Birth Registration Handbook PDF

GENERAL INFORMATION
INTRODUCTION
This handbook describes birth registration in the Texas vital registration system.
It provides instructions for completing and filing birth certificates along with
related permits.
A birth certificate is a permanent legal record of an individual’s birth. The birth

certificate is an individual’s basic claim and proof of citizenship, identification and
relationship to his or her parent(s). It serves as the primary document for
individuals to enter school, play little league sports, obtain a social security
number and account, a driver’s license, a marriage license, a passport, and to
prove citizenship to be qualified to work in this country.
In addition to being the primary document of identification for an individual, a birth

certificate provides information used in a variety of medical and health-related
research efforts. Birth statistics are used to assess the general health of Texas
citizens. Birth statistics also help identify adequacy of prenatal care, pregnancy
outcome based on birth weight and length of gestation, abnormal conditions of
mothers and babies and specific geographic concerns.
Because birth statistics are no more accurate than the information submitted on
the birth certificate it is very important that all birth certificates be completed and
filed with accuracy and promptness.
REGISTRATION REQUIREMENTS
A Certificate of Birth (VS-111) must be filled within five (5) days of the date of
birth for every live birth in Texas [HSC §192.003 (d)]. The Certificate of Birth
should be registered with the State of Texas – Vital Statistics Unit though the
Texas Electronic Registration (TER) system. Persons responsible for registering
births will need to sign up for TER and will receive a user ID and password. To
sign up for TER go to www.texasvsu.org.
The Texas Administrative Code (TAC) defines a “live birth” as the complete
expulsion or extraction from its mother of a product of conception, irrespective of
the duration of pregnancy, which, after such separation, breathes or shows any
other evidence of life such as beating of the heart, pulsation of the umbilical cord,
or definite movement of voluntary muscles, whether or not the umbilical cord has
been cut or the placenta is attached; each product of such a birth is considered
live born. [25 TAC §181.1(18)] A Certificate of Birth must be filed for all live
births regardless of length of gestation or chance of survival.
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Should the infant die after being determined a live birth, a Certificate of Death
(VS-112) must also be filed. For instructions on completing a Certificate of Death,
see the Handbook on Death Registration.
When a fetal death occurs, then a certificate of birth would not be filed, the
Certificate of Fetal Death (VS-113) would be filed. The Texas Administrative
Code defines a “fetal death” as death prior to the complete expulsion or
extraction from its mother of a product of conception, irrespective of the duration
of pregnancy; the death is indicated by the fact that after such separation, the
fetus does not breathe or show any other evidence of life such as beating of the
heart, pulsation of the umbilical cord, or definite movement of voluntary muscles
[25 TAC §181.1 (11)]. See the Handbook on Fetal Death Registration for
instructions on completing the Certificate of Fetal Death.
The birth certificate must be filed by the attendant at birth. If the birth occurs in a
licensed institution (hospital, birthing center), an administrator may file the
certificate. If the birth occurs in a non-licensed institution (occurs outside of a
licensed institution) and was attended by a registered, certified or documented
health care provider (doctor, Midwife, EMT) the birth may be registered by the
attendant or by the local registrar after he/she have presented their professional
documentation. If the birth occurs in a non-licensed institution and a registered
attendant is not present, the birth should be registered by the father or mother of
the child or the owner/ householder of the premises where the birth occurred.
Documentation is required from the parent(s) before a birth certificate may be
filed. Chapter 4 of this handbook provides detailed filing information.
Births must be filed using TER or the forms prescribed by the Department of
State Health Services (DSHS), Vital Statistics Unit. The most recent revision of
the form must be used.
CONFIDENTIALITY / CERTIFIED COPIES

Requests for information registered in the TER system on Certificates of Birth is
considered confidential. Certified copies may be issued only to properly qualified
applicants who have submitted proof of their identification and have fully
identified the record requested.
The fact of birth (name, date and place) of an individual is public knowledge;
however, the birth certificate is not. A birth certificate is a confidential record for
the first 75 years after filing and may be released only to a properly qualified
applicant. [HSC §191.051 (a); 25 TAC §181.1(2); GC §552.115] A certified copy
of a birth certificate includes only the upper “legal” portion down to and including
the registrant’s signature.
In addition to the demographic information, information held under the section

entitled “Confidential Information for Medical and Public Health Use” are
confidential and are not considered open records for the purpose of the open
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records law. That information, including parents’ signatures and social security
numbers, are not included in a certified copy and may not be released or made
public on subpoena or otherwise, except for statistical purpose, where no person,
patient, or facility is identified. [HSC §192.002 (b)]
PENALTIES
It is a Class A misdemeanor if a person knowingly discloses the medical or
health information, or knowingly induces or causes another to disclose
information. It is a Class C misdemeanor if a person refuses or fails to furnish
any correct information in the person’s possession affecting a certificate. It is also
a Class C misdemeanor if a person fails, neglects, or refuses to fill out and file a
birth certificate with TER, the local registrar or deliver the certificate upon request
to the person with the duty to file it. To falsely obtain, use, or alter another
person’s Certificate of Birth is a third degree felony.
LICENSED INSTITUTION RESPONSIBILITIES

A birth that occurs in a licensed institution (hospital, birthing center) may be
registered in TER by the hospital administrator, the birthing center administrator,
or a designee of the appropriate administrator in lieu of the physician or midwife
in attendance of the birth. [HSC §192.003 (b)]
The responsibilities of the person registering the birth at a licensed institution

(hospital, birthing center) in the birth registration process are as follows:
Obtain information needed for completion of the birth certificate from

appropriate sources. Sources include the mother of the child, mother’s
physician, infant’s physician, or medical records. Information may be obtained
from the immediate family or other sources as needed.
Complete a Certificate of Birth for each live birth that occurs in the hospital or
en route to the hospital.
If the parents are not married to each other, provide whenever possible an
opportunity for the father to acknowledge paternity, including the
Acknowledgment of Paternity (AOP) form and the required oral and written
notification of rights and responsibilities.
Inform the parents that they may request an application for child support
services by calling the Office of Attorney General at 1-800-252-8014.
Review the certificate and AOP if applicable, for completeness and accuracy
and fax into VSU at 1-888-561-3138.
Obtain the appropriate parents’ signatures on the Verification of Birth Facts

document.
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File the certificate in TER within five (5) days from the date of birth. [HSC
§192.003]
Cooperate with the Vital Statistics Unit (VSU) and local registrars concerning
queries on certificate entries.
Instructions for filing a birth certificate in TER can be found at www.texasvsu.org.
Contact [email protected] for technical assistance with TER.
MIDWIFE RESPONSIBILITIES
A birth that is performed with a Midwife may be registered in TER by the midwife
or designated registrant. If the midwife is not a TER participant he/she will need
to register the birth as a paper record.
Midwives must be documented each March with the Texas Department of State
Health Services (DSHS – formerly TDH). [Title 25 TAC §37.175] The Certificate
of Birth should be filed in TER or with each local registrar in whose district he or
she intends to deliver births. [Title 25 TAC §81.26 (1)] after his/her health
department documents have been provided to the local registrar.
The responsibilities of the midwife in the birth registration process are as follows:
Midwives must be documented each March with the Texas Department of

Health. [Title 25 TAC §37.175]

Complete a Certificate of Birth for each live birth that the midwife attended.
notification of rights and responsibilities.
Inform the parents that they may request an application for child support
services by calling the Office of Attorney General at 1-800-252-8014.
Review the certificate and AOP if applicable, for completeness and accuracy
If applicable fax AOP into VSU at 1-888-561-3138.
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Obtain the appropriate parents’ signatures on the Verification of Birth Facts
document.
File the certificate in TER within five (5) days from the date of birth. [HSC
§192.003]
NON-LICENSED INSTITUTION RESPONSIBILITIES

NON-INSTITUTIONAL BIRTH ATTENDED BY A REGISTERED,
CERTIFIED OR DOCUMENTED HEALTH CARE PROVIDER.
A birth that occurs in a non- licensed institution (any institution that is not
licensed) should be registered by the attendant.
If the birth is attended by a registered, certified or documented health care

provider, such as a midwife, doctor, or EMT, the birth may be registered by the
attendant after he or she has presented his or her professional documentation to
the local registrar.
The responsibilities of the registered, certified or documented health care

provider in the birth registration process are as follows:
Presented his or her professional documentation to the local registrar.

Complete a Certificate of Birth.
notification of rights and responsibilities. Inform the parents that they may
request an application for child support services by calling the Office of
Attorney General at 1-800-252-8014.
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Review the certificate and AOP if applicable, for completeness and accuracy.
If applicable fax AOP into VSU at 1-888-561-3138.
Obtain the appropriate parents’ signatures on the birth certificate (VS-111).
File the certificate in within five (5) days from the date of birth with the local
registrar. [HSC §192.003]
NON-INSTITUTIONAL BIRTH NOT ATTENDED BY A REGISTERED,

CERTIFIED OR DOCUMENTED HEALTH CARE PROVIDER.
If there is no physician, midwife, or person acting as midwife in attendance at a
non-institutional birth, documentation is required from the parent(s) before a birth
certificate may be filed.
In an effort to control fraudulent filings of birth records and to place control over
blank forms, the Texas Vital Statistics Unit (VSU) and Texas Board of Health
developed and approved rules for filing birth certificates for children born outside
licensed institutions. [25 TAC §181.26] To insure uniform compliance throughout
the state, VSU developed the following administrative comments and
instructions.
To file a birth certificate with the appropriate local registrar the following proof
must be presented to the local registrar by the person in attendance at the birth
in the following order of preference:
1. The father or mother of the child; or

2. The owner or householder of the premises where the birth occurs.
The registrar may provide to the person filing the birth record a “Mothers Work
Sheet” in order to gather the information to be placed on the birth record.
A birth a birth certificate can be filed only upon personal presentation of the
following evidence
Note: Only one affidavit of personal knowledge of one of the four items can be
used.
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PROOF OF PREGNANCY, PRESENTED IN FOLLOWING ORDER OF
PREFERENCE;
An affidavit (notarized) presented from a licensed, registered, or certified
health care provider who is qualified to determine pregnancy as part of the
scope of his or her license or registration, or certification; or
An affidavit (notarized) along with photocopy of ID (for example, a driver’s

license or government ID, etc.) presented from one person, other than the
parents, having knowledge of the pregnancy/birth
PROOF THAT THE INFANT WAS BORN ALIVE;

A medical record or a letter from a licensed, registered, or certified health
care provider or medical institution; or
An affidavit (notarized) along with photocopy of ID (for example, a driver’s

license or government ID, etc.) presented from one person, other than the
parents, having knowledge of the pregnancy/birth.
PROOF THAT THE INFANT WAS BORN IN THE REGISTRATION DISTRICT;

If the birth occurred outside the mother’s primary place of residence, proof
shall consist of an affidavit (notarized) along with a photocopy of ID from a
person having knowledge of the mother’s presence in the registration district
on the date of the birth.
If the birth occurred in the mother’s primary place of residence, proof of

residence in the following order of preference:
o A utility bill, telephone, or other bill which includes the mother’s name
and address;
o A rent receipt which includes the mother’s name, address, and

signature of the mother’s landlord;
o A driver’s license, or state issued identification card, which includes the
mother’s current address on the face of the license or card;
o An envelope addressed to the mother at her place of residence, and

post marked prior to the date of birth; or
o An affidavit (notarized) attesting to the mother’s place of residence

along with a photocopy of ID from a person, other than the father, who
was either living with the mother at the time of the alleged birth, or has
other knowledge of the mother’s residency.
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PROOF THAT THE INFANT WAS BORN ON THE DATE STATED.
A medical record or a letter from a licensed, registered, or certified health
care provider or medical institution; or
An affidavit (notarized) presented from one person along with photocopy of

