BIRTH REPORT This part to be added to the Birth Register This part to be detached and sent for statistical processing To be filled by the informant To be filled by the informant To be filed 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 no 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 house where the birth took place) 1. Hospital/Institution Name: 2. House Address: 7. Information's nameaddress) after completing all columns 1 to 20 informant will put date and signature here) 8. Town or village of Resinous 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 c) Name of the District: 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. Fathers 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. Mothers level of the 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) 14. Age of the mother in (In completed years) at the 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 the birth 16. Number of children born alive to the mother so far including this child (Number of children born alive to include to 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. Relative 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) To be filled by the Registrar Registration No. Reg. Date Registration Unit District Town/Village Remarks (If any) Name and Signature of the Registrant Name Code No District Tahsil Town/ Village Registration unit Reg. No. Date of birth Sex 1. Male 2. Female Place of birth 1. Hospital
