FORM NO. 1 BIRTH REPORT

Legal information

This part to be added to the Birth Register

BIRTH REPORT

Statistical Information

This part to be detached and sent for statistical processing

FORM NO. 1

In the case of multiple births, fill in a separate form for each child and write “Twin birth” or “Triple birth” etc., as the case may be, in the remarks column in the box below left.

To be filled by the informant

1. Date of Birth : (Enter the exact day, month and year the child was born e.g. 1-1-2000

2. Sex : (Enter “male or female”, do not use abbreviation)

3. Name of the Child, if any : (if not named, leave blank)

4. Name of the father: (Full name as usually written)

5. Name of the mother : (Full name as usually written)

6. Place of birth : (Tick the appropriate entry 1 or 2 below and give the name of the Hospital/Institution or the address of the where the birth took place).

1. Hospital/ Name:

Institution

2. House Address:

7. Informant’s name :

Address :

(After completing all columns 1 to 20, informant will put date and signature here)

Date : Signature or left thumb mark of the informant

To be filled by the informant

8. Town or village of residence of the mother: (Place where the mother usually lives. This can be different from the place where the delivery occurred. The house address is not required to be entered)

(a) Name of Town/Village:

(b) Is it a town or village: (Tick the appropriate entry below)

1. Town 2. Village

(d) Name of State:

9. Religion of the Family: (Tick the appropriate entry below)

1. Hindu 2. Muslim 3. Christian

4. Any other religion : (Write name of the religion)

10. Father’ s level of education :

(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write class VI)

11. Mother’s level of education :

(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write class VI)

12. Father’s occupation:

(If no occupation write ‘Nil’)

13. Mother’s occupation:

(If no occupation write ‘Nil’)

To be filled by the informant

14. Age of the mother : (In complete years) at the time of marriage: (If married more than once, age at first marriage may be entered)

15. Age of the mother : (In completed years) at the time of this birth):

Text Box: (See Rule 5)
BIRTH REPORT FORM

16. Number of children born alive to the mother so far including this child) : (Number of children born alive to include also those form earlier marriage(s), if any

17. Type of attention at delivery:

(Tick the appropriate entry below)

1. Institutional –Government

2. Institutional –Private or Non-Government

3. Doctor, Nurse or Trained midwife

4. Traditional Birth Attendant

5. Relatives or others

18. Method of Delivery: (Tick the appropriate entry below)

1. Natural

2. Caesarean

3. Forceps/Vacuum

19. Birth Weight (in kgs.) (if available):

20. Duration of pregnancy (in weeks):

(Columns to be filled are over. Now put signature at left)

To be filled by the Registrar

Registration No.: Registration Date:

Registration Unit:

Town/Village: District:

Remarks : (if any)

Name and Signature of the Registrar

To be filled by the Registrar

Name: Code No.

District:

Tahsil:

Town/Village:

Registration Unit:

Registration No.: Registration Date:

Date of Birth:

Sex: 1 Male, 2. Female

Place of Birth: 1 Hospital/Institution 2. House.

Name and Signature of the Registrar