Panchayat:Repo18/vol2-page0404

Form No. 3

(See Rule 5]
STILL BIRTH REPORT FORM

Still Birth Report
Legal Information This part to be added to the

Still Birth Register
Still Birth Report Statistical Information
This part to be detached and sent fo
statistical processing
In the case of multiple births, fill in a separate
form for each child and write 'Twin birth'
Tor 'Triple birth’ etc., as the case may be,
in the remarks column in the box below left.
To be filled by the informant

Date of Birth: (Enter the exact day, month and year e.g. 1-1-2000)
Sex: (Enter 'Male' or 'Female', Do not use abbreviation)
Name of the father: (Full name as usually written)
Name of the mother: (Full name as usually written)
Place of Birth: (Tick the appropriate entry below and give the name of the Hospital/ Institution or the address of the house where the birth took place)

1. Hospital/ :Institution

Name

2. House Address:
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 12, informant will  put date and signature here.)
Date:
Signature of left thumb marks of the informant
To be filled by the informant

7. 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 Town/Village:
(b) Is it a town or village: (Tick the appropriate entry below) 1. Town
2. Village
(c) Name of District:
(d) Name of State:
Age of the mother (in completed years) at the time of this birth:
Mother'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)
Type of attention at delivery: (Tick the appropriate entry below)
1. Institutional - Government
2. Institutional - Private or Non-Government
3. Doctor, Nurse or Trained midwife
4. Traditional Birth Attendant
5. Relatives or others
Duration of pregnancy (in weeks)
Cause of foetal death (if known)
(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                         To be filled by the Registrar
Name :               Code No.        Registration No:         Registration Date

District:                                         Date of Birth:
Tahsil:                                          Sex: 1. Male 2. Female
Town/Village:                                 Place of Birth: 1. Hospital/Institution
Registration Unit::                          2. House


Name and Signature of the Registrar