SAMPLE REGISTRATION SYSTEM

FORM No.11: FINALISED LIST OF OUTCOME OF PREGNANCY

(Finalised after matching of Forms 4 & 9 and reverification)

January-June, 200.._(I HYS)

State________________________________ July-December,200_ (II HYS)
District_______________________________ Name of Sample Unit.................................
Village/Town_____________________ Unit Code ...................................................

Interval between previous and current

Particulars of
Particulars of pregnant women Particulars of Outcome of Pregnancy

undergone sterilization wife-1,

previous live birth

Whether any of the spouse has

(Institutional-1, Domiciliary-2)
Present age in completed years

Previous child alive-1, dead-2

Date of abortion, (if abortion)
Relationship to Head(code*)

Date of birth of the previous

live birth (in months)

Yes-1, No-2, Not Known-3
SRS Household No.

Events netted by **
Order of current live birth

husband-2, none-3
Place of LB/SB/abortion
LB-1, SB-2, Abortion-3

Birth weight(...Kg...gm)
delivery/abortion (code)

Date of birth, if LB/SB

Residential status (Code)

Sex ( M-1, F-2, O-3 )

SRS House No.

Multiciplicity of birth
(Single-1,Multiple-2)
Is the birth registered
Level of education *

Type of attention at
S.No.

Name of head of the

household

child
Name Identification code*

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25)

0
Code for type of attention at delivery/abortion: Govt. hospital-1, Private hospital-2, Qualified professional-3, Untrained functionary-4, Others-9
Code for residential stauts : URP-1, URA-2, IP-3, IA-4, V-5 Signature_______
* : As given in Form 2 Name____________
**E&S-1, E only-2, S only-3, RV-4 Designation with code________
Date______