ID, other than the parents, having knowledge of the pregnancy/birth.
OTHER SUPPLEMENTAL INFORMATION PROVING HOME BIRTH

At the discretion of the local registrar, these procedures may be supplemented
with any additional requirements needed to verify the circumstances of the birth.
Additional requirements may include, but are not limited to, one or more of the
following:
An unannounced visit by a public health nurse, other health professional,

registrar staff, or other person including city, county, state, or federal law
enforcement officers, prior to registering the birth. This paragraph does not
permit nor give authority to enter these premises unless permission is
obtained from the occupant at the time of the visit;
Multiple forms of identifying documents, with or without photographs, when

the documents described in this section are unavailable;
Personal appearance of both parents, either together or separately; or
Personal appearance of the infant whose birth certificate the parents are
attempting to file
Any person who cannot meet the documentation requirements should be referred
to the State Registrar and the Fraud Prevention Program. See the information
under “Persons and/or Records Not Meeting Requirements for Filing.”
The documentation that has been submitted as proof should be returned to the
person filing the record after the birth record is accepted.
Each local registrar must notify the Fraud Prevention Program of any suspicious
documents or records submitted or filed with his or her office.
If the individual(s) attempting to file the birth records of a child not born in an
institution cannot meet the four essential elements required for filing (proof of
pregnancy, proof the infant was born alive, proof the infant was born in the
registration district, and proof the infant was born on the date stated), the local
registrar will forward the record and all documentation to the State Registrar for
his or her determination.
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The local registrar will send a cover letter with the documentation
explaining why he or she cannot accept the record for filing.
The local registrar will give a letter to the parent(s) and/or person trying to
file the record telling them why he or she cannot accept the record for
filing and that the request and documentation have been sent to Austin for
the State Registrar’s determination.
Upon receipt of the birth record from the local registrar within one year of
the date of birth, the State Registrar will direct the Fraud Prevention
Program to further verify or investigate as necessary to determine to
accept or not accept the documentation sent. If the documentation is
deemed unacceptable the State Registrar will send a letter referring the
parent(s) to a Texas district court for a judicial determination and order to
file a Certificate of Birth. If the birth occurred more than a year before the
parent(s) attempt to file a delayed birth certificate, and the documentation
is deemed unacceptable, the State Registrar may refer the case to the
county judge of the alleged county of birth for a judicial decision.
ACKNOWLEDGEMENT OF PATERNITY
When the biological father and mother are not married (or the marriage ended
within 300 days of the child’s birth) this form is signed by both parents to
establish a legal finding of paternity. The biological father becomes the legal
father and has all rights and duties of a parent. His name may go on the birth
certificate. A certified person will assist in the AOP process. See the
Acknowledgement of Paternity (AOP) handbook from the Office of Attorney
General (OAG) for details on the process.
PATERNITY REGISTRY
The Texas Vital Statistic Unit has established a Paternity Registry for men to
voluntarily assert their parental rights. The purpose of the Paternity Registry is to
“protect the parental rights of fathers who affirmatively assume responsibility for
children they have fathered, and expedite adoptions of children whose biological
fathers are unwilling to assume responsibility for their children by registering with
the registry or otherwise acknowledging their children.” [TFC §160.251(b) (1-2)]
A man is not required to register with the Paternity Registry. It is unnecessary for
him to register if he is listed as the biological father on the child’s birth certificate,
if he has completed an AOP with the child’s mother, or if he has been
adjudicated to be the biological father of the child by a court of competent
jurisdiction. The Paternity Registry does provide an opportunity for a father to
assert his parental rights when he cannot complete the AOP or be listed as the
father on a child’s birth certificate.
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NOTICE OF INTENT TO CLAIM PATERNITY
The Notice of Intent to Claim Paternity form is used to add the father’s name to
the Paternity Registry maintained by the Vital Statistic Unit (VSU). [TFC
160.256] A man who wishes to claim paternity for a child he may have fathered
can complete a Notice of Intent to Claim Paternity. This form is used in situations
where the father and mother do not have a continuing relationship and the man is
not listed as the father on the birth certificate or AOP or when the biological
father is unable to sign the AOP because he and the mother cannot obtain a
denial of paternity from the man to whom she was married at or within 300 days
before the birth.
The Notice of Intent form must be filed before or within 30 days of the date of
birth of a child. [TFC 160.256] The man should also be encouraged to obtain
legal advice and petition the court for the establishment of legal paternity.
The Notice of Intent form will not legally establish paternity nor can it be used to
add a man’s name to the child’s birth certificate. It is simply an assertion of belief
that he is the father of a child and wishes to preserve his rights as a parent.
The following is a list of examples (not all-inclusive) in which the man may use
the Notice of Intent to Claim Paternity form to register his assertion of paternity to
protect his rights:
A man and woman have a consenting sexual relationship for a brief period
of time and they have no further contact. The man understands the
woman may have become pregnant and he wishes to assert his paternity
for the possible child. He would complete the Notice of Intent to Claim
Paternity form to register his assertion.
A man and woman do not agree that he is the father of her child. The
man wishes to assert his paternity.
More than one man claims to be the father of the child. Each man would
complete a separate Notice of Intent.
The mother refuses to complete and sign the AOP form.
The mother was married at or within 300 days before the child’s birth and
the mother and biological father cannot obtain a denial of paternity from
her current or former husband.
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ARTIFICIAL INSEMINATION
If a husband and wife consent to the artificial insemination of the wife, any
resulting child is the child of the couple; the resulting child is not the child of the
donor, unless the donor is the husband of the woman. The consent must be in
writing and must be acknowledged. If the mother of the child was married at the
time of conception or the birth of the child, the husband of the mother is
presumed to be the father of the child unless otherwise determined by a court of
competent jurisdiction.
SURROGACY
An increasing number of births are occurring as the result of a surrogate
agreement. In these situations, the question usually arises as to what parent’s
names are to be shown on the original birth certificate. The existing policy states
that the mother of the newborn is the woman who gives birth to the child; the
father is the husband of the mother. The donors, as appropriate, must seek
parenthood through the adoption process or petition a Texas District Court to
determine the maternal and paternal individuals and order this office (Vital
Statistics Unit) and the hospital to place the names of these individuals on the
record instead of the birth person and her husband.
In other words, if a woman is implanted with a fertilized egg and delivers an

infant, she should be named as the mother of the child on the record of birth
unless an existing court order deems otherwise. In addition, if she is married, her
husband would be considered to be the presumed father of the child unless an
existing court order deems otherwise. The donor parents in this case cannot be
named on the birth certificate until they have an adjudication of parentage from a
court of competent jurisdiction. If the donor parents cannot provide this within the
required filing time, the birth record should be filed with the woman who gave
birth to the child.
TER WORKSHEETS
One method of collecting the information for a birth certificate includes the use of
worksheets. Many hospitals are currently using worksheets of various types and
formats. VSU has developed three worksheets in a format that will aid in the
collection of this information. Hospitals may use these worksheets as they are,
modify them, or develop their own in whatever format they deem most useful.
The mother’s worksheet on birth certificate, VS-109.1, is for information supplied

by the mother, either by having her fill it out, or by having the hospital staff
interview her and fill in the information for her. This worksheet is available in
Spanish (VS-109a.1). The medical data worksheet, VS-109.2, is provided for
hospital personnel to collect medical information about the mother and child. The
worksheets are available from at www.texasvsu.org.
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ITEM-BY-ITEM INSTRUCTIONS
ITEM-BY-ITEM INSTRUCTION OVERVIEW
The TER birth registration consists of 8 tabs (sections) – General; Mother 1;
Mother 2; Father 1; Father 2; Medical 1; Medical 2 and Certifier.
The best way to fill in the information is to use the tab key on the computer
keyboard to move forward after a blank is filled in. (type – tab) This will assure
that you do not skip any blanks or miss any pop-up information. Some
information blanks contain drop down choices and others will need information
typed into the blank.
The blanks are color coded. The yellow blanks request information; once the
information is entered the box will turn white. The blue blanks will pre-populate
information based on previous entries.
GENERAL – (TAB 1)
RECORD TYPE
Registration will vary according to record type selected. One of the choices must
be selected.
Born at Facility;
Born En Route to Facility ;
Foundling; or
Home Birth (Hospital / Birth Center will not automatically propagate).
Please Note: Hospitals and Birthing Centers may not file a Home Birth.
MOTHER’S MEDICAL RECORD NUMBER

This is a mandatory – to save item and must be filled out before the record can
be saved. This number is generated by the registering entity (hospital, birthing
center, local registrar).
DATE AOP SENT

If the father of the child is required to fill out an Authorization of Paternity form the
date it is sent in appears here. If this form is not used then this date will remain
empty.
CHILD’S PLACE OF BIRTH

The hospital or birth center name and address will automatically populate when
selecting “Born at Facility” or “Born En Route to Facility” above in record type.
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Midwives can enter the place of birth through the Add on the Fly (AOF) process
when attending a non-institutional birth. Name the place where the birth
occurred. Delivery in places of business or public places are examples of places
that would be entered through the AOF process.
A birthing center located in and operated by a hospital is considered part of the

hospital and births in such a center should be reported as occurring in the
hospital. Licensed birthing centers include those facilities that are operated
independently from hospitals (autonomously).
The “Clinic/Doctor’s Office” category includes other non hospital outpatient

facilities where births occasionally occur.
Accurately entering the birth Place of Birth information permits analysis of the
number and characteristics of births by type of facility and is helpful in
determining the level of utilization and characteristics of births occurring in such
facilities.
NAME OF FACILITY
Enter the full name of the facility (hospital, birthing center) in which the birth
occurred. It is very important to be consistent in entering the hospital name; there
should be no variations. The name of the facility will be the legal name. The
facility name will pre-populate in TER when “born at facility” is selected.
If the mother is en route to the hospital when the child is born and the hospital is
the first place where the child is removed from the conveyance, “En route” should
be indicated. In this case the Hospital should complete the birth record to show
the name of the city or town in which the facility of destination is located.
If it has been determined that the child was not first removed from conveyance at
the hospital, the birth record should filed by the parent(s) with the local registrar
of the city, town, village, or location where the child was first removed from the
conveyance.
If the birth occurred at home, enter the house number and street name of the
place where the birth occurred. If the birth occurred at some place other than
those described above, enter the number and street name of the location.
The hospital name is used for follow up and query programs by the Texas Vital
Statistics Unit and is of historical value to the parents and child.
PLACE OF BIRTH
Type – Enter the type of facility
State – Enter the state where the birth occurred
County – Enter the county where the birth occurred.
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City – Enter the city or town in which the infant was born. If outside the city
limits, enter the Justice of the Peace precinct number. Spell out the word
“Precinct”; do not abbreviate.
If the mother is en route to the hospital and the child is born in a moving vehicle,
the birth record should be completed to show the name of the city or town in
which the facility of destination is located. “En route” should be shown followed
by the name of the facility of destination.
For a birth occurring in international airspace or international waters on a flight or

