FORM - 1
| Form No. 1 |
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[See Rule 5] BIRTH REPORT FORM !!
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| Birth Report
Legal Information
This part to be added to the Birth Register
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Birth Report Statistical Information
This part to be detached and sent for
statistical processing
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In case of multiple births, fill in a seperate
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.
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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)
- [5A. Permenant address of the parents 5B. Address of the parents at the time of
birth of the child.]
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/ Name:
Institution 2. House Address:
7.Informant's name: (
1) Address:
(2) Counter Signature and seal of the authorities concerned (in the case of
hospitals/Institutions)
(After completing all columns 1 to 20, informant
will put date and signature here:)
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To be filled by the informant
Date . Signature of left thumb marks of 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 occured. The house address is not required to be entered.) (a) Name of TownVillage: (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: Religion of the family: (Tick the appropriate entry below)
1. Hindu 2. Muslim 3. Christian 4. Any other religion (Write name of the
religion) 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)
Mother's level of education: (Enter the complete 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')
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To be filled by the informant
13. Mother's occupation:
(If no occupation write 'Nil')
14.
Age of the mother (in completed 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:
16. Number of children born alive to the
mother so far including this child: (Number of children born alive to include also those from earlier marriage(s), if
any)
17. Type of attention at delivery: (Tick the
appropriate entry below)
1. Institutional - Government
2. Institutional - Private or Non-Govern
ment
3. Doctor, Nurse of 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/Vaccum 19. Birth Weight (in kgs.) (if available): 20. Duration of pregnancy (in weeks):
(Columns to be filled are over. Now put signature at left)
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| To be filled by the Registrar Registration No:
Registration Date: Registration Unit: Town/Village:
District: Remarks (if any)
Name and Signature of the Registrar
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To be filled by the Registrar Name:
Code No. District: Tahsil: Town/Village: Registration Unit:
To be detached and sent for statistical processing
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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
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വർഗ്ഗം:റെപ്പോയിൽ സൃഷ്ടിക്കപ്പെട്ട ലേഖനങ്ങൾ
