knife/ blade used to cut the umbilical cord?
a. Yes b. No c. DNK
21. Was it a live/ still birth: a. Live Birth b. Still birth (go to Section C)
Details of baby after birth
22. Did the baby ever cry, move or breath?
a. Yes b. No c. DNK
23. Were there any bruises or signs of injury on child's body after the birth?
a. Yes b. No c. DNK
24A Did baby had any visible malformation at birth?
a. Yes b. NO c. DNK
24B Compared to other cildren in your area, what was the child's size at birth?
a. Very small b. Smaller than average c. Average
d. Larger than average e. DNK
24C What was the birth weight?
a. Kgs. b DNK

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25A Did baby stop crying after some time? (Denoting any illness)
a. Yes b. No (go to Q 26A) c. DNK (go to Q 26A)
25B If yes, how many days after birth did baby stop crying?
a. < 1 day b. days
26A When was baby first breasfed?
a. Immediately/ within one hour of birth b. Same day child was born
c. Second day of later d. Never breastfed (go to Q 27A)
e. DNK
26B Was baby able to suckle normally during the first day of life?
a. Yes b. No (go to Q 27A) c. DNK (go to Q 27A)
26C If yes, did baby stop being able to suck in a normal way?
a. Yes b. No (go to Q 27A) c. DNK (go to Q 27A)
26D If yes, how many days after birth did baby stop sucking?
a. < 1 day b. days
27A Was the baby ever given anything to drink other than breast milk?
a. Yes b. No (go to Q 28A) c. DNK (go to Q 28A)
27B If yes, what was given (specify)__________________
a. Frequency per day b. DNK
Details of sickness at the time of death
28A Did baby have fever?
a. Yes b. No (go to Q 29A) c. DNK (go to Q 29A)
28B If yes, how many days did the fever last?
a. < 1 day b. days
29A Did baby have any difficulty in breathing?
a. Yes b. No (go to Q 30A) c. DNK (go to Q 30A)
29B If yes, for how many days did the difficulty with breathing last?
a. < 1 day b. days
30A Did baby have fast breathing?
a. Yes b. No (go to Q 31A) c. DNK (go to Q 31A)
30B If yes, for how many days did the fast breathing last?
a. < 1 day b. days
31 Did baby have in-drawing of the chest?
a. Yes b. No c. DNK
32A Did baby have a cough?
a. Yes b. No c. DNK
32B Did baby's have grunting (demonstrate)?
a. Yes b. No c. DNK
32C Did baby's nostrils flare with breathing?
a. Yes b. No c. DNK
33A Did baby have diarrhoea (frequent liquid
stools)?
a. Yes b. No (go to Q 34A) c. DNK (go to Q 34A)
33B If yes, for how many days were the stools frequent or liquid?
a. < 1 day b. days
34A Did baby vomit?
a. Yes b. No (go to Q 35A) c. DNK (go to Q 35A)
34B If yes, for how many days did baby
vomit
a. < 1 day b. days

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35A Did baby have redness around, or discharge from, the umbilical cord stump?
a. Yes b. No c. DNK
36 Did baby have yellow eyes or skin?
a. Yes b. No c. DNK
37 Did baby have spams or fits (convulsions)?
a. Yes b. No c. DNK
38 Dis baby become unresponsive or unconscious?
a. Yes b. No c. DNK
39 Did baby have a bulging fontanelle (describe)?
a. Yes b. No c. DNK
40 Did the child's body feel cold when touched?
a. Yes b. No c. DNK
41 Were the child's hands, legs or lips discoloured (blue, other colour)?
a. Yes b. No c. DNK
42. Did She/he have yellow Palms/soles?
a. Yes b. No c. DNK
43 Was there blood in the stools?
a. Yes b. No c. DNK
Section C: Written narrative in local language
44 Please describle the symptoms in order of appearance, doctor consulted or hospitalization history of similar episodes, enter
the result from reports of the investigations if available. (use additional sheets if required)
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45. What did the respondent think the newborn died of? (Allow the respondent to tell the illness in his or her own words)

Interviewer's Signature: …………………………………………

Interviewer Name: ………………………………………………
Designation: …………………………………………………….
Signature/ Left thumb Impression of respondent
Date: ……../……./……………………

Assigned cause of death*

*Assigned at district level

DNO will have to communicate the assigned cause of death to respective block
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