FORM NO.

1 BIRTH REPORT In the case of multiple births, fill in a separate

Legal information
BIRTH REPORT form for each child and write 'Twin birth' or
'Triple birth' etc., as the case may be, in the
FORM
Statistical information NO.1
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

To be filled by the informant To be filled by the informant To be filled by the informant

1. Date of Birth : (Enter the exact day, month 10. Town or Village of Residence of the mother: (Place where the 16. Age of the mother (in completed
and year the child was born e.g. 1-1-2000) mother usually lives. This can be different from the place where the years) at the time of marriage :
delivery occurred. The house address is not required to be entered.) (If married more than once, age at first
2. Sex : (Enter “Male, “ Female” or Transgender) marriage may be entered)
a) Name of Town/Village :
do not use abbreviation)
17. Age of the mother (in completed
b) Is it a town or village : (Tick the appropriate entry below) years) at the time of this birth :
Name of the child, if any :
3. (If not named, leave blank) 1. Town 2. Village
18. Number of children born alive to the
Name of the father : mother so far including this child :
c) Name of District :
4. (Full name as usually written) (Number of children born alive to
UID No of Father (if any) include also those from earlier
d) Name of State :
marriage(s), if any)
Name of the mother : 11. Religion of the Family : (Tick the appropriate entry below)
5. (Full name as usually written) 19. Type of attention at delivery : (Tick the appropriate

To be detached and sent for statistical processing

UID No of Mother (if any) 1. Hindu 2. Muslim 3.Christian entry below)

Institutional – Government

BIRTH REPORT FORM

4. Any other religion :(write name of the religion) 1.
Address of parents at the time of 2. Institutional– Private or Non-Government
6. 12. Father’s level of education :
Birth of the Child

FORM No. 1
(See Rule 5)
(Enter the completed level of 3. Doctor, Nurse or Trained midwife
education e.g. if studied upto class
Permanent address of parents:
7. VII but passed only class VI, write 4. Traditional Birth Attendant
Place of birth : (Tick the appropriate entry 1 or 2 below and give the name class VI)
8. 5. Relatives or others
of the Hospital/Institution or the address of the house where the birth took
13. Mother’s level of education :
place) 20. Method of Delivery : (Tick the appropriate entry below)
(Enter the completed level of
1.Hospital/ Name : education e.g. if studied upto class 1. Natural
Institution VII but passed only class VI, write
class VI) 2. Caesarean
2.House Address :
14. Father’s occupation : 3. Forceps/Vacuum
(If no occupation write ‘Nil’)
21. Birth Weight (in kgs.) (if available) :
9. Informant’s name :
15. Mother’s occupation :
Address : (If no occupation write ‘Nil’) 22. Duration of pregnancy (in weeks) :

(After completing all

columns 1 to 22,
informant will put
date and signature
here :)

Date: Signature or left thumb mark of the informant (Columns to be filled are over. Now put signature at left)

To be filled by the Registrar To be filled by the Registrar

Registration No. : Registration Date : Name Code No. Registration No. : Registration Date :
Registration Unit : District : Date of Birth :
Town/Village : District : Tahsil : Sex : 1.Male 2.Female
Remarks : (if any) Town/Village : Place of Birth : 1.Hospital/Institution 2.House
Registration Unit :

Name and Signature of the Registrar Name and Signature of the Registrar