FORM B1

REPUBLIC OF KENYA
ORIGINAL
THE BIRTHS AND DEATHS REGISTRATION ACT
(Cap. 149)
ACKNOWLEDGEMENT OF BIRTH NOTIFICATION (FOR PARENTS)
Serial

1. NAME OF CHILD: ……………………………………………………………………………………………………………….

First name Other name Father’s (surname or tribal) name

2. DATE OF BIRTH : .................................................... 3. SEX:* Male Female

Day month year

5. NATURE OF BIRTH: Born alive Born dead

7. NAME OF MOTHER ……………………………………………………………………………………………………………….
First name Maiden name Father’s (surname or tribal) name
I certify that the above information has been notified and recorded.

17. DATE .......................................... 18. REGISTRATION ASSISTANT FOR: 19. NAME AND SIGNATURE
Day month year (state sub-location or health institution)

…………………………………………………….. ……………………………………
See Instruction III (b) on the cover.
Note.-To obtain a birth certificate, present this notification to the District Registrar of Births where this birth
occurred.
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FORM B1
REPUBLIC OF KENYA ORIGINAL
3E BIRTHS AND DEATHS REGISTRATION ACT
(Cap. 149)
REGISTER OF BIRTH

Serial
1. NAME 2. DATE OF BIRTH
…………………………………………………………………………… ……………………………………………………
First name Other name Father’s (surname or tribal) name Day Month Year
CHILD

3. SEX: 4. TYPE OF BIRTH Other, specify 5. NATURE OF BIRTH

1 2 1 2 1 2
Male Female Single Twin ..………………. Born alive Born dead

6. PLACE OF BIRTH ………………………………………………………………………………………………/…………………………….

Sub-location or Estate and town or health institution District

7. NAME ………………………………………………………………………………………………………… 8. AGE ... ……………………

First name Maiden name Father’s (surname or tribal) name
MOTHER

9. IS MOTHER MARRIED TO FATHER?*

10. RESIDENCE ……………………………… ..…………...
Yes No Sub-location or Estate or town District

11. PREVIOUS BIRTHS TO MOTHER: No. born alive ............................................................ No. born dead ……………………...
(excluding current one)
FATHER

12. NAME …………………………………………………………………………………………………………………………………………..

First name Other name Father’s (surname or tribal) name

13. NAME ..................................................................................................................................................................................................................

INFORMANT

First name Other name Father’s (surname or tribal) name

14. CAPACITY OF INFORMANT'

1 2 3 4 5
Parent T.B.A. Midwife Medical Attendant Other, specify ……………………………….
REGISTRATION

I certify that to the best of my knowledge the information 15. DATE .......................................... 16. SIGNATURE
ASSISTANT

given above is correct. Day month year

……………………………………..

17. DATE .................................. 18. REGISTRATION ASSISTANT FOR 19. NAME AND SIGNATURE
Day month year (state sub-location or health institution)
REGISTRAR

………………………………………………………………. ……………………………………

20. DISTRICT ....................................... ....... ..................... ....... 21 REGISTRATION NO. …………………………………………

22. DATE ............................................... 23. NAME ................................................................. 24. SIGNATURE …………………………….

* Cross the appropriate box, thus (x).
If mother is not married to father, do not insert the name of father GPK(L)
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 REPUBLIC OF KENYA— MINISTRY OF HEALTH
CHILD HEALTH CARD—- IMMUNIZATION
Particulars of child and mother, see reverse
CLINIC’S NAME ……………………………………….. ….……………………………………..……

CLINIC’S No. ……………………………………………………………… CHILD No. ………...

TYPE OF IMMINIZATION DATE PLACE
TUBERCULOSIS (B.C.G)

POLIOMYELITIS 1 st Dose
(ORAL)
2 nd Dose
3 rd Dose

D.P.T

(DIPHTERIA, 1 st Dose
WHOOPING ,
COUGH, 2 nd Dose
TETANUS)
3 rd Dose

MEASLES

BOOSTERS TYPE

TYPE

TYPE

OTHER IMMUNIZATIONS TYPE

TYPE

SIBLINGS (brothers and sisters)

NAME DATE OF BIRTH SEX ALIVE DEAD

9
Pg 2 of 2

10

11