Items:

 1. In the last 12 months, was anyone in your household killed or injured in an incident other than a road traffic accident? By injured, I mean that their injuries were severe enough that for at least one day they could not carry out their normal daily activities.

Response Options:
Yes
No

 2. What is the name of the firstnext person killed or injured?

Response Option:
Name = _____
Enter the name of each person killed or injured, starting with the name the respondent mentions first.

 3. In what type of incident was (NAME) killed or injured? [If a person had more than one incident, ask questions about the most recent incident only.]

Response Options:
Fireburning
Animal bite
Fall
Drowning Near drowning
Poisoning
Electrical injury
Struck by personobject
Cut or stabbed
Gunshot
Other (specify)
Don’t know

 4. How did the death or injury happen?

Response Options:
Accidental
Natural disaster
Violence assault
Self-harm
Don’t know

 5. Was (NAME) male or female?

Response Options:
Male
Female

 6. What kind of injuries did (NAME) have as a result of the incident? [record all mentioned]

Response Options:
Cutbiteopen wound
Broken bone
Burn
Poisoning
Head injury
Internal injury
Suffocation
Other (specify)
Don’t know

 7. Does (NAME) continue to have any health problems as a result of the incident?

Response Options:
Yes
No
Don’t know

 8. In what ways does (NAME) continue to have health problems as a result of the injury? [record all mentioned]

Response Options:
Paralyzed
Brain damage
Disfigurement
Loss of limb
Los of limb function
Loss of eyesight
Loss of hearing
Chronic pain
Emotional trauma
Other (specify)
Don’t know