ANNEXURE-I Women Death First Information ... - Nrhmharyana.org

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Sr.NoName ofdeceasedAgeDateofdeathAddressHusband’s nameCause of death(tick √)MaternalNon-MaternalPrimaryinformationprovidedbyDate of fieldinvestigationIf died due tomaternal causes,pl. specifyreasonsAction takenSignature & Date of MO I/C of the PHC/CHC/SDH/Other:Note: Maternal death is defined as the death of a woman who dies from any cause related to or aggravated by pregnancy or its management(excluding accidental or incidental causes) during pregnancy or child birth or within 42 days of termination of pregnancy, irrespective ofduration and site of pregnancy.
Annexure VMaternal Death Review Form{To be filled by the District Level Committee after receiving the report of CBMDR (Annexure-II) and of MO Incharge(Annexure-III)Name of the Deceased:Husband’s Name:Age:Address:Block & District from where death reportedDate of Death:Place of Death:Whether first information report received within 24hours of deathWhether CBMDR conducted (Yes/No):If yes, date of reportWhether CBMDR report received by the districtcommittee (Yes/No)?Whether MO’s report (Annexure-III) received(Yes/No) ?Date of receipt of report
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ANNEXURE-I Women Death First Information ... - Nrhmharyana.org

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