To be filled
by the informant |
|
10. |
Town or Village of Residence of the
mother :
(Place where the mother usually lives. This can
be different from the place where the delivery
occurred. 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 : |
|
11. |
Religion of the Family:
(Tick the appropriate entry below)
1. Hindu 2. Muslim 3. Christian
4. Any other religion : (Write the name
of the religion) |
|
12. |
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) |
|
13. |
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 V) |
|
14. |
Father's Occupation :
(If no occupation write 'Nil') |
|
15. |
Mother's Occupation :
(If no occupation write 'Nil') |
|
To
be filled by the informant |
|
16. |
Age of the mother (in completed
years) at the time of marriage :
If Married more then once, age at
first marriage may be entered) |
|
17. |
Age of the mother (in completed
years) at the time of this of this birth : |
|
18. |
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) |
|
19. |
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 Attendent
5. Relatives or others |
|
20. |
Method of Delivery:
(Tick the appropriate entry below)
1. Natural
2. Caesarean
3. Forceps/Vacuum |
|
21. |
Birth Weight (in kgs.) (if available) : |
|
22. |
Duration of pregnancy (in weeks) |
|
(Columns to filled are over. Now put signature at left) |
|