Panchayat:Repo18/vol2-page0404: Difference between revisions
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<div style="text-align: right; direction: ltr; margin-left: 1em;">Tor 'Triple birth’ etc., as the case may be,</div> | <div style="text-align: right; direction: ltr; margin-left: 1em;">Tor 'Triple birth’ etc., as the case may be,</div> | ||
<div style="text-align: right; direction: ltr; margin-left: 1em;">in the remarks column in the box below left.</div> | <div style="text-align: right; direction: ltr; margin-left: 1em;">in the remarks column in the box below left.</div> | ||
|- | |- | ||
| To be filled by the informant <br> | | To be filled by the informant <br> | ||
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7. Town or Village of Residence of the mother: (Place where the mother usually lives. This can be | 7. 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.) <br> | different from the place where the delivery occured. The house address is not required to be entered.) <br> | ||
(a) Name of | (a) Name of Town/Village: <br> | ||
(b) Is it a town or village: (Tick the appropriate entry below) | (b) Is it a town or village: (Tick the appropriate entry below) | ||
1. Town <br> | 1. Town <br> | ||
2. Village<br> | 2. Village<br> | ||
(c) Name of District: <br> | (c) Name of District: <br> | ||
(d) Name of State: Age of the mother (in completed years) at the time of this birth: 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) Type of attention at delivery: (Tick the appropriate entry below) 1. Institutional - Government 2. Institutional | (d) Name of State:<br> Age of the mother (in completed years) at the time of this birth:<br> 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)<br> Type of attention at delivery: (Tick the appropriate entry below)<br> 1. Institutional - Government<br> 2. Institutional | ||
- Private or Non-Government Doctor, Nurse or Trained midwife <br> | - Private or Non-Government<br> 3. Doctor, Nurse or Trained midwife <br> | ||
4. Traditional Birth Attendant <br> | 4. Traditional Birth Attendant <br> | ||
5. Relatives or others Duration of pregnancy (in weeks) Cause of foetal death (if known) (Columns to be filled are over. Now put signature at left) | 5. Relatives or others<br> Duration of pregnancy (in weeks)<br> Cause of foetal death (if known)<br> (Columns to be filled are over. Now put signature at left) | ||
|- | |- | ||
| To be filled by the Registrar Registration No: | | To be filled by the Registrar <br>Registration No: Registration Date: <br>Registration Unit: <br>Town/Village: District: <br>Remarks (if any): | ||
Registration Date: Registration Unit: Town/Village: | |||
District: Remarks (if any): | |||
Name and Signature of the Registrar | Name and Signature of the Registrar | ||
|| | || To be filled by the Registrar To be filled by the Registrar | ||
Name : Code No. Registration No: Registration Date | |||
Date of Birth: | District: Date of Birth: <br> | ||
Sex: 1. Male | Tahsil: Sex: 1. Male 2. Female <br> Town/Village: | ||
2. Female | Place of Birth: 1. Hospital/Institution<br> Registration Unit:: 2. House | ||
Place of Birth: 1. Hospital/Institution Registration Unit: | <br><div style="text-align: right; direction: ltr; margin-left: 1em;">Name and Signature of the Registrar</div> | ||
2. House Name and Signature of the Registrar | |||
|} | |} | ||
{{create}} | {{create}} |
Latest revision as of 05:12, 24 January 2019
(See Rule 5]
STILL BIRTH REPORT FORM
Still Birth Report
Legal Information This part to be added to the Still Birth Register
|
Still Birth Report Statistical Information
This part to be detached and sent fo
statistical processing
In the case of multiple births, fill in a separate
form for each child and write 'Twin birth'
Tor 'Triple birth’ etc., as the case may be,
in the remarks column in the box below left.
|
To be filled by the informant Date of Birth: (Enter the exact day, month and year e.g. 1-1-2000) 1. Hospital/ :Institution Name
2. House
Address: (After completing all columns 1 to 12, informant will put date and signature here.)Date: Signature of left thumb marks of the informant
|
To be filled by the informant 7. 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.) |
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 To be filled by the Registrar
Name : Code No. Registration No: Registration Date District: Date of Birth: Name and Signature of the Registrar
|
ഈ താൾ 2018 -ലെ പഞ്ചായത്ത് റെപ്പോ നിർമ്മാണം യജ്ഞത്തിന്റെ ഭാഗമായി സൃഷ്ടിച്ചതാണ്. |