voyage that ends in Texas, complete a Texas birth certificate, but enter the
actual place of birth in so far as it can be determined. For a birth occurring at sea
or in flight, it should be marked “Other” and show “At Sea” or “In Flight.” and
should show the name of the vessel or aircraft e.g., SS Everett Hill (at sea) or -
Global Airlines Flight 263” (in flight), along with the latitude and longitude where
the birth occurred. Show the county where the infant was first removed from the
vessel or aircraft. Show the city where the infant was first removed. It is important
that the left hand margin of the certificate contain some citation of the page and
volume number of the ship’s log.
If a baby is found in this state and the place of birth is unknown, a Texas birth
certificate should be completed. The place where the baby was found should be
considered the place of birth.
CHILD’S INFORMATION
TIME OF BIRTH
Enter either military time or standard time; select am or pm.
Enter the exact time (hour and minute) the child was born according to local time.
If daylight saving time was the official prevailing time when the birth occurred, it
should be used to record the time of birth. Be sure to indicate whether the time of
birth is A.M. or P.M. One minute after 12 noon is entered as “12:01pm”, and one
minute after midnight is entered as “12:01am.” Births occurring at midnight
should be recorded as “12:00am,” (or “12 mid” in Certificate Manager), and births
occurring at noon should be recorded as “12:00pm” (or “12 noon” in Certificate
Manager).
In cases of plural births, the exact time that each infant was delivered should be
recorded as the hour and minute of birth for that infant.
This item documents the exact time of birth for various legal uses, such as the
order of birth in plural deliveries. When the birth occurs around midnight, the
exact hour and minute may affect the date of birth. For births occurring at the end
of the year, the hour and minute affect not only the day but the year of birth, a
factor in establishing dependency for income tax purpose.
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DATE OF BIRTH
This is a mandatory –to-save item and must be filled out before the record can be
saved. The date must be entered in the following format MM/DD/YYYY.
Enter the exact month, day, and year that the infant was born.
Pay particular attention to the entry of the month, day, or year when the birth
occurs around midnight or on December 31. Consider a birth at midnight to have
occurred at the end of the day rather than at the beginning of the next day.
If a baby is found in this state, enter the word “found” and the date as the date of
birth.
PLURALITY
This is a mandatory – to – save item and must be filled out before the record can
be saved. If a single birth is indicated, the following field indicating birth order will
auto-populate and the user may continue tabbing through to the next field. In a
birth order field, a selection must be made.
PLURALITY-BIRTH ORDER
This is a mandatory – to – save item and must be filled out before the record can
be saved. Specify the birth as single, twin, triplet, quadruplet, etc.
Specify the order in which the infant being reported was born: first, second, third
etc.
NUMBER OF INFANTS ALIVE

When plurality is greater than one, the Number of Infants Alive field is activated.
Select from the list.
When a plural delivery occurs, prepare and file a separate certificate for each
infant born alive. File certificates relating to the same plural delivery at the same
time. However, if holding the completed certificates while waiting for incomplete
ones would result in late filing, the completed certificates should be filed first.
These items are related to other items on the certificate (for example, period of
gestation and birth weight) that have important health implications. This
information is also used to study multiple deliveries and high risk infants who may
require additional medical attention.
MOTHERS CURRENT LEGAL NAME

FIRST NAME:
Enter the mother’s first name.
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MIDDLE NAME:
Enter the mother’s middle name. If there is no middle name, leave this item
blank; do not enter NMI, NMN, etc.
LAST NAME:
Enter the mother’s last name.
CHILDS CURRENT LEGAL NAME

FIRST NAME:
Enter the infant’s first name. If the parents have not selected a given name for
the infant, enter “Infant.” Do not enter the last name of the mother as the child’s
first name. Do not leave this item blank.
MIDDLE NAME:
Enter the infant’s middle name and any names other than First and Last. If there
is no middle name, leave this item blank; do not enter NMI, NMN, etc.
LAST NAME:
Enter the infant’s last name. The child’s last name does not have to be the same
as either parent. Also enter any suffixes following the last name.
No numerical characters can be used in names [ Example: 123456789], but you

may spell out a number in a name. [Example: One, Two, Three, etc.]
No obscenities, or non alphabetic characters are permitted.
Special Characters that are used in languages other than English are not
permitted. [Examples: è, é, ê, ë, å, ä, ã, ü, ø, ö, ó, ć, etc.]
Parents may name the infant any name they desire as long as it will fit in the
space provided on the certificate.
The parent(s) do not have to give the child their surname; for instance John
Jones and Mary Brown, husband and wife, may name their child Tommy Green,
Jr.
A mother may give her child a supposed father’s name without his name
appearing on the birth certificate as the father.
A last name may be hyphenated, as in Jones-Brown.
16
MOTHERS ADDRESS (RESIDENCE)
RESIDENCE ADDRESS:
The mother’s residence is the place where her household is located. This is not
necessarily the same as her home state, voting residence, mailing address, or
legal residence.
The state, county, city and street address should be for the place where the
mother actually lives. Never enter a temporary residence, such as one used
during a visit, business trip or vacation.
Residence for a short time at the home of a relative, friend, or home for unwed
mothers for the purpose of awaiting the birth of the child is considered temporary
and should not be entered here. However, place of residence during a tour of
military duty or during attendance at a college is not considered temporary and
should be entered on the certificate as the mother’s place of residence.
Enter the number and street name of the mother’s residence, Rural Route
number, or description that will aid in identifying the location.
RESIDENCE STATE:
Enter the state in which the mother lives. This may differ from the state for her
mailing address. If the mother is not a U.S. resident, enter the name of the
country.
APT. #:
Enter the apartment number, if appropriate.
STATE/FOREIGN COUNTRY/TERRITORY:
This field is a Type-Ahead Combo box. Select from the drop down list. If your
selection is not on the list, it may be entered via “Add on the Fly” (AOF) process.
County: Enter the name of the county in which the mother lives. That county pick
list will automatically populate with the counties that are in the state that was
specified in the previous field.
CITY /TOWN OR LOCATION:

Enter the city or town in which the mother resides. Do not enter the word “Rural”
if outside city limits; enter only the city name. This field is a Type-Ahead Combo
box.
The city/town or location pick list will automatically populate with the cities/towns
that are in the county that was specified in the previous field. Select a city from
the list. If the city is not on the list, it may be entered via “add on the fly” (AOF)
process.
17
ZIP CODE:
The zip code pick list will automatically populate with the zip codes that are
associated with the city that was specified in the previous field. Select a zip code
from the list. If the zip code is not on the list, it may be entered via “add on the fly”
(AOF) process
ZIP CODE EXTENSION:

If a zip code extension is applicable, it may be entered in this field. Otherwise,
leave this field blank.
Note : Statistics on births are tabulated by place of residence of the mother. This
makes it possible to compute birth rates based on the population residing in that
area. Data on births by place of residence of the mother are used to prepare
population estimates and projections. These data are used in planning for and
evaluating community services and facilities, including maternal and child health
programs, schools, etc. Private businesses and industries also use these data for
estimating demands for services. Inside city limits is used to properly assign to
either the city or the remainder of the county.
SAME AS RESIDENCE ADDRESS (MAILING ADDRESS)

This field is a type-Ahead Combo box. If the mothers mailing address is the same
as her residence address, the remaining fields under mother’s mailing address
will auto-populate, and the users may tab through to the next screen.
Note: if changes are made to the residence information fields, the changes will
also be reflected in the mailing address fields.
If the mother’s mailing address is NOT the same as her residence address, tab
through to the next field. Enter the mother’s mailing address only if it is different
from her street address. Enter the entire address, including the city, state, and
zip code.
It is important to distinguish between the mothers mailing address and her

residence address because each serves a different purpose. They are not
substitutes for one another.
This information is used to mail the social security card and approved public
health information / reminders to the mother.
18
MOTHER 1 – (TAB 2)
MOTHER’S DATE OF BIRTH
Enter the exact month, day and year that the mother was born. The date entered
must be in the following format: MM/DD/YYYY.
MOTHER’S AGE
This field will auto-fill based on the information entered in the previous field.
MOTHER’S BIRTH STATE, TERRITORY OR FOREIGN COUNTRY OF BIRTH

Select the State, territory or Foreign Country of the mother’s birth. If it is not on
the list, it may be entered via “On the Fly” (AOF) process. Enter the mother’s
place of birth.
If the mother was born in the United States, enter the name of the state; if the
mother was born in a foreign country or a U.S. territory, enter the name of the
country or territory.
If no information is available regarding place of birth, enter “Unknown” in this

item. If the mother was born in the United States or a U.S. Territory, but the
exact state or territory is unknown, enter “United States.”
If the mother was born in a foreign country but the country is unknown, enter
“Foreign.”
This item provides information on recent immigrant groups, such as Asian and
Pacific Islanders, and is used for tracing family histories. It is also used to
compare the childbearing characteristics of women who were born in the United
States with those of foreign born women.
MOTHERS SSN
Enter the mother’s social security number. A parent may refuse to give his or her
social security number, but it is strongly recommended it be obtained if possible.
In some instances one or both may not have social security numbers. Should
they refuse to provide their number, or not have a number, leave this field blank;
do not enter “unknown.”
SSN FOR BABY

Mark the “Yes” box if the parent wants a Social Security number issued for the
baby; mark “No” if the parent does not. Answering “yes” to this question will
enable the Social Security Letter and will make the record eligible to be included
in the SSA Extract.
19
If the “Yes” block is not checked or the child does not have a name, no social
security number will be issued by the Social Security Administration through the
birth registration process.
It will take approximately two weeks from the time of electronic transmission for
the parent to receive the social security card from the Social Security
Administration.
MOTHER RELINQUISH RIGHTS

Select from the list. Mother Relinquish Date This field will only enable if the
answer to the previous question is “yes”. The date entered must be in the
following format: MM/DD/YYYY.
MOTHER’S EDUCATION.
Select from the list. Enter the total number of years of education completed. If
education is unknown, enter “Unknown.” For no education, enter “None.”
A person who enrolls in college but does not complete one full year should not be
identified with any college education in this item.
Do not include beauty, barber, trade, business, technical, pre kindergarten,

kindergarten, or other special schools when determining highest grade
completed. Zero (0) indicates no regular schooling; 1-12 indicates years of
elementary/secondary school completed; 13-16 represent 1-4 years of college;
and 17+ indicates graduate education beyond a bachelor’s degree.
Education is correlated with fertility and birth outcome, and is used as an

indicator of socioeconomic status. This item is also used to measure the effect of
education and social economic status on health, childbearing, and infant
mortality.
MOTHER’S OCCUPATION AND INDUSTRY

Enter the mother’s occupation during most of her working life (e.g., homemaker,
student, teacher, clerk, programmer, attorney, realtor, artist, nurse, etc.). If
occupation is unknown, enter “Unknown.” For no occupation, enter none. Many
women specify “housewife” because they stopped working after pregnancy
began or shortly before birth. Ask them if they were working any time in the last
two years. Do not use “self employed.”
MOTHER’S TYPE OF BUSINESS

