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Livebirth Template -Form Fill
Information
Q01
District Name
Q02
Block Name
Q03
Household ID
Q04
Date of visit
Q05
Focal child ID
Q06
Name of the child
Q07
Sex of the [CHILD’s NAME]
Boy
Girl
Q08
Name of the respondent
Q09
Did respondent give consent for interview?
Yes
No
Q10
What is the relationship of the respondent with the focal child?
Mother
Father
Grandmother
Grand father
Other (specify)
Q11
Who else was present for this interview?
No one else
Mother
Father
Grandmother
Other (specify)
Q12
Is the child currently alive?
Yes
No
Q13
Please tell me the date of birth of the [CHILD’s NAME]
Q14
Did you/ the mother go to her parents or other relative’s house elsewhere other than this village/town for this delivery of [CHILD’s NAME]?
Yes
No
Q15
How many months pregnant were you (mother of baby) when the baby was delivered?
Q16
Where was [CHILD’s NAME] born?
MCH
DH/SDH/RH
CHC/PHC
UHC/UHP/UFWC
APHC/SHC
NGO hospital/clinic
Private hospital/clinic
RMP/quack
Home
On the route to hospital
BIRTHS IN PRIVATE SECTOR OR HOME
A01
Do you have the birth certificate of [CHILD’s NAME]?
Yes, shown
Yes, not shown
No
Don’t know
A01A
Can I take the picture of the birth certificate of [CHILD’s NAME]?
No, refused
Yes, picture taken
Picture not taken , (specify)
A02
Was the birth of [CHILD’s Name] registered?
Yes
No
Applied but not received
Do not know
A03
At what age did you obtain/apply for the birth certificate for [CHILD’s NAME]
A04
Where did you obtain / apply for the birth certificate form for [CHILD’s NAME]?
Did not go to any place
At the health facility
Village Panchayat Office
Block development office
Sub divisional office
Nagar nigam/Nagar palika parishad/Nagar panchayat
Jan seva kendra
Other (specify)
Don’t know
A05
How many times did you visit the concerned place to obtain/apply for the birth certificate for [CHILD’s NAME]?
A06
How much did you have to pay in total to get /apply for the birth certificate for [CHILD’s NAME]?
A06_1
Total cost incurred (Rs.)
A06_2
Money given to ASHA
A06_3
Money given to AWW
A06_4
Money given to ANM
A06_5
Money given to Data entry operator
A06_6
Money given to Jan seva Kendra
A06_7
Cannot say
A07
Who guided you to obtain/ apply for the birth certificate for [CHILD’s NAME]?
No one, by myself
ASHA
AWW
ANM
Doctor
Family members
Gram Pradhan/village mukhiya
Yes, ward member /councillor
Other (specify)
Don’t know
A08
Did you contact ASHA or AWW or ANM or Gram Pradhan/village Mukhiya/ward member/councillor to arrange for the birth certificate for [CHILD’s NAME]?
No
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member /councillor
A09
Did the ASHA, AWW, ANM or Gram Pradhan/ village Mukhiya / ward member/councillor arrange for the birth certificate?
None of them
ASHA
AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member /councillor
A10
Why did the ASHA/AWW/ANM/ Gram Pradhan/village Mukhiya / ward member/councillor did not facilitate the birth registration?
Birth at private facility/home
Asked money for registration
Registration process stopped due to Covid-19 lockdown
Ask to come later, birth report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
A11
Were you given any documentation from the place of delivery or by health provider who delivered the baby?
Yes
No
A11A
Interviewer: Record if the documentation shown has “Birth Certificate” written on it.
Yes, written on it
No
Other (specify)
A11B
Were you told anything by the health provider about the document given to you for the [CHILD’s NAME]?
Nothing was told
Yes, told this is birth certificate
Yes, told this receipt will help me in getting birth certificate
Other (specify)
A12
Was the following information available on the document provided?
A12_1
Date of birth
Yes
No
Don’t know
A12_2
Time of birth
Yes
No
Don’t know
A12_3
Birth weight
Yes
No
Don’t know
A12_4
Sex
Yes
No
Don’t know
A12_5
Name of the baby
Yes
No
Don’t know
A12_6
Name of the father
Yes
No
Don’t know
A12_7
Name of the mother
Yes
No
Don’t know
A12_8
Place of birth
Yes
No
Don’t know
A12_9
Mode of delivery
Yes
No
Don’t know
A13
Why did you decide to register [CHILD’s NAME] birth?
A useful government record
Required for school admission
Useful as a proof of date of birth
Useful for employment
Useful for AADHAR card registration
Useful to have the birth certificate
Other, specify
A14
Please rate your experience based on ease of the process of registering the birth/obtaining birth certificate.
A15
Why do you not have the birth certificate for [CHILD’s NAME] currently?
Cannot find it right now
Do not know where it is kept
It is in my parent’s house
Applied and waiting to recieve it from the authority
Others, specify
A16
Why was the birth of [CHILD’s NAME] not registered?
Baby died immediately after birth
Child is too young
No need for it
Will get it when need arises
Did not think about it
No one told us to register
No idea where to register
Went to get it but staff was not available
Could not afford the cost of certifcate
Child born in another state
Facility to obtain certificate is too far
Due to Covid-19 lockdown office are closed
FLW not responding to request to register/not supportive to register
Registration period is over
Registration process stopped due to election
Registration process stopped due to flood
Gram Pradhan/village mukhiya not register
Did not go due to Covid-19
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor did not register
No one at home during that time to register
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor refused to register due to home death
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor refused to register due to private hospital death
ASHA/AWW/ANM/Gram Pradhan/village mukhiya/ ward member/councillor asked for money to register
No Aadhar card
Other(specify)
A17
Did you contact ASHA or AWW or ANM or Gram Pradhan/village mukhiya / ward member/councillor to arrange for the birth certificate for [CHILD’s NAME]?
