(IPHS) Guidelines - NRHM Manipur

Annexure 8Facility Based Maternal Death Review FormNote: This form must be completed for all deaths, including abortions and ectopic gestation related deaths, inpregnant women or within 42 days after termination of pregnancy irrespective of duration or site of pregnancy.Attach a copy of the case records to this form.Complete the form in duplicate within 24 hours of a maternal death. The original remains at the institution wherethe death occurred and the copy is sent to the person responsible for maternal health in the State.FB-MDR no:For Office use Only:Year:1. General InformationAddress of Contact Person at District and State:Residential Address of Deceased Woman:Address where Died:Name and Address of facility:Block:District:State:Indian Public Health Standards (IPHS) Guidelines for Community health centres 35