FORM NO.
1 BIRTH REPORT BIRTH REPORT In the case of multiple births, fill in a separate form
(See Rule 5) Statistical Information for each child and write ‘Twin birth’ or FORM No.1
Legal Information ‘Triple birth’ etc., as the case may be, in the remarks (See Rule 5)
This part to be detached and send for Statistical Processing column in the box below left.
This part to be added to the Birth
To be filled by theRegister
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 mother 16. Age of the mother (in completed years)
and year the child was born e.g. 1-1-2000) usually lives. This can be different from the place where the delivery at the time of marriage :
occurred. The house address is not required to be entered.) (If married more than once, age at first
marriage may be entered)
2. Sex : (Enter “Male, or “ a) Name of Town/Village : 17. Age of the mother (in completed years)
Female”) do not use abbreviation) at the time of this birth :
b) Is it a town or village : (Tick the appropriate entry below)
3. Name of the child, if any :
(If not named, leave blank) 1. Town 2. Village
18. Number of children born alive to the
4. Name of the father : c) Name of District : mother so far including this child :
(Full name as usually written) (Number of children born alive
UID No of Father (if any) d) Name of State : to
11. Religion of the Family : (Tick the appropriate entry below) include also those from earlier
marriage(s), if any)
Name of the mother : 1.Hindu 2. Muslim 3.Christian
5. (Full name as usually
written) UID No of Mother 4. Any other religion : (write name of the religion)
(if nay) 12. Father’s level of education : 19. Type of attention at delivery : (Tick the appropriate entry
below)
-------------------To be detached and sent for statistical Processing
(Enter the completed level of 1. Institutional – Government
6. Address of parents at the time of
education e.g. if studied upto class
Birth of the Child 2. Institutional– Private or Non-Government
VII but passed only class VI, write
7. Permanent address of parents:
class VI) 3. Doctor, Nurse or Trained midwife
Mobile No:
4. Traditional Birth Attendant
8. Place of birth : (Tick the appropriate entry 1,2 or 3 below and give the name 5. Relatives or others
of the Hospital/Institution or the address of the house where the birth 13. Mother’s level of education :
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took place) (Enter the completed level of 20. Method of Delivery : (Tick the appropriate entry below)
education e.g. if studied upto class 1. Natural
1.Hospital/ Institution Name VII but passed only class VI, write 2. Caesarean
& Address:
2.House Address : class VI) 3. Forceps/Vacuum
3.Others: 14 Father’s occupation :
9. (If no occupation write ‘Nil’) 21. Birth Weight (in kgs.) (if available) :
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
Name : Code No.
Registration No: Registration date : 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.
Registration Unit : House Name and Signature of the Registrar
Name and Signature of the Registrar