Enter the kind of business or industry related to the mother’s occupation (e.g.,
ranching, retail, consulting, education, farming, government, manufacturing, etc.).
If the kind of business is unknown, enter “Unknown.” For no kind of business,
enter “None.”
20
MOTHER OF HISPANIC ORIGIN
Check one (1) from the list. If “yes”, other Spanish? Hispanic? Latino” is
checked, enter the Hispanic Origin in the specify field. Mark “Yes” or “No” to
indicate whether the mother is of Hispanic origin. Enter the country (ies) of
Hispanic origin. If the mother indicates that she is of multiple Hispanic origins,
enter the origins as reported, separated by commas (for example, Mexican,
Puerto Rican).
This item is not a part of the Race item; a person of Hispanic origin may be of
any race.
Each question, Race and Hispanic origin, should be asked and treated as an
independent item. Hispanics comprise the second largest ethnic minority in this
country. This item provides data to measure differences in fertility and pregnancy
outcome as well as variations in health care for people of Hispanic and non
Hispanic origin. Without collection of data on persons of Hispanic origin, it is
impossible to obtain valid demographic and health information on this important
group of Americans.
Note: Information on race/ethnicity is essential in producing data for various

populations. It is used to study cultural variations in access to health care and
pregnancy outcomes (infant mortality and birth weight). Race/ethnicity is an
important variable in planning for and evaluating the effectiveness of health
programs and in preparing population estimates.
MOTHER’S RACE FRAME

Enter the race of the mother as obtained from the parents or other informant. For
Asians and Pacific Islanders, enter the national origin of the mother, such as
Chinese, Japanese, Korean, Filipino, Samoan, Vietnamese, or Hawaiian.
Check one or more races to indicate how the mother identifies herself.
01 White
02 Black or African American
03 American Indian or Alaska Native If “American Indian or Alaska Native”
is checked, enter the name of the enrolled or principle tribe in the field.
04 Asian Indian
05 Chinese
06 Filipino
07 Japanese
08 Korean
09 Vietnamese
10 Other Asian If “Other Asian” is checked, enter the “other Asian” race in
the “specify field”.
11 Native Hawaiian
12 Guamanian or Chamorro
13 Samoan
21
14 Other Pacific Islander If “Other Pacific Islander” is checked, enter the
“other pacific islander” race in the specify field.
15 Other If “Other” is checked, enter the “Other” race in the ‘Specify” field.
99 Unknown
MOTHER 2 – (TAB 3)
MOTHER’S HEALTH INFORMATION
DID THE MOTHER RECEIVE WIC FOOD FOR HERSELF BECAUSE SHE WAS
PREGNANT WITH THIS CHILD?
MOTHER’S HEIGHT
Enter feet and inches.
MOTHER’S WEIGHT (POUNDS)

Pre-pregnancy – enter the pre-pregnancy weight in pounds.
At Delivery – enter the mother’s weight at the time of the delivery in
pounds.
Note: This will indicate the amount of weight in pounds gained by the mother
during the pregnancy.
CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

Enter the approximate amount in a single cigarette count or in packs per day.
Enter 0 if a non smoker. This section is divided into four quarters; three months
before, first three months; second three months and third trimester. Each section
will need to be answered.
Note: Smoking during pregnancy may have an adverse impact on pregnancy

outcome. This information is used to evaluate the relationship between certain
lifestyle factors and pregnancy outcome and to determine at what levels these
factors clearly begin to affect pregnancy outcome.
MOTHER’S MARITAL STATUS

The following choices are available.
Never married – if this selection is made, focus will automatically advance
to the “Paternity Affidavit” field.
Widowed – If this selection is made, focus will automatically advance to
the “Married within 300 days” field.
Divorced – If this selection is made, focus will automatically advance to
the “Married within 300 days” field.
22
Currently Married – If this selection is made, focus will automatically
advance to the “Paternity Affidavit” field.
Note: Common law marriage is a legal marriage in Texas. If the parent’s state
they are married by virtue of common law, as long as they are not married to
another party and they both are at least 18 years of age, then the person
completing the birth certificate should not question the validity of the marriage. A
woman is legally married even if she is separated. However, a person is no
longer legally married when the divorce is granted by a judge.
Married but refusing Husband Information – If this selection is made, TER

will assume that there will not be a Paternity Acknowledgement attached
to the record and will disable both the fathers and presumed fathers
information.
Note: This information is used to monitor the differences in health and fertility
between married and unmarried women.
MARRIED WITHIN 300 DAYS

The following choices are available.
Yes – If this selection is made, focus will automatically advance to the
“Paternity Affidavit” field.
No – If this selection is made, focus will automatically advance to the
“Paternity Affidavit” field.
Yes, but refusing Father’s Information – If this selection is made, TER will
assume that there will not be a Paternity Acknowledgement attached to
the record and will disable both the fathers and presumed fathers
information.
AOP
MOTHERS NAME PRIOR TO FIRST MARRIAGE

The following fields are available
FIRST NAME:
Enter the mother’s first name.
MIDDLE NAME:
Enter the mother’s middle name. If there is no middle name, leave this item
blank; do not enter NMI, NMN, etc.
23
LAST NAME:
Enter the mother’s last name prior to her first marriage .
SUFFIX:
Enter any suffixes following the last name
Note: The mother’s maiden surname is important because it remains constant

throughout her life, in contrast to other names, which may change because of
marriage or divorce. This is also the basic link to the child’s maternal lineage.
FATHER 1 – (TAB 4)
If the mother is married at the time birth, (or was married and the marriage ended
not more than 300 days before the birth), the husband or former husband of the
mother is presumed to be the father of the child. [FC §160.201(b)(1), FC
§160.204] If the husband or former husband actually is the father of the child, his
information can be added to the birth certificate, and no signatures or
Acknowledgment of Paternity are required.
If the parents state that they are married by common law, VSU will accept the
birth certificate without an AOP as long as “Mother Married” is checked “Yes”.
However; the Office of the Attorney General recommends that an AOP be signed
in cases involving common-law marriage because of the difficulty of proving a
common-law marriage if it is ever challenged.
When the parents are not married, or the mother is married to someone other
than the father (or was married and the marriage ended within 300 days before
the birth of the child), paternity may be voluntarily established by using a
witnessed Acknowledge of Paternity, Form VS-159.1 (AOP). If the form is
properly completed and attached to the birth certificate, the father’s information
can be included on the birth certificate.
If a man believes he is the father and the mother does not agree, he may file a
Notice of Intent to Claim Paternity VS-130 before or within 30 days from the date
of the child’s birth. It will not legally establish paternity or allow him to be named
on the birth certificate, but it allows him to assert that he believes he is the father
and wishes to preserve his rights as a parent.
If you have a question about whether to add the father’s name to the birth
certificate, or when and how to complete the AOP see the section of this
handbook on “Paternity” .
FATHER’S CURRENT LEGAL NAME

FIRST NAME:
Enter the father’s first name.
24
MIDDLE NAME:
Enter the father’s middle name. If there is no middle name leave this item blank;
do not enter NMI, NMN, etc.
LAST NAME:
Enter the father’s last name.
SUFFIX:
Enter any suffixes following the last name.
FATHER’S DATE OF BIRTH

The date entered must be in the following format; MM/DD/YYYY. Enter the exact
month, day, and year that the father was born. If unknown, tab through this
section.
FATHER’S BIRTH STATE, TERRITORY, OR FOREIGN COUNTRY

Select the state, territory or foreign country of the father’s birth. If not on
the list, it may be entered via “Add on the fly” (AOF) process.
Enter the father’s place of birth. If the father was born in the United States,
enter the name of the state. If the father was born in a foreign country or a
U.S. territory, enter the name of the country or territory.
If no information is available regarding place of birth, tab through this

section. If the father was born in the United States or a U.S. Territory, but
the exact state or territory is unknown; enter “United States.”
If the father was born in a foreign country, but the country is unknown,
enter “Foreign.”
FATHER’S SSN
Enter the father’s social security number.
Note: A parent may refuse to give his or her social security number, but it is
strongly recommended it be obtained if possible. In some instances one or both
may not have social security numbers. Should they refuse to provide their
number, or not have number, leave this field blank; do not enter “unknown.”
FATHER’S EDUCATION
Enter the total number of years of education completed. If education is unknown,

enter “Unknown.” For no education, enter “None.” A person who enrolls in
college but does not complete one full year should not be identified with any
25
college education in this item. Do not include beauty, barber, trade, business,
technical, pre kindergarten, kindergarten, or other special schools when
determining highest grade completed.
Note: Education is correlated with fertility and birth outcome, and is used as an
indicator of socioeconomic status. This item is also used to measure the effect of
education and social economic status on health, childbearing, and infant
mortality.
FATHER’S OCCUPATION AND INDUSTRY

Enter the father’s occupation during most of his working life (e.g., homemaker,
student, teacher, clerk, programmer, attorney, realtor, artist, nurse, etc.). If
occupation is unknown, enter “Unknown.” For no occupation, enter “None.” Do
not use “self employed.”
FATHER’S TYPE OF BUSINESS (INDUSTRY)

Enter the kind of business or industry related to the occupation (e.g., ranching,
retail, consulting, education, farming, government, manufacturing, etc.). If the
kind of business is unknown, enter “Unknown.” For no kind of business, enter
“None.”
FATHER OF HISPANIC ORIGIN

Check one (1) from the list. If “yes”, other Spanish? Hispanic? Latino” is checked,
enter the Hispanic Origin in the specify field. Mark “Yes” or “No” to indicate
whether the father is of Hispanic origin. Enter the country (ies) of Hispanic origin.
If the father indicates that he is of multiple Hispanic origins, enter the origins as
reported, separated by commas (for example, Mexican, Puerto Rican).This item
is not a part of the Race item; a person of Hispanic origin may be of any race.
Each question, Race and Hispanic origin, should be asked and treated as an
independent item. Hispanics comprise the second largest ethnic minority in this
country. This item provides data to measure differences in fertility and pregnancy
outcome as well as variations in health care for people of Hispanic and non
Hispanic origin. Without collection of data on persons of Hispanic origin, it is
impossible to obtain valid demographic and health information on this important
group of Americans.
FATHER’S RACE CHECK

Enter the race of the father as obtained from the parents or other informant. For
Asians and Pacific Islanders, enter the national origin of the father, such as
Chinese, Japanese, Korean, Filipino, Samoan, Vietnamese, or Hawaiian.
Check one or more races to indicate how the mother identifies herself.
01 White
02 Black or African American
26
03 American Indian or Alaska Native If “American Indian or Alaska Native”
is checked, enter the name of the enrolled or principle tribe in the field.
04 Asian Indian
05 Chinese
06 Filipino
07 Japanese
08 Korean
09 Vietnamese
10 Other Asian If “Other Asian” is checked, enter the “other Asian” race in
the “specify field”.
11 Native Hawaiian
12 Guamanian or Chamorro
13 Samoan
14 Other Pacific Islander If “Other Pacific Islander” is checked, enter the
“other pacific islander” race in the specify field.
15 Other If “Other” is checked, enter the “Other” race in the ‘Specify” field.
99 Unknown
Note: Information on race/ethnicity is essential in producing data for various

populations. It is used to study cultural variations in access to health care and
pregnancy outcomes (infant mortality and birth weight). Race/ethnicity is an
important variable in planning for and evaluating the effectiveness of health
programs and in preparing population estimates.
FATHER 2 – (TAB 5)
PATERNITY – GENETIC TESTING
FATHER’S MAILING ADDRESS

SAME AS MOTHER’S MAILING ADDRESS
If the father’s mailing address is the same as the mother’s mailing address,
select “yes.” If his address is different from the mother’s, enter the father’s
complete mailing address, including city, state, and zip code.
RESIDENCE ADDRESS
The father’s residence is the place where his household is located. This is not
necessarily the same as his home state, voting residence, mailing address, or
legal residence. The state, county, city and street address should be for the place
where the father actually lives. Never enter a temporary residence, such as one
used during a visit, business trip or vacation.
Residence for a short time at the home of a relative, friend, or home for unwed
mothers for the purpose of awaiting the birth of the child is considered temporary
27
and should not be entered here. However, place of residence during a tour of
military duty or during attendance at a college is not considered temporary and
should be entered on the certificate as the father’s place of residence.
Enter the number and street name of the father’s residence, Rural Route
number, or description that will aid in identifying the location.
RESIDENCE STATE
Enter the state in which the father lives. This may differ from the state for his
mailing address. If the father is not a U.S. resident, enter the name of the
country.
28
APT. #:
STATE/FOREIGN COUNTRY/TERRITORY
COUNTY
Enter the name of the county in which the father lives. That county pick list will
automatically populate with the counties that are in the state that was specified in
the previous field.
CITY /TOWN OR LOCATION

