Quality Assessment of Demographic Data in the WHO MONICA Project

Appendix 1. Population demographics reporting form

Annual Demographic and Mortality data
POPULATION DEMOGRAPHICS REPORTING FORM
Form: A
Version: 1          17.4.86 		FOR MDC USE ONLY
Seq.no:

Received:

Please print carefully or type the requested information. Please complete all blanks in accordance with the instuctions provided. Complete one form for each MONICA Reporting Unit each year.

1.
MONICA Collaborating Centre name: Code:|___|___|
2.
MONICA Reporting Unit name: Code:|___|___|
3.
Calendar year for which information is being provided: |___|___|___|___|
4.
Complete the following table (Do not include here those population groups which are excluded from the survey or event registration.):
Age group
(years)		 Number of    Total   
 Males  Females
25-29      
30-34      
35-39      
40-44      
45-49      
50-54      
55-59      
60-64      
65-69      
70-74      
Total      
5.
Total number of inhabitants in the MONICA Reporting Unit, including all ages and sexes without any exclusions: |________________|
6.
If you recorded the numbers in item 4 by hand, please write above each number printed to the right the numbers as used for item 4 0  1  2  3  4  5  6  7  8  9
7.
Source of information:
(Enter correct code in
box to the right)		 1. Direct census count
2. Intercensal estimate		 3. Population register
4. Other (explain in item 9)		 Code: |___|
8.
Person providing information: ___________________
(Please type or print)		 ___________________
Signature		 Date: _____/_____/_____
day   month   year  
9.
Comments or reservations about data provided: