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1. Patient ID # 2. Patient s name: 3. Name of Health Facility Catchment area: 5. Village: 4. Payam: 7. Parity: / / / 9. Date of delivery: Day/Month/Year 11. Place of delivery : (check one) 8. Gravida: / / / 10. Time of Delivery : 12. Serious Adverse Event: (check all appropriate) Home Health facility In transit from home to health facility Other (please specify) / / / / / /.

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