1. Woman’s Identification Number ___ ___ /___ ___ / ___ ___ ___ / ___ ___ ___ ___ ___ ___ ___ / ___ ___
S T / D S / B L K / V I L L A G E / H H
(This ID number for use by MAPEDIR staff only)
__________________________________________________________________________________________
DEATH OF A REPRODUCTIVE AGE WOMAN
NOTIFICATION FORMAT
Background information
1. Name of deceased woman
2. Address of woman’s usual residence
__________ / __________ / _________ / __________
( village / block / district / state )

3. Where did she stay during her fatal 1. Her own home (other than with her in-laws)
illness?
2. Her in-law’s home
3. Her parent’s home
4. Health facility where she (aborted/labored and
delivered)
5. Other
8. Don’t know
4. What is the address of this place (where she
stayed during her fatal illness)? __________ / __________ / _________ / __________
( village / block / district / state )
This is the basis of the woman’s identification #
5. Name of head of household of this place (where
she stayed during her fatal illness)
6. Relationship of head of household of this place
(where she stayed during her fatal illness) to the
woman
7. Date of woman’s death ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y )
8. Date of death notification ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y )
9. Key informant’s name
Reproductive age woman death notification form – July 1, 2007 Page 1

2. Woman’s Identification Number ___ ___ /___ ___ / ___ ___ ___ / ___ ___ ___ ___ ___ ___ ___ / ___ ___
S T / D S / B L K / V I L L A G E / H H
(This ID number for use by MAPEDIR staff only)
__________________________________________________________________________________________
I would like to ask you some questions about the illness that led to <NAME>’s death.
1. Was the woman pregnant (not yet in labor) at the time of her death?
1. Yes ___ (Finish) 2. No ___
2. Did she die during an abortion or within 6 weeks after having an abortion (spontaneous or
induced, including MTP)?
1. Yes, spontaneous ___ (Finish) 2. Yes, induced ___ (Finish) 3. No __
3. Did she die while in labor or delivery?
(“Delivery” includes having a stillbirth.)
1. Yes ___ (Finish) 2. No ___
4. Did she die within 6 weeks after giving birth?
(“Giving birth” includes having a stillbirth.)
1. Yes ___ (Finish) 2. No ___
THANK THE RESPONDENT AND FINISH
Supervisor
Classify the death:
1. Suspected maternal death: _____ (1, 2, 3 or 4 = Yes)
2. Non-maternal death: _____ (1, 2, 3 and 4 = No)
Reproductive age woman death notification form – July 1, 2007 Page 2