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member/councillor
no
A18
Why did the ASHA/AWW/ANM or Gram Pradhan/village mukhiya / ward member/councillordid not facilitate the birth registration?
Birth at private facility/home
Asked money for registration
Registration process stopped dueto Covid-19 lockdown
Ask to come later, birth report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
A19
Did you/family try to get the birth certificate yourself?
Yes
No
A20
, Were you given any documentation from the place of delivery or by health provider who delivered the baby?
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member/councillor
no
A21
Interviewer: Record if the documentation shown has “Birth Certificate” written on it.
Yes, written on it
No
Other (specify)
A22
Were you told anything by the health provider about the document given to you for the [CHILD’s NAME]?
Nothing was told
Yes, told this is birth certificate
Yes, told this receipt will help me in getting birth certificate
Other (specify)
A23
Was the following information available on the document provided?
A23_1
Date of birth
Yes
No
Don’t know
A23_2
Time of birth
Yes
No
Don’t know
A23_3
Birth weight
Yes
No
Don’t know
A23_4
Sex
Yes
No
Don’t know
A23_5
Name of the baby
Yes
No
Don’t know
A23_6
Name of the father
Yes
No
Don’t know
A23_7
Name of the mother
Yes
No
Don’t know
A23_8
Place of birth
Yes
No
Don’t know
A23_9
Mode of delivery
Yes
No
Don’t know
A24
Is this the only/last birth reported in this household?
Yes
No
BIRTHS IN THE PUBLIC SECTOR
B01
Do you have birth certificate of [CHILD’s NAME]?
Yes
No
Applied but not received
Do not know
B02
Was the birth of [CHILD’s Name] registered?
Yes
No
Applied but not received
Do not know
B03
Where did you obtain / apply for the birth certificate form for [CHILD’s NAME]?
Did not go to any place
At the health facility
Village Panchayat Office
Block development office
Sub divisional office
Nagar nigam/Nagar palika parishad/Nagar panchayat
Jan seva kendra
Other (specify)
Don’t know
B04
How many times did you visit the concerned place to obtain/apply for the birth certificate for [CHILD’s NAME]?
B05
Did you get the birth certificate before the baby was discharged from the facility after birth or you went later to get it?
At the time of discharge
Later, family member got it
Later, ASA/AWW got it
Not received yet
Do not recall
B06
Did you or a family member had to ask for the birth certificate or the facility or health worker provided on its own?
Had to ask for it
Facility provided on its own
Health worker provided
Others, specify
B07
Did you obtain the birth certificate within one month of the birth?
Yes
No
B08
At what age did you obtain/apply for the birth certificate for [CHILD’s NAME]
B09
How much did you have to pay to get /apply for the birth certificate for [CHILD’s NAME]?
B10
Who guided you to obtain/apply for the birth certificate for [CHILD’s NAME]?
No one, by myself
ASHA
ANM
AWW
Doctor
Family members
Gram Pradhan/village mukhiya
Others (specify)
Don’t know
B11
Why did you decide to register [CHILD’s NAME] birth?
It was registered automatically by the facility
Useful government record
Needed for school admission
Useful as a proof of date of birth
Useful for employment
Useful for AADHAR card registration
Useful to have the birth certificate
Other (specify)
B12
Please rate your experience based on the ease of the process of registering this birth/obtaining birth certificate.
B13
Why do you not have the birth certificate for [CHILD’s Name] when the birth was registered?
Cannot find it right now
Do not know where it is kept
It is in my parent’s house
Misplaced
Have it but cannot find currently
Other (specify)
Don’t know
B14
Why was the birth of [CHILD’s Name] not registered?
Baby died immediately after birth
Child is too young
No need for it
Will get it when need arises
Did not think about it
No one told us to register
No idea where to register
Went to get it but staff was not available
Could not afford the cost of certifcate
Child born in another state
Facility to obtain certificate is too far
Due to Covid-19 lockdown office are closed
ASHA or AWW or ANM or Gram Pradhan/village Mukhiya/ ward member/councillor not responding to request to register/not supportive to register
Registration period is over
Registration process stopped due to election
Registration process stopped due to flood
Other, specify
Don’t know
B15
Did you contact ASHA or AWW or ANM or Gram Pradhan/village mukhiya/ ward member/councillor to arrange for the birth certificate for [CHILD’s NAME]?
No
Yes, ASHA
Yes, AWW
Yes, ANM
Yes, Gram Pradhan/village mukhiya
Yes, ward member/ councillor
B16
Why did the ASHA/AWW/ANM/ Gram Pradhan/village mukhiya / ward member/councillor did not facilitate the birth registration?
Birth at APHC/SHC
Asked money for registration
Registration process stopped due to Covid-19 lockdown
Ask to come later, birth report forms not available
Busy due to work
Registration period was over
Registration process stopped due to election
Registration process stopped due to floods
Other (specify)
B17
Did you/family try to get the birth certificate yourself?
Yes
No
B18
Do you know if the birth of [CHILD’s Name] was automatically registered by the facility where the delivery occurred?
Yes
No
B19
Is this the only/last birth reported in this household?
Yes
No
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