Legal Information
Statistical Information
Instructions

1. Date of Birth

2. sex

3. Name of the father

4. Name of the mother

5. Place of birth

checked > Hospital / Institution	name
checked > House	address
checked > Other Place

6. Informant's name

Address

Date

Signature or left thumb mark of the informant.

7. Town or Village of Residence of the mother
Name of Town / Village		Is it a town or village	checked > Town checked > Village
Name of the district		Name of the state
9. Age of the mother at the time of this birth (in completed years)		8. Mother's level of education
10. Type of attention at delivery	checked >1. Institutional - Government checked >2. Institutional - Private or Non Government checked >3. Doctor, Nurse or Trained midwife checked >4. Traditional Birth Attendant checked >5. Relatives or others
11. Duration of pregnancy (in weeks)		12. Cause of foetal death (if known)

1. Enter the exact day, month and year of the child was born e.g.1-1-2000

2. Enter "male" or "female", do not abbrevation

3. If not named leave blank

4. Full name as usually written

5. 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.
e.g. 1. Hospital.

6. 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.

7. Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write class VI.

8. Tick the appropriate entry below e.g. 1. Institutional - Government

In case of multiple births, fill in a separate form for each child and write 'Twin birth' or 'Tiple Birth' etc, as the case may be, in the remarks column in the box below left.