FORM NO.1 BIRTH REPORT Legal Information Statistical Information In case of multiple births, fill in separate form for each This part to be added to Birth Register This part to be detached and sent for statistical Processing child and write 'Twin birth' or 'Triple birth' etc as may be in the remarks column in the box below left. 14. Age of the mother at the time of marriage (in complete years) : To be filled by the informant To be filled by the informant 15. Age of the mother at the time of birth (in complete years): 1. Date of Birth : 8. Town or village of Residence of the mother : 16. Name of children born alive to the mother so far including this child 2. Sex/Male /Female : ( a) Name of Town/Village : 17. Type of attention at delivery (Tick appropriate entry below): 3. Name of the child : ( b) Is it a Town or Village (Tick the appropriate entry below): 1. Institutional - Government 4. Name of the father : 1. Town 2. Village Private/Non-government 5. Name of the mother : ( c) Name of District : 2. Doctor, Nurse or Trained midwife 6. Place of birth : ( d) Name of State : 3. Traditional Birth Attendant I. Hospital/Institution Name : 9. Religion of the family (Tick the appropriate entry below): 4. Relatives or other II. House : 1. Hindu 2. Muslim 3. Christian 18. Method of delivery (Tick the appropriate entry below): Address: 4. Any other religion (write name of religion) 1. Natural 2. Caesarean 3. Forceps/Vacuum 7. Informant's name : 10. Father's level of Education : 19. Birth weight (in kgs) : Address : 11. Mother's level of Education : 20. Duration of Pregnancy (in weeks) : Date : 12. Father's occupation : 13. Mother's occupation : Signature or left thumb mark of the informant Registration No. : Registration Date : To be filled by the Registrar To be filled by the Registrar Date of Birth : Registration No. : Registration Date : Name : Code No. Sex 1. Male Registration unit : District : 2. Female Town/Village : District: Tahsil : Place of Birth Remarks (if any) Town /Village : 1. Hospital Registration unit : 2. Institution 3. House Name and signature of Registrar Name and signature of the Registrar
