FORM NO.1 BIRTH REPORT LEGAL INFORMATION This part to be added to the Birth Register 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. Permanent address: 6. Name of the mother (Full name as usually written) 7. Place of birth: (Tick the appropriate entry 1 or 2 below and given the name of the Hospital/Institution or the address of the house where the birth took place) 1. Hospital/Institution Name: 2. House Address: 8. 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 Registrar Registration No. Registration date: Registration Unit: Town/Village: District: Remarks: (If any) Name and signature of the Registrar In the case of multiple births, here is a specimen BIRTH REPORT form for each child and write "Twin birth or FORM Triplet birth" etc. as the case may be in the NO. 1 STATISTICAL INFORMATION remarks column in the box below left. This part to be detached and sent for statistical processing To be filled by the informant 9. 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 (c) Name of District: (d) Name of State: 10. Religion of the family: (Tick the appropriate entry below) 1. Hindu 2. Muslim 3. Christian 4. Any other religion: (write name of the religion) 11. Father's level of education: (Enter the completed level of education e.g. if studies upto class VII but passed only class VI write class VI) 12. Mother's level of education: (Enter the completed level of education e.g. if studies upto class VII but passed only class VI write class VI) 13. Father's occupation: (If no occupation write Nil). 14. Mother's occupation: (If no occupation write Nil). To be filled by the Registrar NAME: Code no. District: Tahsil : Town/Village: Registration Unit: To be filled by the Informant 15. Age of the mother (in completed years) at the time of marriage: (If married more than once age at first marriage may be entered) 16. Age of the mother (in completed years) at the time of this birth : 17. Number of the children born alive to the mother so far including this child: (Number of children born alive to include also those from alive to include Also those from earlier marriage(s), if any) 18. Type of attention at delivery: (Tick the appropriate entry below) 1. Institutional - Government 2. Institutional - Private or Non - Government 3. Doctors, Nurse or Trained midwife 4. Traditional birth attendant 5. Relatives or others 19. Methods of delivery: (Tick the appropriate entry below) 1. Natural 2. Caesarean 3. Forceps/Vacuum 20. Birth weight (in Kgs.) (If available) 21. 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: Date of birth: Sex: 1. Male 2. Female Place of birth: 1. Hospital/Institution 2. House Name and signature of the Registrar
