CDR Form

S No

Name of Data Field

Field Type

Value/ Options

Validation/ Logic/ Condition

(In case of a newborn, name of the mother should be used. eg: Baby of Nirmala)

1

Name of the child

Textbox

• Accept alphabets only
  
• Character limit 100
  
• All letter should be in caps

2

Date of Birth

Textbox

3

Age

Textbox

4

Visit Date

Date

Mandatory

5

Gender

Radio Button:

Select:

• Female
  
• Male
  
• Transgender
  

6

Mother's Name

Textbox

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

7

Father's Name

Textbox

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

Complete Address

8

Address

Textbox

9

House Number

Textbox

10

Mohalla/Colony

Textbox

11

Landmarks, if any

Textbox

12

Pin code

Textbox

Phone number of parents/family member (Living in same household)

13

Landline

Textbox

14

Mobile Number

Textbox

15

Date of Death

Textbox

16

Time

Icon

To set the time

17

Place of Death

Radio Button

Select:

• Home
  
• Hospital
  
• In transit
  

18

Name of First Informant

Textbox

19

Signature/Name of ASHA

Textbox

20

Date of Notification

Textbox