Certificate of Live Birth Worksheet
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Mother’s Name_______________________________________ Mother’s Medical Record #_____________________________ CERTIFICATE OF LIVE BIRTH WORKSHEET The information you provide below will be used to create your child’s birth certificate. The birth certificate is a document that will be used for legal purposes to prove your child’s age, citizenship and parentage. This document will be used by your child throughout his/her life. State laws provide protection against the unauthorized release of identifying information from the birth certificates to ensure the confidentiality of the parents and their child. It is very important that you provide complete and accurate information to all of the questions. In addition to information used for legal purposes, other information from the birth certificate is used by health and medical researchers to study and improve the health of mothers and newborn infants. Items such as parent’s education, race, and smoking will be used for studies but will not appear on copies of the birth certificate issued to you or your child. ____________________________________________________________________________________________ TYPE OF BIRTH --- PICK ONE: Born at Facility Born En-Route to Facility Born at Non Participating Facility Born En-Route to Non Participating Facility Home Birth Foundling 111. Facility name:* ____________________________________________________________________ (If not institution, give street and number) 222. City, Town or Location of birth: ______________________________________________________ 333. County of birth: ____________________________________________________________________ 444.4. Place of birth: Hospital Freestanding birthing center ( freestanding birthing center is one that has no direct physical connection to a hospital) Home birth Planned to deliver at home? Yes No Clinic/Doctor’s Office Other (specify, e.g., taxi cab, train, plane __________________________ *Facilities may wish to have pre-set responses (hard-copy and/or electronic) to questions 1-5 for births which occur at their institutions. 555.5. Time of birth: ___________ AMAMAM PMPMPM NOON MIDNIGHT 666. Date of birth: ___ ___/___ ___/___ ___ ___ ___ M M D D Y Y Y Y 777.7. Plurality (Specify SINGLE, TWIN, TRIPLET, QUADRUPLET, QUINTUPLET, SEXTUPLET, SEPTUPLET, or OCTUPLET for 8 or more. (Include all live births and fetal losses resulting from this pregnancy.):______________ 888.8. If not single birth (Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live births and fetal losses resulting from this pregnancy): ________________________ 9. If not single birth, specify number of infants inin tthishis delivery born alive: _________ 6/20/2012 PAGE 1 VERSION 28 INDIANA'S BIRTH WORKSHEET 10. Sex (Male, Female, or Not yet determined): __________________________________ 111111.. What will be your BABYBABY’’’’SSSS legal name (as it should appear on the birth certifcertificate)?icate)? _____________________________________________________________________________________ First Middle Last Suffix (Jr., III, etc.) 11121222.. MOTHER: What is your current legal name? _______________________ _________________ _______________________ ____________ First Middle Last Suffix (Jr., III, etc.) 11131333.... MOTHER: Where do you usually livelive--------thatthat isis--------wherewhere is your household/residence located? Building number: ______________________ Pre-directional ___________________________________ Name of street _______________________________________________________________________ Street Designator, eg Street, Avenue, etc. _______________________________ Post Directional __________________________________ Apartment Number _____________ State: _______________________(or U.S. Territory, Canadian Province) If not United States, C ountry ________________________________________ City, Town, or Location:_______________________________ County: _______________________ Zip: _______________ 11141444.. Is. Is this household inside city limits (inside the incorincorporatedporated limits of the city, town or location where you live)? Yes No Don’t know 11151555.. MOTHER: What is your mailing address? Same as residence [Go to next question] Building number: ______________________ Pre-directional ___________________________________ Name of street _______________________________________________________________________ Street Designator, eg Street, Avenue, etc. _______________________________ Post Directional __________________________________ Apartment Number _____________ State: _______________________(or U.S. Territory, Canadian Province) If not United States, C ountry ________________________________________ City, Town, or Location:_______________________________ County: _______________________ Zip: _______________ 11161666.. MOTHER: What is your date of birth? (Example: 0303 ---04-040404----1977)1977) ___ ___/___ ___/___ ___ ___ ___ M M D D Y Y Y Y AGE: ________________ 11171777.. MOTHER: In what State, U.S. territory, or foreign country werewere you born? Please specify one of the following: State ___________________________________County ____________________________ City ___________________________ OR U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Northern Marianas ___________________________ OR Foreign country ___________________________________________ MOTHER: If you were born in the U.S. please answer the next two questions as well. In What County were you born? ___________________________________________ In What City were you born? ______________________________________________ UNKNOWN 11181888.. MOTHER: What is your Social Security Number? _________ _____________ ____________ ________________------------__________________ __ ______ ____________------------__________________ ____________ ________________ __ ______ ____________ 6/20/2012 PAGE 2 VERSION 28 INDIANA'S BIRTH WORKSHEET 11191999.. Do you want a Social Security Number issued for yyourour baby? Yes (Please sign request below) No (Continue) I request that the Social Security Administration assign a Social Security number to the child named on this form and authorize the State to provide the Social Security Administration with the information from this form which is needed to assign a number. (Either parent, or the legal guardian, may sign.) Signature of infant’s mother or father_____________________________________________________ Date: ___ ___/___ ___/___ ___ ___ ___ M M D D Y Y Y Y 202020.20 . Will infant be placed for Adoption? Yes No 22212111.. MOTHER: What is the highest level of schooling thatthat you wilwilll have completed at the time of delivery? (Check the box that best describes your education. If you are currentlycurrently enrolled, check the box that indicates the previous grade or highest degree received). 8th grade or less 9th - 12th grade, no diploma High school graduate or GED completed Some college credit but no degree Associate degree (e.g. AA, AS) Bachelor’s degree (e.g. BA, AB, BS) Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD) 22. MOTHER: What is your usual occupation or industry in which you work? Please fill in below. For example your occupation is Teacher, CPA, Waitress, Clerk, etc., and the industry in which you work is Department Store, Law Firm, Hospital, Factory, etc. Usual Occupation: _____________________________________________________________________ Usual Industry: ________________________________________________________________________ Unemployed Unknown 22232333.. MOTHER: Are you Spanish/Hispanic/Latina? If not Spanish/HisSpanish/Hispanic/Latina,panic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate boxbox.... No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latina (e.g. Spaniard, Salvadoran, Dominican, Columbian) (specify)____________________________________ 22242444.. MOTHER: What is your race? (Please check all that applyapply).).).). White Black or Af rican American American Indian or Alaska Native (name of enrolled or principal tribe(s)) ____________________________________________ Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian (specify)______________________________________ Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify)______________________________ Other (specify) ___________________________________________ MOTHER: Additional Information To Be Filled In IfIfIf A PATERNITY AFFIDAVIT IS TO BE FILED FOR THIS BIRTH If Not Filing Paternity Affidavit skip to question 303030.30 ... 2225.25. What is Your Phone Number? Required ________________________________________________________________________________________________ 6/20/2012 PAGE 3 VERSION 28 INDIANA'S BIRTH WORKSHEET 22262666.. What is the name of your Employer (Company name)name)?? Optional _________________________________________________________________________________________ 2227.27. What is your Employer's addressaddress?? Optional _________________________________________________________________________________________________ 2228.28. What is the name of your Medical Insurance CompanyCompany?? Optional _________________________________________________________________________________________________ 2229.29. What is your Medical Insurance Policy number? Optional __________________________________________________________________________________________