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Name of the PW

Auto-populate

Age

Auto-populate

Contact No. 1

Contact No. 2

Text Box

• Contact No. 1: This number should Auto-fill
• Contact No. 2: This should be free text and
•  Non-Mandatory;
• Accept numeric (integer) value only
• Accept 10 digits only
• Should not start form zero
• Should start with digit 6, 7, 8 or 9

Should Not accept all same digits

SC/HWC/TG Hosp

Text Box

• Accept alpha-numeric values
• Character limit 100

All letter should be in caps

Block

Text Box

• Accept alpha-numeric values
• Character limit 100

All letter should be in caps

Husband’s Name

Auto-Populate

Nearest SC/HWC

Text Box

• Accept alpha-numeric values
• Character limit 100

All letter should be in caps

Nearest 24*7 PHC

Text Box

• Accept alpha-numeric values
• Character limit 100

All letter should be in caps

Nearest FRU

Text Box

• Accept alpha-numeric values
• Character limit 100

All letter should be in caps

Nearest USG centre

Text Box

• Accept alpha-numeric values
• Character limit 100

All letters should be in caps

Blood Group

 Spinner

Choose:

• A +ve 
• B +ve 
• AB +ve
• O +ve
• A -ve
• B -ve
• AB -ve
• O -ve

Auto Fill if available

OR

Select form Spinner

Blood donors identified

Text Box

• Accept alphabets only
• Character limit 50

All letter should be in caps

Birth Companion

Text Box

• Accept alphabets only
• Character limit 50

All letter should be in caps

Person who will take

care of Children, 

if any when the PW

 is admitted for delivery

Text Box

• Accept alphabets only
• Character limit 50

All letter should be in caps

Name and Contact number

of VHSND/Community

member for support

during emergency

Text Box

• Accept alphabets only
• Character limit 100

All letter should be in caps

Mode of transportation in

case of labor Pain

Text Box

• Accept Alpha-numeric values
• Character limit 100

All letter should be in caps

Submit

Button

Once submitted, change the Color of

button “Micro Birth Plan” to

Orange on the Card