Enter the city or town in which the father resides. Do not enter the word “Rural” if
outside city limits; enter only the city name. This field is a Type-Ahead Combo
box. The city/town or location pick list will automatically populate with the
cities/towns that are in the county that was specified in the previous field. Select
a city from the list. If the city is not on the list, it may be entered via “add on the
fly” (AOF) process.
ZIP CODE
associated with the city that was specified in the previous field. Select a zip code
from the list. If the zip code is not on the list, it may be entered via “add on the fly”
(AOF) process.
ZIP CODE EXTENSION

if a zip code extension is applicable, it may be entered in this field. Otherwise,
PRESUMED FATHER’S INFORMATION

If the mother is married at the time birth, (or was married and the marriage ended
not more than 300 days before the birth), the husband or former husband of the
mother is presumed to be the father of the child.
PRESUMED FATHER’S DATE OF BIRTH

The date entered must be in the following format; MM/DD/YYYY. Enter the exact
month, day, and year that the presumed father was born. If unknown, tab through
this section.
PRESUMED FATHER’S SSN

Enter the presumed father’s social security number.
29
PRESUMED FATHER’S CURRENT LEGAL NAME
FATHER’S FIRST NAME
Enter the presumed father’s first name.
FATHER’S MIDDLE NAME

Enter the presumed father’s middle name. If there is no middle name leave this
item blank; do not enter NMI, NMN, etc.
FATHER’S LAST NAME

Enter the presumed father’s last name.
FATHER’S SUFFIX
Enter any suffixes following the last name.
PRESUMED FATHER’S MAILING ADDRESS

It is important to distinguish between the presumed father’s mailing address and
his residence address because each serves a different purpose. They are not
substitutes for one another.
ADDRESS
Enter the number and street name of the presumed father’s mailing address,
Rural Route number, or description that will aid in identifying the location.
RESIDENCE STATE
Enter the state in which the presumed father’s receives mail. If the presumed
father is not a U.S. resident, enter the name of the country.
30
APT. #:
STATE/FOREIGN COUNTRY/TERRITORY
COUNTY
Enter the name of the county in which the presumed father receives mail. That
county pick list will automatically populate with the counties that are in the state
that was specified in the previous field.
CITY /TOWN OR LOCATION

Enter the city or town in which the presumed father receives mail. Do not enter
the word “Rural” if outside city limits; enter only the city name.
This field is a Type-Ahead Combo box. The city/town or location pick list will
automatically populate with the cities/towns that are in the county that was
specified in the previous field.
Select a city from the list. If the city is not on the list, it may be entered via “add
on the fly” (AOF) process.
ZIP CODE
associated with the city that was specified in the previous field.
Select a zip code from the list. If the zip code is not on the list, it may be entered
via “add on the fly” (AOF) process.
ZIP CODE EXTENSION

if a zip code extension is applicable, it may be entered in this field. Otherwise,
MEDICAL 1 – (TAB 6)
PRENATAL CARE
PRENATAL CARE?
If the mother had no pre-natal care, select “No” from the drop down list.
If the mother had pre-natal care, select “Yes” from the drop down list.
If the mother’s pre-natal history is unknown, select “unknown” from the drop
down list.
31
Pregnancy history fields will be disabled if you answered “No” or “Unknown”.
DATE OF FIRST VISIT

Enter the date of this pregnancy in which the mother first received care from a
physician or other health professional, or attended a prenatal clinic. The date
must be entered in the following format: MM/DD/YYYY.
The month of pregnancy in which prenatal care began is measured from the date
last normal menses began and not from the date of conception.
DATE OF LAST VISIT

Enter the date of this pregnancy in which the mother last received care from a
physician or other health professional, or attended a prenatal clinic. The date
must be entered in the following format: MM/DD/YYYY.
TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

Enter the number of prenatal visits the mother had for this pregnancy. Enter the
number of visits made to a health care provider for supervision of the pregnancy.
If the answer is “None,” or unknown this item will be disabled.
This information is used to determine the relationship of prenatal care to the

health of the child at birth. The number of women receiving delayed care or no
care is of considerable interest to public health officials because inadequate care
may be harmful to both the mother and fetus.
DATE OF LAST NORMAL MENSES BEGIN

Enter the start date of the mother’s last normal menses prior to the start of this
pregnancy. The date must be entered in the following format. MM/DD/YYYY.
This item, in conjunction with the date of birth, is used to determine length of
gestation. A record with a plausible date that the Last Normal Menses began
provides a cross check with length of gestation based on ultrasound or other
techniques.
SOURCE OF PRENATAL CARE

Mark the appropriate box(es) to indicate all sources of prenatal care during this
pregnancy. If the “Other” box is marked, enter the other source of prenatal care.
PREGNANCY HISTORY
LIVE BIRTHS NOW LIVING
Enter the number of children born alive to this mother who are still living; do not
include this child. If this child is the mother’s first, or if all previous live-born
children have died, marks “None.”
32
LIVE BIRTHS NOW DEAD
Enter the number of children born alive to this mother who are no longer living;
do not include this child. If this child is the mother’s first, mark “None.”
DATE OF LAST LIVE BIRTH

If applicable, enter the date of the last live birth for this mother. The date must be
entered in the following format. MM/YYYY.
If this certificate is for the second birth of a twin set, enter the date of birth for the
first baby of the set, if it was born alive. Similarly for triplets or other multiple
births, enter the date of birth of the previous live birth of the set. If all previously
born members of a multiple set were born dead, enter the date of the mother’s
last delivery that resulted in live birth. If this certificate is for the second birth of a
twin set and the first was born dead, enter the delivery date of that fetus.
Similarly, for other multiple births, if any previous member of the set was born
dead, enter the delivery date of that fetus.
Note: These items are used to determine total birth and live birth order, which
are important in studying trends in childbearing and child spacing. They are also
useful in studying health problems associated with birth order (for example, first
births to older women) and determining the relationship of birth order to infant
and prenatal mortality.
NUMBER OF OTHER PREGNANCY OUTCOMES

Enter the number of other pregnancy outcomes for this mother. This includes
prenatal death and abortion
DATE OF LAST OTHER PREGNANCY OUTCOME

Enter the date of the last other pregnancy outcome for this mother.
The date entered must be in the following format: MM/YYYY. Example: 02/2005.
RISK FACTORS IN THIS PREGNANCY

Check all that apply. If none apply, check ‘none of the above’
INFECTIONS
INFECTIONS PRESENT AND/OR TREATED DURING THE PREGNANCY
Check all that apply.
HIV TEST DONE PRENATALLY:

HIV TEST DONE AT DELIVERY

33
OBSTETRIC PROCEDURES
ONSET OF LABOR
Check all that apply
MEDICAL 2 – (TAB 7)
CHARACTERISTICS OF LABOR & DELIVERY
METHOD OF DELIVERY
This information is used to relate method of delivery with birth outcome, to
monitor changing trends in obstetric practice and to determine which groups of
women are most likely to have cesarean delivery. Information in this item can
be used to monitor delivery trends in Texas and across the United States.
WAS DELIVERY WITH FORCEPS ATTEMPTED BUT UNSUCCESSFUL?

WAS THE DELIVERY WITH VACUUM EXTRACTION ATTEMPTED BUT

UNSUCCESSFUL?
FETAL PRESENTATION AT BIRTH

If ‘Other’ is selected, enter clarifying information in the field.
FINAL ROUTE AND METHOD OF DELIVERY

IF CESAREAN, WAS A TRIAL OF LABOR ATTEMPTED?

This field will only enable if the answer to the previous question is ‘Yes’.
MATERNAL MORBIDITY
CHILDS HEALTH INFORMATION

BIRTH WEIGHT
Enter the infant‘s birth weight, in either grams or pounds and ounces. Do not
convert from one measure to the other. Weight in grams should be entered to the
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left of the printed “Grams:” Weight in pounds and ounces should be entered to
the left of the printed “Pounds, Ozs.”
Do not enter fractions. Round fractional ounces to the nearest ounce; round
fractional grams to the nearest gram.
This is the single most important characteristic associated with infant mortality. It
is also related to prenatal care, socioeconomic status, marital status, and other
factors surrounding the birth. Consequently, it is used with other information to
plan for and evaluate the effectiveness of health care.
OBSTETRIC ESTIMATE OF GESTATION (WEEKS)

Please enter the obstetric estimate of the infant’s gestation.
If the obstetric estimate of gestation is not known, enter one question mark (?) in
the space.
Do not complete this item based on the infant’s date of birth and the mother’s
date of LMP.
CALCULATED GESTATION (WEEKS)

The Calculated Gestation (Weeks) will be automatically calculated from the date
entered in the Date of Birth field and the date entered in the Date Last Normal
Menses Began field.
CHILD’S SEX
If sex and name are inconsistent, verify both entries. If sex cannot be determined
after verification with medical records, mother of child, or other sources, select
“Not Yet Determined”
This item aids in identification of the infant. It is also used for measuring sex
differentials in health related characteristics and for making population
estimates and projections.
APGAR SCORE
At 5 minutes / At 10 minutes
Enter the infant’s Apgar score at 5 minutes, and if the score at 5 minutes is less
than 6, enter the infant’s Apgar score at 10 minutes.
If the infant’s Apgar score is not known or was not taken at 5 minutes or 10
minutes, enter “unknown”.
If Apgar score is not taken at 5 minutes or 10 minutes select “Not Taken”.
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WAS INFANT TRANSFERRED WITHIN 24 HOURS DELIVERY?
ABNORMAL CONDITIONS OF THE NEW BORN

Mark each abnormal condition associated with the newborn infant. If more than
one abnormal condition exists, mark each condition.
This item cannot be left blank.
This information should be obtained from the infant’s physician or the medical
records .
ASSISTED VENTILATION REQUIRED IMMEDIATELY FOLLOWING DELIVERY (LESS

THAN 30 MINUTES):
A mechanical method of assisting respiration for newborns with a respiratory
failure. In this case, the ventilation assistance lasts for less than 30 minutes.
Synonym to be included in this item: Intubated with 02 less than 30 minutes
ASSISTED VENTILATION REQUIRED FOR MORE THAN SIX HOURS:

Newborn placed on assisted ventilation for 30 minutes or longer.
Synonym to be included in this item: Intubated with O2 30 minutes or more.
NICU ADMISSION:
Check if baby was admitted into the NIC unit.
NEWBORN GIVEN SURFACTANT REPLACEMENT THERAPY:

Check if this item applies.
ANTIBIOTICS RECEIVED BY THE NEWBORN FOR SUSPECTED NEONATAL SEPSIS:

Sepsis: A systemic infection diagnosed in the newborn. ICD-9 code 771.8
SEIZURE OR SERIOUS NEUROLOGICAL DYSFUNCTION:

