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-Birth certificate

Yes                                                                        No

If No, why?

If yes, how?

-Death certificate

Yes                                                                        No

If No, why?

If yes, how?

F/Family planning

-Are contraceptives available?

Yes                                                                        No

If No, why?

-Are all types available?

Yes                                                                        No

If No, why?

-Use of contraceptives

Yes                                                                        No

If No, why?

-Type(s) of contraceptives use (please notify)

-Change in type of contraceptives (please explain the reason(s)

-Availability of counseling

Yes                                                                        No

If No, why?

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