Submission Time

start

end

today

1.2 Division

1.3 District

1.4 Rural / Urban

1.5 Enter Block

1.9 Name of urban planning unit

1.10 Organization of monitor

1.13 Designation of the Monitor

2.3-Sex of the newborn

2.4-Date of brith

2.6-Place of Delivery

2.7-Mode of delivery

2.8-Post natal stay period (in hour) at facility

2.9-Is birth registration certificate received ?

2.10-Was the newborn breastfed within 1 hour of the birth?

2.11-Was the birth weight taken within 24 hours of birth?

2.12-Is this newborn low birth weight (<2500 gm) or preterm?