Form-1 (Birth Report) Generator

To be filled by the informant

Date of Birth : (Enter the exact day, month and year the child was born e.g. 1-1-2000)

Sex : (Enter “male” , “female”) do not use abbreviation)

Name of the child, if any : (If not named, leave blank)

Name of the father : (Full name as usually written)

UID No of Father (if any) :

Name of the mother : (Full name as usually written)

UID No of Mother (if any) :

Address of parents at the time of Birth of the Child :

Permanent address of parents :

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 :

Informant's name :

Address :

(After completing all columns 1 to 22, informant will put date and signature here :)

Date :

Signature or left thumb mark of the informant

To be filled by the informant

10.

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 :

11.

Religion of the Family : (Tick the appropriate entry below)

[ ] 1.Hindu [ ] 2. Muslim [ ] 3.Christian [ ] 4. Any other religion :(write name of the religion)

12.

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)

13.

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)

14.

Father’s occupation : (If no occupation write 'Nil')

15.

Mother’s occupation : (If no occupation write 'Nil')

(Columns to be filled are over. Now put signature at left)

To be filled by the informant

16.

Age of the mother (in completed years) at the time of marriage : (If married more than once, age at first marriage may be entered)

17.

Age of the mother (in completed years) at the time of this birth :

18.

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)

19.

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

20.

Method of Delivery : (Tick the appropriate entry below)

[ ] 1. Natural [ ] 2. Caesarean [ ] 3. Forceps/Vacuum

21.

Birth Weight (in kgs.) (if available) :

22.

Duration of pregnancy (in weeks) :

FORM NO. 1	BIRTH REPORT	BIRTH REPORT		FORM NO. 1 (See Rule 5)
	Legal information	Statistical information	In the case of multiple births, fill in a separate 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.
	This part to be added to the Birth Register	This part to be detached and sent for statistical processing

Registration No. :	Registration Date :
Registration Unit :
Town/Village :	District :
Remarks : (if any)
Name and Signature of the Registrar

Reg. No. :	Reg. Date :
Date of Birth :
Sex : 1.Male 2.Female
Place of Birth : 1.Hospital/Institution 2.House
Name and Signature of the Registrar

Birth Report Verification