Background: India accounts for one-fourth of the global incident tuberculosis (TB) case load and tops the list of highburden countries. Initial default and loss to follow-up are important challenges in achieving the objectives of the Revised National TB Control Programme (RNTCP). Objective: A study was carried out to estimate the proportion of initial defaulters, reasons for initial default, and recommendations to reduce initial default. Materials and Methods: A record-based study was carried out to identify the initial defaulters among new sputumpositive TB patients diagnosed during 1 year (2013) in four medical colleges of Puducherry. On the basis of the completeness of recorded residential address and availability of the patients, 38 patients were contacted and enrolled in the study. A pretested and predesigned questionnaire was used to interview the patients and open-ended questions were used to elicit the reason for initial default. Results: The proportion of initial default among all the four medical colleges was 15.3%. Patient-related factors for initial default were long distance to the health facility, lack of support from the family members, being advised against alcohol consumption while taking treatment, monetary constraints, job constraints, not convinced about results by the health facility, stigma related to TB, and lack of awareness regarding TB. Health system-related factors were unpleasant experience with the health system, lack of dissemination of adequate information regarding further course of action to the patients, and nonavailability of the laboratory staff. Conclusion: The magnitude of initial default was found to be high in Puducherry and most of the reasons for initial default found in this study were preventable. Systematic methods to prevent initial default need to be chalked out by program managers in collaboration with various medical colleges under the RNTCP.