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THE REGISTRATION OF BIRTHS & DEATHS RULES, 1999


'''
'''
==== FORM - 3 ====
<center>'''Form No. 3'''
(See Rule 5]<br>
STILL BIRTH REPORT FORM
'''
'''
{| class="wikitable"
{| class="wikitable"
|-
 
!  !! '''Form No. 3'''
(See Rule 5]<br>
STILL BIRTH REPORT FORM


|-
|-
| Still Birth Report
| <div class="center" style="width: auto; margin-left: auto; margin-right: auto;">Still Birth Report</div>
Legal Information This part to be added to the<br>
<div class="center" style="width: auto; margin-left: auto; margin-right: auto;">Legal Information This part to be added to the</div><br><div class="center" style="width: auto; margin-left: auto; margin-right: auto;">Still Birth Register</div>
Still Birth Register  
  || <div style="text-align: left; direction: ltr; margin-left: 1em;">Still Birth Report Statistical Information</div>
  || Still Birth Report Statistical Information
<div style="text-align: left; direction: ltr; margin-left: 1em;">This part to be detached and sent fo</div>
This part to be detached and sent for
<div style="text-align: left; direction: ltr; margin-left: 1em;">statistical processing</div>
statistical processing
<div style="text-align: right; direction: ltr; margin-left: 1em;">In the case of multiple births, fill in a separate </div>
In the case of multiple births, fill in a separate  
<div style="text-align: right; direction: ltr; margin-left: 1em;">form for each child and write 'Twin birth' </div>
form for each child and write 'Twin birth'  
<div style="text-align: right; direction: ltr; margin-left: 1em;">Tor 'Triple birth’ etc., as the case may be,</div>
or 'Triple birth’ etc., as the case may be,
<div style="text-align: right; direction: ltr; margin-left: 1em;">in the remarks column in the box below left.</div>
in the remarks column in the box below left.
 
 
 
|-
|-
| To be filled by the informant <br>
| To be filled by the informant <br>
Line 33: Line 25:
Name of the mother: (Full name as usually written) <br>
Name of the mother: (Full name as usually written) <br>
Place of Birth: (Tick the appropriate entry below and give the name of the Hospital/ Institution or the address of the house where the birth took place) <br>
Place of Birth: (Tick the appropriate entry below and give the name of the Hospital/ Institution or the address of the house where the birth took place) <br>
1. Hospital/ Name:Institution <br>
<div style="text-align: left; direction: ltr; margin-left: 1em;">1. Hospital/ :Institution</div> <br>
<div style="text-align: center; direction: ltr; margin-left: 1em;">Name</div>
2. House
2. House
Address: Informant's name: <br>
Address:<br> Informant's name: <br>
(1) Address:<br>
(1) Address:<br>
(2) Conter Signature and seal of the authorities
(2) Counter Signature and seal of the authorities
concerned (in the case of hospitals/Institutions) (After completing all columns 1 to 12, informant will
concerned (in the case of hospitals/Institutions)<br>
o put date and signature here.)
(After completing all columns 1 to 12, informant will put date and signature here.)<br>
Date:
 
Date:
Date:<div style="text-align: right; direction: ltr; margin-left: 1em;">Signature of left thumb marks of the informant</div>
Signature of left thumb marks of the informant
  || To be filled by the informant <br>
  || To be filled by the informant <br>
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 TownVillage: <br>
(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:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Registration Date: <br>Registration Unit: <br>Town/Village:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; 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
  || o be filled by the Registrar To be filled by the Registrar
  || To be filled by the Registrar &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;      To be filled by the Registrar
Registration Date:
 
Registration No: Name Code No.
Name :&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;  Code No.&nbsp; &nbsp; &nbsp; &nbsp; Registration No:&nbsp; &nbsp; &nbsp; &nbsp;  Registration Date
Date of Birth: District:
District:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;Date of Birth: <br>
Sex: 1. Male
Tahsil:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;  Sex: 1. Male 2. Female <br> Town/Village:&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
2. Female Tahsil: Town/Village:
&nbsp; &nbsp; &nbsp;Place of Birth: 1. Hospital/Institution<br> Registration Unit::&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;  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

Form No. 3

(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)
Sex: (Enter 'Male' or 'Female', Do not use abbreviation)
Name of the father: (Full name as usually written)
Name of the mother: (Full name as usually written)
Place of Birth: (Tick the appropriate entry 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:
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 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.)
(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:
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 - Private or Non-Government
3. Doctor, Nurse or Trained midwife
4. Traditional Birth Attendant
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)

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:
Tahsil:                                          Sex: 1. Male 2. Female
Town/Village:                                 Place of Birth: 1. Hospital/Institution
Registration Unit::                          2. House


Name and Signature of the Registrar

വർഗ്ഗം:റെപ്പോയിൽ സൃഷ്ടിക്കപ്പെട്ട ലേഖനങ്ങൾ