1. 1INTERVIEWER’S SELF-ASSESSMENT CHECKLIST
Interview and informed consent forms (before the interview)
A. ___ Have blank consent forms
B. ___ Have a blank MAPEDIR format for reference
C. ___ Have the MAPEDIR format given by the supervisor for the respective
suspected maternal death, with Section 1 filled by the supervisor
Locating information and transportation
A. ___ Understand address and locating information for assigned interview
B. ___ Understand transportation method to interview location
C. ___ Meeting(s) arranged with village leader/other community member(s), if
needed to help locate or be introduced to a household with a death
At the household, before the interview
A. ___ Inform household member of the reason for the interview
B. ___ Show household member my personal identification
C. ___ Ask to speak with the person(s) who know the most about the
circumstances of the woman’s death
D. ___ Arrange another visit if the best respondent(s) were not home or
preferred another interview time
E. ___ Read and explained (if necessary) the informed consent form to the
respondent(s)
F. ___ Obtain each respondent’s mark on a separate consent form
Completed interview
A. ___ Interviewer ID information (section 2 of MAPEDIR format) is complete
B. ___ Deceased woman’s ID information is complete on each page of the
Interviewer’s self-assessment checklist page 1

2. MAPEDIR format
C. ___ All sections of the format are complete, with all pages present
D. ___ Read all questions exactly as written on the MAPEDIR format
E. ___ No or only a few questions answered, “Don’t know”
or
___ If several “DK,” list problem questions by section and number:
_____________________________________________________________
F. ___ Respondents answered all questions
or
___ If a respondent refused to answer a question, record the number and
reason: _____________________________________________________
G. ___ Responses within the interview were consistent with each other
or
___ Any inconsistent responses were resolved during the interview
H. ___ Answered any questions the respondents asked
Interaction with supervisor and interviewer team
A. ___ Submit completed MAPEDIR format and marked consent form(s) to the
supervisor
B. ___ Discuss checklist and any problems with supervisor
C. ___ Resolved problems:
_____________________________________________________________
D. ___ Unresolved problems that may require a change in procedures:
_____________________________________________________________
E. ___ Give any death reports received in the community to supervisor
F. ___ Participate in team meeting (date: ______________)
Interviewer’s self-assessment checklist page 2