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Kenya Birth Registration Form A1

1. This document is a birth registration form from Kenya containing information about a newborn child. It includes fields for the child's name, date and place of birth, names of the parents, and signature of the registering official. 2. The form also requests additional confidential medical data about the mother, including her age at the time of birth, marital status, and details of any previous births. 3. The certifying informant is asked to sign and indicate their capacity, whether they are the mother, father, midwife, or medical attendant providing information about the birth.

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236 views1 page

Kenya Birth Registration Form A1

1. This document is a birth registration form from Kenya containing information about a newborn child. It includes fields for the child's name, date and place of birth, names of the parents, and signature of the registering official. 2. The form also requests additional confidential medical data about the mother, including her age at the time of birth, marital status, and details of any previous births. 3. The certifying informant is asked to sign and indicate their capacity, whether they are the mother, father, midwife, or medical attendant providing information about the birth.

Uploaded by

ben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

FORM A1 KENYA

REGISTER OF BIRTH

REGISTRAR'S SERIAL NUMBER:

DISTRICT:

1. FULL Baptismal or given Middle or Tribal Surname or tribal name of


NAME
OF name (s) name Father
CHILD
Son or
daughter of
2 DATE Date of Month Month 3. SEX Male 1.
OF OF
BIRTH CHILD Female 2.
4 FULL Baptismal or Middle or Surname or tribal
NAME given name (s) tribal name Name of her father
OF Son of
FATHER

5 FULL Baptismal or Middle or Maiden surname or tribal


NAME given name (s) tribal name name of her Father
OF Daughter of
MOTHER
IMPORTANT—Use typewriter or ballpoint or pen with black or dark blue ink.

6 EXACT No. of house and street or road Name of town if any or village/ If in Institution-name of hospital or
PLACE if any Sub-location and Location medical centre
OF
BIRTH
This is a permanent legal record. Be sure the carbon copy is legible

Code
BINDING MARGIN

7 NORMAL If mother not normally resident


RESIDENCE at above place state district in
OF which she lives
MOTHER
Code

8. CERTIFICATE TO BE COMPLETED BY INFORMANT


I hereby certify that I attended the above birth or have knowledge of the fact that the

Above child was born (alive) 1 (dead) 2 on the date and at the place
Check Specified and that I am the
Capacity
in which
Information
given.
I Mother of 2 Father of 3 Midwife who 4 Medical 5 or specify
The Child the child attended birth Attendant

Signature……………….. ………………………………. Date Record Signed……………..……….…………..


(If informant is illiterate he should add his mark
and a witness to such mark should sign here) ...........................................................................................................................................
Date Record Received:
9. SIGNATURE OF REGISTRAR:

CONFIDENTIAL MEDICAL DATA


(This section must be completed as fully as possible)
10. AGE OF MOTHER AT BIRTH OF CHILD: Years

11. IS MOTHER MARRIED TO FATHER? (By Ceremony, Custom, etc.): Yes No


1 2
12. PREVIOUS BIRTHS TO MOTHER: Number Born Alive …………… Number Born Dead………

13. IF A PLURAL BIRTH. STATE WHETHER TWIN OR TRIPLET ……………………………………………………..

AND ORDER OF BIRTH (I.E. 1ST OR 2ND) ……………………………………………………...

NOTE- A separate record is required for each child.


GPK (L)

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