Seizures: A seizure of any etiology. Frequent and serious neonatal problem,
usually focal, migratory clonic jerks of extremities, alternating hemiseizures, or
primitive subcortical seizures. A sudden, brief attack of altered consciousness,
motor activity, sensory phenomena, or inappropriate behavior. ICD 9 code 779.0
SIGNIFICANT BIRTH INJURY (SKELETAL FRACTURE(S), PERIPHERAL NERVE

INJURY, AND/OR SOFT TISSUE/ SOLID ORGAN HEMORRHAGE WHICH REQUIRES
INTERVENTION):
Check if applies.
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NONE OF THE ABOVE:
If it is Abnormal Conditions of the New Born is not known enter “None of the
Above”
Note: Information on abnormal conditions of the newborn helps measure the

extent infants experience medical problems and can be used to plan for their
health care needs. This item also provides a source of information on abnormal
outcome in addition to congenital anomalies or infant death. These data allow
researchers to estimate the number of high risk infants who may benefit from
special medical services.
CONGENITAL ANOMALIES
Mark each anomaly of the child. Do not include birth injuries. The checklist of
anomalies is grouped according to major body systems. If there are no
congenital anomalies of the child, select None of the Above. This item must be
completed. This information should be obtained from the mother’s and infant’s
physician or the medical records (obstetric and pediatric).
ANENCEPHALY
Partial or complete absence of the brain and skull. Also called anencephalus,
acrania, or absent brain. Babies with craniorachischisis (anencephaly with
contiguous spine defect) should also be included in this category.
MENINGOMYELOCELE/SPINA BIFIDA
Spina bifida refers to herniation of the meninges and/or spinal cord tissue
through a bony defect of spine closure. Meningomyelocele refers to herniation of
meninges and spinal cord tissue. Babies with meningocele (herniation of
meninges without spinal cord tissue) should also be included in the category.
Both open and closed (covered with skin) lesions should be included. Spina
bifida occulta (a midline bony spinal defect without protrusion of the spinal cord
or meninges) should not be included in this category.
CYANOTIC CONGENITAL HEART DISEASE

Congenital heart defects which cause cyanosis. Includes but is not limited to
transposition of the great arteries (vessels), teratology of Fallot, pulmonary or
pulmonic valvular atresia, tricuspid atresia, truncus arteriosus, total/partial
anomalous pulmonary venous return with or without obstruction.
CONGENITAL DIAPHRAGMATIC HERNIA

Defect in the formation of the diaphragm allowing herniation of abdominal organs
into the thoracic cavity.
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OMPHALOCELE
A defect in the anterior abdominal wall, accompanied by herniation of some
abdominal organs through a widened umbilical ring into the umbilical stalk. The
defect is covered by a membrane, (different from gastroschisis, see below),
although this sac may rupture. Also called exomphalos. Umbilical hernia
(completely covered by skin) should not be included in this category.
GASTROSCHISIS
An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in
herniation of the abdominal contents directly into the amniotic cavity.
Differentiated from omphalocele by the location of the defect and absence of a
protective membrane.
LIMB REDUCTION DEFECT (EXCLUDING CONGENITAL AMPUTATION AND

DWARFING SYNDROMES)
Complete or partial absence of a portion of an extremity secondary to failure to
develop.
CLEFT LIP WITH OR WITHOUT CLEFT PALATE

Cleft lip with or without cleft palate refers to incomplete losure of the lip. Cleft lip
may be unilateral, bilateral or median; all should be included in this category.
CLEFT PALATE ALONE

Cleft palate refers to incomplete fusion of the palatal shelves. This may be limited
to the soft palate or may also extend into the hard palate. Cleft palate in the
presence of cleft lip should be included in the “Cleft Lip with or without cleft
Palate” category, rather than here.
DOWN SYNDROME:
Trisomy 21
Karotype (select from list)
Confirmed, Pending or Unknown.
SUSPECTED CHROMOSOMAL DISORDER

Includes any constellation of congenital malformations resulting from or
compatible with known syndromes caused by detectable defects in chromosome
structure.
Karotype (select from list)
Confirmed, Pending or Unknown.
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HYPOSPADIAS:
Incomplete closure of the male urethra resulting in the urethral meatus opening
on the ventral surface of the penis. Includes first degree – on the glans ventral to
the tip, second degree – in the coronal sulcus, and third degree – on the penile
shaft.
NONE OF THE ABOVE

Indicates no congenital anomalies were identified by the time of the birth
certificate completion.
Note: Information on congenital anomalies is used to identify health problems

that require medical care and to monitor the incidence of the stated conditions. It
is also used to study unusual clusters of selected anomalies, to track trends
among different segments of the population, and to relate the prevalence of
anomalies to other characteristics of the mother, infant, and the environment.
IMMTRAC CONSENT
ImmTrac is the Texas immunization registry developed by the Texas Department
of State Health Services (DSHS). ImmTrac is a free, confidential registry
designed to consolidate immunization records from multiple providers and store a
child’s immunization information electronically in one secure central system.
ImmTrac offers physicians and other healthcare providers and authorized users
easy online access to a child’s immunization history. The Registry is part of a
DSHS initiative to increase vaccination coverage for children across Texas.
With written parental consent, the ImmTrac Registry receives vaccination

information for a child from private and public healthcare providers across the
state, including input from the Vital Statistics Unit of DSHS, Women, Infant and
Children (WIC) clinics, Medicaid, the Texas-Wide Integrated Client Encounter
System (TWICES), and health plans. Upon registration with ImmTrac,
immunization information is available to schools, licensed child-care facilities,
local health departments, public health districts, payors, and state agencies
having legal custody of a child. Parents may request their child's ImmTrac record
from their physician or their local health department.
Please indicate the parent’s choice regarding consent for ImmTrac participation.
The birth registrar will be required to affirm that this information accurately
reflects the parent’s choice.
If the parent has not yet been offered the option to consent for ImmTrac
participation you may skip this section and answer at a later time this section
must be completed for legal release of the birth registration in TER.
More information on the ImmTrac program can be found at

www.dshs.state.tx.us/immunize/immtrac
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CERTIFIER – (TAB 8)
ATTENDANT / CERTIFIER
ATTENDANT
Select an attendant from the list. If the attendant is not on the list the Attendant’s
Name and Mailing Address may be entered via “On the Fly’ (AOF) process.
Type the full name and address of the person who delivered the baby (that is, the
person who was with the mother when the baby emerged from the birth canal-
regardless of who cut the umbilical cord). Enter the street and number, city or
town, state and zip code.
ER physicians are considered to be the attending physician when an infant is

delivered en-route to the facility if no other attendant can be identified or located
for signature.
In the case of a foundling, the ER physician, the Chief of Staff Services, the
Hospital Administrator or, as a last resort, the case Social Worker may be shown
on the record as attendant. The record should be completed in so far as is
possible.
A single line may be drawn through the word “attendant.” If the mother was alone
when the baby was born, she should be listed as the attendant.
However, she must file the birth certificate as a non-institutional birth and present
the documents required for such a filing to the local registrar in the registration
district where the birth occurred [See Non-Institutional Births for more
instruction]. No record may be accepted for filing without the attendant’s name
and address being completed. The mailing address is used for inquiries to
correct or complete items on the record and for follow back studies to obtain
additional information about the birth.
IS CERTIFIER SAME AS ATTENDANT?

If yes is selected, the remaining fields will populate under attendant information.
CERTIFIER INFORMATION
Select a certifier from the list. If a certifier is not on the list, the certifier may be
entered via “On the fly’ (AOF) process. This is the person who will be
electronically certifying the record in TER.
DATE CERTIFIED
This will pre-populate with the date the record is electronically certified by the
certifier.
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PRINCIPAL SOURCE OF PAYMENT FOR THIS DELIVERY
Select the principal payment source from the list, or select “other” from the list
and enter the source in the “other” specify field.
MOTHER MEDICAID/CHIP NAME

If the mother is enrolled in CHIP enter that name in the Medicaid/CHIP name.
If it is not known if she is enrolled in CHIP, but mother is enrolled in Medicaid

enter mother’s Medicaid name in the Medicaid/CHIP name.
MOTHER MEDICAID/CHIP NUMBER

Use the mother's CHIP Perinatal ID number or Enrollment Confirmation Letter
number to enter the into Medicaid/CHIP number field.
If CHIP Perinatal number is not known, enter the mother's Emergency Medicaid
ID number, if known.
If neither CHIP or Medicaid numbers are known, enter mother's name,

and nine "9's " into the Medicaid/CHIP number field, so it appears as:
999999999
If the hospital is not participating in the auto forwarding process, hospital will
have to manually complete DHS 7484 form for those records where the
mother’s Medicaid number is used.
Hospitals do not need to complete the DHS 7484 form for these records where
the CHIP perinatal number is entered.
To participate in the automatic forwarding email [email protected] with

your
o Facilities name;
o Medicaid provider number; and
o Your name and title.
Medicaid contact: Karen Roach @ (512) 231-5643 (check status or obtain 7484
form)
Enter the mother’s Medicaid number, if known. The number contains nine digits.
INFANT MEDICAL RECORD NUMBER

Enter the infant’s medical record number
INFANT PRIMARY CARE PHYSICIAN

Enter the infant’s primary care physician.
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WAS MOTHER TRANSFERRED TO THIS FACILITY FOR DELIVERY?
Select yes, no or unknown from the list. Select NO if this is the first facility the
mother was admitted to for delivery.
Select YES if the mother was transferred from one facility to another facility
before the child was delivered.
SPECIFY FACILITY:
Enter the name of the facility from which the mother was transferred.
If the mother was transferred during labor from the care of a documented
midwife, answer YES and enter the word MIDWIFE followed by the midwife’s
name.
If the mother was transferred more than once, enter the name of the last facility
from which she was transferred.
Transfer information is important in identifying high-risk deliveries and following

up on maternal and infant deaths.
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CORRECTIONS TO BIRTH CERTIFICATE RECORDS
The Certificate of Birth is a permanent legal document that is very important to
the registrant for his or her entire life. If it appears altered in any way, the
registrant may be questioned about its authenticity.
ERRORS DETECTED BEFORE LEGAL AND STATISTICAL

RELEASE:
When an error is detected on a birth record in before it has been certified and
released to the state office then the correction can be made.
ERRORS DETECTED AFTER LEGAL RELEASE:

If the birth certificate has already been certified and released to the state then an
amendment to the birth certificate will need to be filed.
AMENDMENT TO AND SUPPLEMENTAL BIRTH RECORDS.

