MDSR Form

S No

Name of Data Field

Field Type

Value/ Options

Validation/ Logic/ Condition

1

Date of death

Label

2

Address

Textbox

3

Husband's name

Textbox

• Accept alphabets only
  
• Character limit 50
  
• All letter should be in caps

4

Cause of death

Radio button

• Maternal
  
• Non-maternal
  

If died due to maternal cause, specify reasons

If died due to maternal cause, specify reasons

Textbox

5

Date of field investigation

Textbox

6

Action taken

Radio button

• Yes
  
• No
  

7

Signature of MO I/C of the block:

Textbox

8

Date

Textbox