Transcription of BI-24 Form
1 OF SOUTH AFRICADEPARTMENT OF HOME AFFAIRSNOTICE OF BIRTH(PERSONS UNDER ONE YEAR)[Section 9 of Act of 1992: Regulation 5 (1)]r illilr lllll lllll lllll llll llll9999A. CHILDS urnameForenames in fullDate of birthPlace of birth: CityffownAre the parents of the childmarried to each other?Date of marriageCOMPLETE WITH BLACK BALLPOINT PENulmGenderCountryCivillf yesNature of marrigemmnCuslomary IReligiouslB. NATURAL FATHER OF CHILD/PARENT section 5 of the Children's Status Act, 1987xldentity numberDate of birthSurnameForenames in fullPlace of birthCitizenshipMTuImPermanent residence oermit NATURAL MOTHER OF CHILD ldentity numberDate of birthPresent surnameMaiden nameForenames in fullPlace of birthCitizenshipmTmmPermanent residence permit ACKNOWLEDGEMENT OF PATERNITY A CHILD BORN OUT OF WEDLOCKI hereby declare that I am the natural father of the above 's permission to the acknowledgement of and surnameSignaturelnitials and surnameSignatureldentity addressdeclare that the above information is numberArea codeDateF:nai!
2 SignatureRelationshio to OFFICIAL USEO ffice stampStatBirthNotice approved by:lnitials and surname:DatePersal ;ai;;;* DELETE WHICHEVER IS NOT OF SOUTH AFRICANOTICE OF BIRTHMust be compteted in black ink. Ptease tick A where applicable. Please refer to instruction booktetINFORMATION FOR MEDICAL AND HEALTH USE ONLYFILE No.: DATE:Placeof birth: Publichospital l--l Privatehospital [__l Doctor'soffice l--l Athome [-_-] Ctinic [-_-] Facititycode mMOTHERP opulation group: African l--l Cotoured l--l Indian l--l White l--l Other (specify) ..Education (Specify only highest class completed):NoneSub AGr. 1 Sub 2 NTC 10 Form 3 NTC 1!Form 4 NTC 3std. 10Gr. 12 Form full cletails of lhc kinrl nf work fhe mother is r'lninoWhat is the main activity of the mother's firm, institution or private employer? Describe the activity in as much detail as possibleFATHERP opulation group: African f_l Cotoured f-l Indian [-_l White l-_l Other (specify)Education (Specify only highest class completed):NoneSub AGr.]]
3 1 Sub 1std. 2 NTC 1std. IGr. 10 Form 3 NTC 2std. IGr. 11 Form 4 NTC 3std. 10Gr. 12 Form frrll dciailc nf thc kind of rrunrk fhp faiher ic .loinnWhat is tha mAin aniiviirr of thc father'q firm inqtittrtinn nr nrirraia emnlnrrar? F)accrihorlalail ac nnccihloMATERNALLive birth fT-l Now livins t-T-l Now dead fT-l Date of previous tive birth fffT_T--T-lAntenatalvisit lTTtll Clinical estimate of gestation t-T_l Newty born birth weight S lffT_lMother transferred prior to fTT*-l lf yes' enter name of facility transferred fromdetivery .. Apgarscore: l min l-T-l smin l--T--lSELECTED RISK FACTORSFOR THIS PBEGNANCY(Complete all items)Tobacco use during pregnancy fVl-NlAlcohot use during pregnancy mAverage number ol f-1_--lcigarettes per day | | IAveraqe number of t--T-=ldrinks-oer weekWeight gained duringpregnancy in kgt--T-t"tEi,1?
4 :'J"" I e'amRsia I rA:t?B?ff:T"Anaemialoiaoetic l33:13:RenalDiseaseInrection lSjlil:::.::.:..:::CONGENITAL ABNORMALITIES OF NEWBORNMETHOD OF THIS DELIVERY (Mark all that apply):wTN Ilf yes, birth afterPrevious C-sectionPrimary C-sectionRepeat C-sectionForcepsVacuumABNORMAL CONDITIONS OF NEWBORN (Ail that appty)NoneAnaemic (HCT<39 HGB<13Gt INeurologicalbirth injuryFetal alcoholsynoromeHyalinemembranediseaseSeizuresMeconiumaspirationsyndromeAssisted ventilation <30 minAssisted >30 minOthar)