GENERAL INFORMATION
The Application to Amend Certificate of Birth (VS-170) may be used in requesting
completion of any item left blank on the original birth certificate or to correct any
errors made during the completion of the original record, except information
relating to paternity.
Note: The Application to Amend Certificate of Birth (VS-170) cannot be used to

add the father’s information to the birth certificate if that information was left
blank.
Documentation submitted in support of the amendment application will be

abstracted and included as part of the amendment. The original documentation
will be returned to the applicant.
There is a fee for filing an amendment. The fee does not include a certified copy
of the birth record. To receive a certified copy of the amended birth record, the
applicant will need to order a certified copy of the amended record.
A copy of the completed amendment will be forwarded to the local registrar in the
registration district in which the birth originally occurred.
A person may not make an affidavit regarding his or her own record. When an
older relative or friend is not available, an exception may be granted by the State
Registrar provided satisfactory documentary evidence is submitted.
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Amendments pertaining to the name of the registrant cannot be accepted
subsequent to a Court Ordered Change of Name. Should you have any
questions about providing supporting documents or filing an amendment, you
may call the Request Processing Division of the Vital Statistics Unit.
PROCEDURES FOR AMENDING CERTIFICATE OF BIRTH

The applicant must submit an Application to Amend Certificate of Birth (VS- 170),
the proper fee, and documentation (if required).
Both parents must sign the affidavit portion of the amendment form (Part III)
when correcting a minor child’s information unless the child has a single parent
or guardian.
When the signature of a parent or older relative is not available, then the
signature of the registrant may be used, along with a supporting documentary
evidence required to justify the correction must be submitted.
A list of suggested acceptable documents to be submitted in support of the

correction or amendment is included on the reverse side of the application form.
This is not an inclusive list.
Documentation must support and verify the facts being corrected or amended.
INSTRUCTIONS FOR COMPLETING THE APPLICATION TO AMEND

CERTIFICATE OF BIRTH (VS-170)
The information related to the applicant, including name, address, telephone
number, and signature, should be filled in at the top of the form (before Part I).
PART I
Full Name of Child
This should be as it is currently listed on the original birth record. If the child was
not named at the time of birth, enter INFANT or BABY GIRL/BOY
Date of Birth
Enter the date of birth as it currently appears on the birth record
Place of Birth
Enter the City and/or County of Birth
Sex
Enter the gender of the child. Enter UNKNOWN if the child’s gender was not
determined at the time of birth.
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State File NO. (If Known)
Enter the birth certificate state file number if known. Do not enter the local file
number. Leave blank if unknown.
Full Name of Father
Enter the full name of the father as it is currently listed on the birth record. If no
father is listed on the birth record, leave this item blank
Full Maiden Name of Mother
Enter the full maiden name of the mother as it listed on the birth record.
PART II
Part II is used to show which item(s) needs to be corrected.
8. Item or Item No.
Enter the item number(s) that needs to be corrected in block 8. The item
numbers must be obtained from the original birth record.
If the Item number is not know enter the name of the item. Example: “First
Name”
9. Entry on Original Certificate
Enter the incorrect or wrong information in block 9, just as it appears on the
original certificate.
10. Correct Information
Enter the correct information in block 10; this will be the correct information that
the applicant desires to be shown on the birth record.
PART III
Part III is the affidavit portion of the form and must be signed before a notary
public, County Clerk, or other person authorized to administer oaths.
The notary public’s, County Clerk, or other person authorized person’s signature,
seal, and commission expiration date must be on the form. For county clerks,
enter the date you term expires.
If the change or correction is to be made to a minor child’s record (17 years old
or less), this affidavit must be signed by the parent(s) listed on the birth
certificate. If both parents are listed on the birth record both parents must sign.
If the registrant is 18 or older, one parent or older relative may sign the affidavit in
the presence of a notary public. The older and closer the relationship of the
affiant (person making the affidavit), the stronger the document will be. In
addition to the signature, the address of the affiant, the relationship of the affiant
to the registrant, and the date the affidavit was signed must be stated.
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DOCUMENTATION
Any significant or major change in the information already recorded on the
certificate will require documentation. Such a change involves information that is
completely different from what is shown on the original record.
Any documentation submitted must show the correct name, date and place of
birth, and the names of the parents. Copies must be certified, or they will not be
accepted.
Examples of acceptable documents include school, baptismal, hospital, military

or social security records. Types of Documents Required as Supporting Evidence
Generally, the affidavit included in the Application to Amend Certificate of Birth

and one acceptable document is sufficient for correction.
AMENDING REGISTRANT’S INFORMATION

Adding information-Items Left Blank on the Original Certificate (Except for last
names or father’s information)
o Registrant up to 17 years of age - Affidavit signed by both parents.
o Adult Registrant (18 and over) - Affidavit signed by parent(s) or older
relative.
Correcting the Spelling of a First, Middle or Last Name (Names having the same
sound or diminutive)
o For registrant up to 17 years - Affidavit signed by both parents if both
parents are listed on the birth record.
o Adult registrant (18 and over) - Affidavit signed by parent(s) or older

relative.
Significant Changes to First or Middle Name(s)
A certified copy of a court order is required.
Changing the Order of a Double Last Name and Adding a Hyphen to the Last
Name One to four (1-4) years of age:
o When both parents are listed on the birth certificate and the child’s last
name on the original birth certificate includes both parents’ last names, the
order of the names may be switched – Affidavit signed by both parents
One to four (1-4) years of age:
o When adding or deleting a hyphen - Affidavit signed by both parents.
o Any other change to a child’s last name - Certified copy of a court order
granting name change.
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Changing the Order of the First or Middle Names
o Registrants up to 17 years of age with both parents listed on the birth
certificate – Affidavit signed by both parents.
o Adult Registrant (18 and over) – Affidavit signed by parent(s) or older

relative.
Changing the Day of Birth

The day of birth can be changed as long as it does not after the day the record
was certified and filed.
o Registrants up to 17 years of age – Affidavit signed by both parents.
o Adult Registrants (18 and over) – Affidavit signed by parent(s) or older

relative.
Change in the Month of Birth

The month of birth can be changed as long as it does not after the record was
certified and filed.
o One (1) year to 17 years – Affidavit signed by attending physician or

medical records clerk or affidavit signed by both parents and one
document.
o Adult (over 18 years) – Affidavit signed by parent(s) or older relative and

one document.
Note: Dates of birth cannot be amended if the date that it is being amended
would be after the local registrar’s file date or date signed by attendant/certifier.
Changing the Sex When the Name Identifies Gender
Examples of name that Identifies Gender: John = Male, Jane = Female. Jose =
Male, Victoria=Female.
o Registrant up to 17 years of age – Affidavit signed by both parents.
o Adult Registrant (18 and over) – Affidavit signed by parent(s) or older

relative.
Changing the Sex When the Name Does Not Identify Gender
Examples of name that Does not Identifies Gender: Angel and Taylor could be
Male or Female Names.
o Registrants up to 17 years of age - Affidavit by medical attendant or

medical records clerk or an affidavit by both parents and one document.
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o Adult Registrant (18 and over) - Affidavit by medical attendant or medical
records clerk or affidavit by parent(s) or an older relative and one
document.
Changing the Sex when Gender Re-Assignment is Completed
Court decree stating that the registrants gender has official been changed and
what it has been changed to.
DOCUMENTS MOST COMMONLY USED TO CORRECT REGISTRANT’S

INFORMATION
Under Six (6) Years Old
o Hospital Record
o Baptismal Record
o Immunization Record
Six (6) Years and Older
o Hospital Record
o Baptismal Record
o Early School Record
o Social Security Record (Not a Social Security Card)
o Military Service Record
o Census Record
AMENDING REGISTRANT’S PARENTS’ INFORMATION

Correcting a First, Middle or Last Name of Registrant’s Parents Correcting the
spelling (name has the same sound or diminutive)
Affidavit signed by affected parent(s).
Adding a First or Middle Name
Affidavit signed by affected parent(s).
Dropping or totally changing a First, Middle, or Last Name
Affidavit signed by parents and one document which must be dated prior to the
Child’s birth. If a document is unobtainable, a certified copy of a court order is
required.
Changing the Place of Birth of Registrant’s Parents Change of State
Affidavit signed by parent(s).
Change of Country
Affidavit signed by parent(s) and one document.
Change from Foreign Country to the United States
Affidavit signed by parent(s) and one document showing they were born in the
United States.
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Age or Date of Birth of Registrant’s Parents
Change is Less than two (2) years.
o Affidavit signed by parent(s).
Change is over two (2) years.

o Affidavit signed by parent(s) and one document.
Color or Race
Affidavit signed by parent(s).
Note: This is only applies to records prior to 1994. From 1994 to present color or
race is not present on the legal birth record.
DOCUMENTS MOST COMMONLY USED TO CORRECT REGISTRANT’S PARENTS’

INFORMATION
o Hospital Record
o Marriage License of Parents
o Birth Certificate of older child born to same parents
o Birth Certificate of the parent whose information is being changed
o Passport
You may contact the State VSU to discuss other documentation that may be
acceptable. For additional assistance in completing and filing the Application to
Amend the Certificate of Birth.
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A NEW BIRTH

CERTIFICATE BASED ON PARENTAGE (VS-166)
The Application for a New Birth Certificate Based on Parentage is used to
change, add, or remove the name of the father to a birth certificate that is already
filed with the local and state registrars. The application must be signed by both
parents in the presence of a notary public, County Clerk, or other person
authorized to administer oaths, unless parentage is established by a court
decree, then only one parent need sign the application before a notary public,
County Clerk, or other person authorized to administer oaths.
The completed application must be sent to the Vital Statistics Unit (VSU) in
Austin (the address is on the back of the form) along with the required fee and
one of the following three types of documentation:
o Certified copy of a biological parents marriage license;
o Certified copy of a court decree that establishes paternity; or
o Notation on the Application for a New Birth Certificate Based on
Parentage indicated when a properly completed Acknowledgement of
Paternity (AOP, form VS-159.1) was completed and faxed into VSU.
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ADDING THE FATHER’S INFORMATION
If the change involves adding a father’s information to a birth certificate on which
the father’s information was left blank you may use one of the following
documents:
o Certified copy of a biological parents marriage license;
o Certified copy of a court decree that establishes paternity; or
o Notation on the Application for a New Birth Certificate Based on
Parentage indicated when a properly completed Acknowledgement of
Paternity (AOP, form VS-159.1) was completed and faxed into VSU..
REMOVING THE FATHER’S INFORMATION

If the change involves removing the father’s information the supporting document
must be a Certified court decree that specifically orders that the man listed on the
birth record be removed from the birth record of said child.
CHANGING THE FATHER LISTED ON THE BIRTH RECORD

If the change involves changing the father’s information listed the birth record
from one man to another, the supporting document must be a Certified Court
Decree that specifically states that the man who is being placed on the birth
record is the biological father of the child and that his name is to be placed on the
birth record as the father.
A properly completed AOP with Denial of Paternity portion of the AOP completed
in front of a certified entity by the person currently listed on the birth record as the
father may also be submitted if the man who is currently listed on the birth record
was placed on the record due to marriage.
Note: Only one AOP can be filed to add a father to the birth certificate. If an AOP
was used to establish paternity between the man currently listed on the birth
record as the father of the child, a court order will be needed to change or
remove that man from the birth record.
The Vital Statistics Unit will create a new supplemental record based on the new
information and will remove the original from the records and file the
supplemental birth record in its place. A copy of the supplemental record will also
be forwarded to the local registrar and will replace the original record in the local
registrar’s files.
VSU will place the Application for a New Birth Certificate Based on Paternity,
supporting documents, and the original birth certificate in a sealed paternity file
upon acceptance for filing. Access to the original certificate of birth and related
documents shall not be authorized except upon order of a court of competent
jurisdiction (Title 25 TAC 181.9(a).
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CHANGING THE SURNAME OF THE CHILD WHEN ADDING FATHER.
When an Application for New Birth Certificate based on Parentage is submitted,
with a certified copy of a marriage license or an Acknowledgment of Paternity
(AOP) is being used, the parents can change the child’s last name to that of the
father or add the father’s last name to the existing last name, without the need of
a court ordered change of name.
If the Application for New Birth Certificate based on Parentage is supported with
court decree that establishes parentage, and that court order specifies a name
change, VSU must change the last name to what the court decree specifies the
last name to be.
ADMINISTRATIVE FILING OF BIRTH RECORDS

