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 Birth Record Form {APPDATE} for Records Close
1. Date of Birth 2. sex   3. Name of the child, if any
4. Name of the father 5. Name of the mother
6. Place of birth
checked > Hospital / Institution name   
checked > House address   
checked > Other Place
7. Informant's name Address

Date  

Signature or left thumb mark of the informant.
8. 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. Religion of the family checked > Hindu   checked > Muslim   checked > Christian   checked > Other  
10. Father's level of education 11. Mother's level of education
12. Father's occupation 13. Mother's occupation
14. Age of the mother at the time of marriage 15. Age of the mother at the time of this birth
16. Number of children born alive to the mother so far including this child 17. Type of attention at delivery
18. Method of Delivery 19. Birth weight in kgs. and gms.
20. Duration of pregnancy
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. Tick the appropriate entry below
8. Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write class VI.
9. If non occupation write 'Nil'
10. If married more than once, age at first marriage may be entered
11. Number of children born alive to include also those from earlier marriage(s), if any
12. Tick the appropriate entry below e.g. 1. Institutional - Government
13. 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.