Panchayat:Repo18/vol2-page0402

FORM - 1

Form No. 1

[See Rule 5] BIRTH REPORT FORM !!

Birth Report

Legal Information This part to be added to the Birth Register


Birth Report Statistical Information

This part to be detached and sent for statistical processing

In case of multiple births, fill in a seperate

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.

To be filled by the informant

1.Date of Birth: (Enter the exact day, month and year the child was born e.g. 1-1-2000)
2.Sex: (Enter 'Male' or 'Female' do not use abbreviation)
3. Name of the Child, if any: (If not named, leave blank)
4. Name of the father: (Full name as usually written)
5.Name of the mother: (Full name as usually written)

  • [5A. Permenant address of the parents 5B. Address of the parents at the time of

birth of the child.]
6.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/ Name: Institution 2. House Address:
7.Informant's name: (
1) Address:
(2) Counter Signature and seal of the authorities concerned (in the case of hospitals/Institutions)
(After completing all columns 1 to 20, informant will put date and signature here:)

To be filled by the informant

Date . Signature of left thumb marks of the informant
8. Town or Village of Residence of the mother: (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.) (a) Name of TownVillage: (b) Is it a town or village: (Tick the appropriate entry below) 1. Town
2. Village (C) Name of the District: (d) Name of State: Religion of the family: (Tick the appropriate entry below)
1. Hindu 2. Muslim 3. Christian 4. Any other religion (Write name of the religion) 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) Mother's level of education: (Enter the complete level of education e.g. If studied upto class VII but passed only class VI, write Class VI)
12. Father's occupation: (If no occupation write 'Nil')

To be filled by the informant

13. Mother's occupation: (If no occupation write 'Nil')
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:
16. 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)
17. Type of attention at delivery: (Tick the appropriate entry below)
1. Institutional - Government
2. Institutional - Private or Non-Govern ment
3. Doctor, Nurse of Trained midwife
4. Traditional Birth Attendant 5. Relatives or others 18. Method of Delivery: (Tick the appropriate entry below) 1. Natural 2. Caesarean 3. Forceps/Vaccum 19. Birth Weight (in kgs.) (if available): 20. Duration of pregnancy (in weeks): (Columns to be filled are over. Now put signature at left)

To be filled by the Registrar Registration No:

Registration Date: Registration Unit: Town/Village: District: Remarks (if any) Name and Signature of the Registrar

To be filled by the Registrar Name: Code No. District: Tahsil: Town/Village: Registration Unit: To be detached and sent for statistical processing

To be filled by the Registrar Registration No.

Registration Date:
Date of Birth: Sex:
1. Male 2. Female
Place of Birth: 1. Hospital/Institution 2. House Name and
Signature of the Registrar