The local registrar shall complete an administrative record of birth for the purpose
of Infant Birth/Death Matching when an infant death occurs, a birth certificate has
not been filed, and a record is not available from the attendant.
The local registrar shall obtain the required information from the medical
examiner/coroner, law enforcement agency, funeral director, hospital, or any
individual with knowledge of the facts of birth.
The local registrar will obtain as much information as possible to complete the
birth record. Information blocks on the record for information that is not available
or cannot be obtained shall be marked “unknown” or “not available.” This
includes information related to the attendant at birth.
The local registrar will file the birth record in his or her records, assigning a
registrar’s file number. The date the record is received or filed by the local
registrar will be shown as the date filed, and the local registrar shall sign the
certificate as both certifier and registrar.
The local registrar’s copy of the record will be marked with the words
“Administrative Filing” in the left margin and the record will be properly marked as
“deceased.” The certificate will be forwarded to the State Registrar with a letter of
explanation stating the reason for the administrative filing.
Upon receipt, the State VSU will date, number, and file the certificate as a current
record. The record will be permanently stamped “Administrative Filing” in the
upper left side margin. The Birth/Death Cross-Match Unit will mark both the
paper and electronic records “deceased” and make the proper notations.
DELAYED FILING OF BIRTH RECORDS

If a certificate of birth is not filed within one year of the date of birth, the certificate
will have to be filed as a delayed record. A person wanting to file a delayed birth
certificate should first send an application for certified copy of birth certificate or
51
written request along with proper photo identification and a fee to the Vital
Statistics Unit in Austin.
If a record is found, VSU will send a certified copy of the birth certificate; if no
record is found, VSU will send forms and instructions for filing a delayed birth
certificate. There is a cost for the search, whether or not a record is found. The
person should then complete the Delayed Certificate of Birth form and send it
with the necessary documentation to the Vital Statistics Unit.
There is a cost for filing a Delayed Certificate of Birth, and the person will need to
order a certified copy of the delayed certificate.
INSTRUCTIONS FOR FILING DELAYED CERTIFICATES OF BIRTH

REGISTRATION BY STATE REGISTRAR
Any birth certificate not filed within one year of the date of birth, may only be filed
by the State Registrar using form VS-122, Delayed Certificate of Birth.
FOR A CHILD OVER 1 YEAR BUT LESS THAN 4 YEARS BORN IN A LICENSED
INSTITUTION
o The Delayed Certificate of Birth (VS-122) signed by the parent; and
o The certification of a hospital or licensed birthing center record relating to
this birth;
The filing fee of $25.00 and if desired, the $12.00 fee for a certified copy.
FOR A CHILD OVER 1 YEAR BUT LESS THAN 4 YEARS NOT BORN IN A
LICENSED INSTITUTION
o The Delayed Certificate of Birth (VS-122) signed by a parent; and
o Proof of pregnancy and proof of mother’s residence in the registration

district at the time of birth are the minimum requirements; and
52
FOR A CHILD 4 YEARS OLD, BUT LESS THAN 15 YEARS OLD
o Delayed Certificate of Birth form (VS-122) signed by a parent, legal
guardian, or legal representative; and
o At least two (2) documents attesting to the date and place of birth, one of
which must verify parents’ names, and only one document may be a
notarized affidavit of personal knowledge;
FOR A PERSON 15 YEARS OR OLDER

IF THE REGISTRANT IS 15 TO 17 YEARS OF AGE
o The Delayed Certificate of Birth (VS-122) signed by a parent, legal
guardian, or legal representative; and
o Three records are required to prove date of birth or age and place of birth.
One of these records must also include parents’ names.
Note: Any record, other than an affidavit, must be five (5) years old or older.
IF THE REGISTRANT IS 18 YEARS OF AGE OR OLDER

o The Delayed Certificate of Birth (VS-122) signed by the registrant; and
o Three records are required to prove date of birth or age and place of birth.
One of these records must also include parents’ names.
Note: Any record, other than an affidavit, must be five (5) years old or older.
The filing fee of $25.00 and if desired, the $11.00 fee for a certified copy.
DOCUMENTARY EVIDENCE FOR DELAYED REGISTRATION OF BIRTH

The documentation submitted must verify the date and place of birth. At least
one record must show the names of parents. Except for the affidavit of personal
knowledge, all other records must be at least five years old.
Records submitted should include:

1. the name of the registrant;
2. date of birth or age;
3. place of birth;and
4. at least one record must show names of parents.
If a copy, or certification from an original record is submitted, it must include:

1. The name and address of the agency, organization, or person having
possession of the original record;
2. The date the original record was made;
3. he date the copy or certification was made; and
53
4. The signature, title, and address of the person preparing the copy or
issuing
SUGGESTED TYPES OF SUPPORTING DOCUMENTS

AFFIDAVIT OF PERSONAL KNOWLEDGE
Only one notarized affidavit can be accepted. The affidavit must be notarized and
show the full name of the registrant, the date of birth, place of birth, and names of
the parents. The affidavit must show the affiant’s signature, current address, and
relationship to the registrant. The affiant must have known about the birth at the
time the birth occurred.
BIRTH CERTIFICATE OF REGISTRANT’S CHILD

For each child born in Texas, send in the name of the child, date and place of
birth, and full names of parents. For each child born outside of Texas, send a
certified copy of his or her birth certificate.
BAPTISMAL CERTIFICATE
Either the original certificate given to the parents or a statement signed by the
present custodian of the church record.
SCHOOL RECORD
A statement or certification signed by the custodian of school records. This would
generally be the Independent School District where the school is/was located.
SOCIAL SECURITY RECORD

A copy of an original application for the social security number. This may be
obtained only by the person named in the SSA account. Contact the Social
Security Administration, Baltimore, Maryland, 21235.
MILITARY DISCHARGE (DD-214)

A copy of official discharge papers of the Army, Navy, Air Force, Marine Corps,
Coast Guard, etc.
REGISTRATION OF WORLD WAR II AND SINCE

For persons who registered before April 1, 1975, a statement can be obtained
from the Federal Records Center, GSA, P. O. Box 6216, Fort Worth, TX, 76115.
The statement should include date and place of birth, and date of registration.
MARRIAGE AND DIVORCE RECORDS

If a marriage license was issued in Texas since January 1, 1966, send names of
both parties, and the county in which the license was issued. If a divorce decree
was granted in Texas since January 1, 1968, send names of both parties, the
date of the divorce, and the county in which it was granted.
54
HOSPITAL RECORD OF BIRTH
A statement signed by the custodian of the hospital records.
PHYSICIAN’S OFFICE RECORD

A statement signed by the physician and based on the office record.
INSURANCE POLICY APPLICATION

An original copy of an application for an insurance policy showing the date and
place of birth. If a photocopy of the application is not attached to the policy, one
may generally be obtained from the company issuing the policy. Be sure to
request information concerning the date and place of birth, policy number, and
the date the policy was issued.
VOTER REGISTRATION APPLICATION

Send a copy issued by the county tax assessor-collector. The copy must show
the exact date on which the certificate was issued.
APPLICATION FOR TEXAS DRIVER’S LICENSE

Initial applications after January 1, 1968, show the place of birth as well as the
date of birth. Certified copies of the original application may be obtained from the
Texas Department of Public Safety, LIDR Bureau, P.O. Box 15999, Austin,
Texas, 78761-5999. You may call (512) 465-2000 for additional information and
to determine the current fee charged for this service. This information does not
apply to renewal applications.
REGISTRATION BY JUDICIAL ORDER (BIRTHS)

If the State Vital Statistics Unit determines that the documentation submitted with
the Delayed Certificate of Birth (VS-122) is unacceptable; a petition for a Court
Ordered Delayed Certificate of Birth must be presented to the county court for
probate matters of the county in which the birth allegedly occurred.
The county probate court may not consider any petition for a delayed registration
of birth unless the applicant first attempted to file a delayed registration with the
State Registrar. The petition must be made on a Court Petition for Delayed
Certificate of Birth (VS-123.1) and accompanied by a statement from the State
Registrar explaining why he or she could not accept the application and
documentation presented.
The Court Ordered Delayed Certificate of Birth (VS-123) prepared in duplicate.

One original should be forwarded to State VSU and the other original filed by the
county clerk.
Note: A delayed birth record is only as valid as the documentation upon which it
is based. An abstract of the supporting documents should be carefully entered
and annotated on the record filed.
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GENERAL INFORMATION

A birth certificate is a permanent legal record of an individual’s birth. The birth

In addition to being the primary document of identification for an individual, a birth

CONFIDENTIALITY / CERTIFIED COPIES

In addition to the demographic information, information held under the section

LICENSED INSTITUTION RESPONSIBILITIES

The responsibilities of the person registering the birth at a licensed institution

Obtain information needed for completion of the birth certificate from

Obtain the appropriate parents’ signatures on the Verification of Birth Facts

Instructions for filing a birth certificate in TER can be found at www.texasvsu.org.

Contact [email protected] for technical assistance with TER.

Midwives must be documented each March with the Texas Department of

Obtain information needed for completion of the birth certificate from

If applicable fax AOP into VSU at 1-888-561-3138.

Instructions for filing a birth certificate in TER can be found at www.texasvsu.org.

Contact [email protected] for technical assistance with TER.

NON-LICENSED INSTITUTION RESPONSIBILITIES

If the birth is attended by a registered, certified or documented health care

The responsibilities of the registered, certified or documented health care

Presented his or her professional documentation to the local registrar.

Obtain information needed for completion of the birth certificate from

Complete a Certificate of Birth.

If applicable fax AOP into VSU at 1-888-561-3138.

Obtain the appropriate parents’ signatures on the birth certificate (VS-111).

Instructions for filing a birth certificate in TER can be found at www.texasvsu.org.

Contact [email protected] for technical assistance with TER.

NON-INSTITUTIONAL BIRTH NOT ATTENDED BY A REGISTERED,

1. The father or mother of the child; or

An affidavit (notarized) along with photocopy of ID (for example, a driver’s

PROOF THAT THE INFANT WAS BORN ALIVE;

An affidavit (notarized) along with photocopy of ID (for example, a driver’s

PROOF THAT THE INFANT WAS BORN IN THE REGISTRATION DISTRICT;

If the birth occurred in the mother’s primary place of residence, proof of

o A rent receipt which includes the mother’s name, address, and

o An envelope addressed to the mother at her place of residence, and

o An affidavit (notarized) attesting to the mother’s place of residence

An affidavit (notarized) presented from one person along with photocopy of

OTHER SUPPLEMENTAL INFORMATION PROVING HOME BIRTH

An unannounced visit by a public health nurse, other health professional,

Multiple forms of identifying documents, with or without photographs, when

Personal appearance of both parents, either together or separately; or

The mother refuses to complete and sign the AOP form.

In other words, if a woman is implanted with a fertilized egg and delivers an

The mother’s worksheet on birth certificate, VS-109.1, is for information supplied

MOTHER’S MEDICAL RECORD NUMBER

DATE AOP SENT

CHILD’S PLACE OF BIRTH

A birthing center located in and operated by a hospital is considered part of the

The “Clinic/Doctor’s Office” category includes other non hospital outpatient

For a birth occurring in international airspace or international waters on a flight or

NUMBER OF INFANTS ALIVE

MOTHERS CURRENT LEGAL NAME

CHILDS CURRENT LEGAL NAME

No numerical characters can be used in names [ Example: 123456789], but you

No obscenities, or non alphabetic characters are permitted.

A last name may be hyphenated, as in Jones-Brown.

CITY /TOWN OR LOCATION:

ZIP CODE EXTENSION:

SAME AS RESIDENCE ADDRESS (MAILING ADDRESS)