Form No.

BIRTH REPORT
LEGAL INFORMATION This part to be added to the Birth register

(See Rule 12)

(To be filled by the informant) 1. P\\ XobXn / Date of birth (Enter the exact day, month and year the child was born eg.1.4.2000) 2. BtWm / s]tm /Sex (Enter Male or Female. Do not use abbreviations) 3. IpnbpsS t]cv / Name of the child; if any (t]cnsn tImfw ]qcnntXn/If not named
leave blank)

: : : : : :

4. ]nXmhns ]qamb t]cv /Name of the father

(Full name as usually written)

5. amXmhns ]qamb t]cv /Name of the mother (Full name as usually written) 5A. amXm]nXmfpsS ncamb tahnemkw / Permanent address of parents 5B. IpnbpsS P\\kabv amXm]nXmfpsS tahnemkw / Address of the parents at the time of birth of the child 6. P\\ ew / Place of birth (_m[IambXv ASbmfsSppIbpw Bip]{Xntbm m]\tam BsWn BbXns t]cpw, hoSmsWn tahnemkhpw tcJsSpWw / Tick the appropriate
entry (a) or (b) and give the name of the Hospital/ Institution or the address of the house where the birth took place)

F. Bip]{Xn/ m]\w t]cv/

Hospital / Institution- Name

: :

_n. hoSv tahnemkw

House - Address 7. hnhcw \evIp hynbpsS t]cpw tahnemkhpw / Informants name and address Bip]{Xn/m]\fnse _shcpsS tamsempw,koepw (Bip]{Xn/ m]\ apJmncw Adnbnphbvv am{Xw)/ Counter signature and seal of
the authorities concerned (in the case of hospitals / institutions)

XobXn / Date: Registration No. Registration Unit Town/ Village Remarks (if any)

hnhcw \evIp hynbpsS Hv/hnceSbmfw/

Signature or left thumb mark of the informant
To be filled by the Registrar

Registration Date: District

Name and Signature of the Registrar

Form No.1

This part to be detached and sent for statistical processing 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.

BIRTH REPORT Statistical Information

(To be filled by the informant) 8. Town or Village of residence of the mother: 13. Mothers occupation: (Name of Corporation/ Municipality/ Gramapanchayat (If no occupation write Nil). :
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 Corporation/ Municipality/ Gramapanchayat (b) Is it a Town/ Village (Tick the appropriate entry below) 1. Town 2. Village (c) Name of District: (d) Name of State:

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 :

9. Religion of the family: (Tick the appropriate 1. Hindu 2. Muslim 3. Christian 4. Any other religion: (write name of the religion) 10. Fathers level of education: (Enter the completed level of education e.g. if studies upto class VII but passed only class VI write class VI)
entry below)

16. 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) :

17. Type of attention at delivery: 1. Institutional Government 2. Institutional Private or Non Government 3. Doctors, Nurse or Trained midwife 4. Traditional birth attendant 5. Relatives or others 18. Method of delivery:
below) (Tick the appropriate entry (Tick the appropriate entry below)

11.Mothers 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. Fathers occupation: (If no occupation write Nil).

1. Natural 2. Caesarean 3. Forceps/Vacuum

19. Birth weight (in Kgs.) (If available) 20. Duration of pregnancy (in weeks)
To be filled by the Registrar

Registration No.

Code No.

Registration date:

Date of birth: Place of birth: 1. Hospital/Institution 2. House Town / Village Registration Unit :

Sex:

1. Male

2. Female

Name and signature of the Registrar

t^mdw \ 1

/ Form No.1

P\\ dntmv

BIRTH REPORT

\nba]camb hnhc / LEGAL INFORMATION Cu `mKw P\\ cPndmbn (t^mdw 7) kqntXmWv / This part to be added to the Birth register (dq 12 t\mpI/ See Rule 12)
(hnhcw \evIp hyn ]qcnntXv / 1. P\\ XobXn / Date of birth (Znhkw, amkw, hjw, DZm:.1.2000 /Enter the exact day, month and year the child was born eg.1.4.2000) 2. BtWm / s]tm /Sex (Npcpsgpv ]mSn/ Enter Male or Female. Do not
use abbreviations) To be filled by the informant)

: : : : : :

3. IpnbpsS t]cv / Name of the child; if any (t]cnsn tImfw ]qcnntXn/If not named
leave blank)

4. ]nXmhns ]qamb t]cv /Name of the father

(Full name as usually written)

5. amXmhns ]qamb t]cv /Name of the mother

(Full name as usually written)

5A. amXm]nXmfpsS ncamb tahnemkw / Permanent address of parents 5B. IpnbpsS P\\kabv amXm]nXmfpsS tahnemkw / Address of the parents at the time of birth of the child 6. P\\ ew / Place of birth (_m[IambXv ASbmfsSppIbpw Bip]{Xntbm m]\tam BsWn BbXns t]cpw, hoSmsWn tahnemkhpw tcJsSpWw / Tick the appropriate
entry (a) or (b) and give the name of the Hospital/ Institution or the address of the house where the birth took place)

F. Bip]{Xn/ m]\w t]cv/ a. Hospital / Institution- Name _n. hoSv tahnemkw b. House - Address 7. hnhcw \evIp hynbpsS t]cpw tahnemkhpw / Informants name and address Bip]{Xn/m]\fnse _shcpsS tamsempw,koepw (Bip]{Xn/ m]\ apJmncw Adnbnphbvv am{Xw)/ Counter signature and seal of
the authorities concerned (in the case of hospitals / institutions)

: :

XobXn / Date: Registration No. Registration Unit Town/ Village Remarks (if any)

hnhcw \evIp hynbpsS Hv/hnceSbmfw/

Signature or left thumb mark of the informant
To be filled by the Registrar

Registration Date: District

Name and Signature of the Registrar

Form No.1

This part to be detached and sent for statistical processing 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.

BIRTH REPORT Statistical Information

(To be filled by the informant) 8. Town or Village of residence of the 13. Mothers occupation: (If no occupation write Nil). : mother:
(Name of Corporation/ Municipality/ Gramapanchayat 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 Corporation/ Municipality/ Gramapanchayat (b) Is it a Town/ Village (Tick the appropriate entry below) 1. Town 2. Village (c) Name of District: (d) Name of State:

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 :

9. Religion of the family: (Tick the 1. Hindu 2. Muslim 3. Christian 4. Any other religion: (write name of the religion) 10. Fathers level of education: (Enter the completed level of education e.g. if studies upto class VII but passed only class VI write class VI)
appropriate entry below)

16. 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) :

17. Type of attention at delivery: 1. Institutional Government 2. Institutional Private or Non Government 3. Doctors, Nurse or Trained midwife 4. Traditional birth attendant 5. Relatives or others 18. Method of delivery:
entry below) (Tick the appropriate (Tick the appropriate entry below)

11.Mothers 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. Fathers occupation: (If no occupation write Nil).

1. Natural 2. Caesarean 3. Forceps/Vacuum

19. Birth weight (in Kgs.) (If available) 20. Duration of pregnancy (in weeks)
To be filled by the Registrar

Registration No. Date of birth:

Code NO.

Registration date: Sex: 1. Male 2. Female

Place of birth: 1. Hospital/Institution 2. House

Town / Village Registration Unit : Name and signature of the Registrar