How to Register an

Out-of-Hospital
Birth

Please call __(530) 889-7158_____________ for an

appointment to register your baby’s birth.

When a birth occurs outside a hospital, the physician or midwife who

attended the birth – or in the absence of a physician or midwife, the
parents – must register the birth.

This packet contains an important worksheet which the physician,

midwife, or parents must complete and take to the local Health
Department within 21 days of the birth. This worksheet and affidavit
will be used to register the baby’s birth.
January 2023
 Table of Contents

Page

Congratulations to Parents 1

Letter to Physician or Midwife 2

Questions Frequently Asked by Parents 4

Instructions for Registering the Birth 8

Attachments

Worksheet for Out-of-Hospital Births

Affidavit of Birth Information for Out-of-Hospital Births

Certificate of Live Birth – Medical Data

Supplemental Worksheet (VS 10A)

Race Identification Worksheet

Weight Conversion Table

What You Need to Know About Your Child’s

Birth Certificate

Importance of Collecting Complete and Accurate

Birth Certificate Information
Dear Parents:

Congratulations to you and your newborn baby!

California Department of Public Health-Vital Records

(CDPH-VR) wants to help you register your baby’s birth and
get a birth certificate. CDPH-VR is offering this help
because you did not give birth in a hospital – where hospital
staff would have registered the birth. If a physician or
certified nurse midwife / licensed midwife attended the birth,
he or she may help you complete the enclosed worksheet.

Please read this pamphlet very carefully. It will walk

you through the process of registering your baby’s birth.

This pamphlet includes a worksheet that must be

completed and taken to the local Health Department
within 21 days of the birth.

Chief Deputy Registrar

Vital Records

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Dear Physician or Midwife:

CDPH-VR understands you recently attended the birth of a child outside of a hospital.
Health and Safety Code Section 102415 requires that you register the birth of this
child with the local Health Department.

This pamphlet provides instructions on how to register the birth. It also contains an
important worksheet that must be completed to register the birth.

1. Please read the pamphlet carefully, complete the Worksheet for

Out-of-Hospital Births, the Affidavit of Birth Information for Out-of-Hospital
Births, and gather the necessary documents related to the birth.

2. Call the local Health Department to schedule an appointment to register the

birth (the phone number is on the cover of this pamphlet).

3. Share the worksheet with the parent(s) of the child prior to the registration
appointment so they can help in gathering worksheet information.

4. Please advise the parents that they need to visit the local Health Department
office to sign the birth certificate. Although CDPH-VR suggests that the parents
sign the certificate at the time of the appointment, a separate appointment can
be made to accommodate their schedule.

The birth will not be registered until all signatures are in place.

By law, the birth certificate must be registered within 21 days of the birth
(Health and Safety Code Section 102400).

The following page provides options available for registering the birth.

Thank you for your time and help in registering the birth of this child.

Chief Deputy Registrar

Vital Records

-2-
Physicians and Midwives: Following are different options that are available for
registering the birth of the child:

If . . . Then . . .

You want your typed 1. Fill out the Worksheet for Out-of-Hospital Births and Affidavit of
name and title on the Birth Information for Out-of-Hospital Births (attached) and give
birth certificate them to the parents.

(but your signature will 2. Refer the parents to the instructions in this pamphlet.
not be included)
3. Instruct the parents to bring your signed Affidavit and other
evidence to prove the five facts listed below to the local Health
Department to register the birth:
a. Identity of parent(s)
b. Pregnancy of the person giving birth
c. Baby was born alive
d. Birth occurred in the county where the
birth certificate is to be registered
e. Identity of the witness
Note: The signed Affidavit from a physician or midwife is
sufficient evidence to prove b, d, and e, but the parents will still
need to provide evidence for facts a and c.
4. Upon review and acceptance of the Affidavit, the clerk will type
your name and title on the birth certificate (item 13D). However,
the signature box (item 13A) will state “Unavailable.”

You want your 1. Fill out the Worksheet for Out-of-Hospital Births and Affidavit of
signature and typed Birth Information for Out-of-Hospital Births (attached) and bring
name and title on the them to your appointment.
birth certificate
2. Call the local Health Department to schedule an appointment to
come in and complete your portion of the certificate.
3. Inform the parents that they need to come to the local Health
Department to sign the certificate and to prove facts a and c
listed above. They can come in at the same time as you, or a
separate appointment can be made to accommodate their
schedule.

Note: The signed Affidavit from a physician or midwife is

sufficient evidence to prove facts b, d, and e listed above, but the
parents will still need to provide evidence for facts a and c.

You do not want your 1. Refer the parents to the instructions in this pamphlet.
signature or typed
name and title on the 2. Inform the parents that without a signature from a physician or
birth certificate midwife on the birth certificate, they will need to provide
evidence of the five facts listed above.

-3-
 Questions Frequently Asked by Parents

Why do I need to You need to register your baby’s birth to comply with state law.
register my baby’s Registering the birth is the only way to create a permanent legal record
birth? of the birth. For babies not born in a hospital, California law requires the
physician or midwife who attended the birth – or in the absence of a
physician or midwife, either one of the parents – to register the birth of a
baby born in California (Health and Safety Code Section 102415).

You also need to register the birth to obtain an official birth certificate.
During your child’s life, they will need an official birth certificate (certified
copy) to:

 Obtain a Social Security Number  Apply for a Driver’s License

 Enroll in School  Travel or Obtain a Passport
 Register to Participate in Sports  Apply for Various Benefits
(Social Security, Military)

Birth certificates are also valuable to establish:

 Proof of Parentage  Inheritance Rights

 Identity  Citizenship

A certified copy of a birth certificate is a legal record of your child’s

birth. Certified copies are recognized in any court.

When should I By law, you must register the birth of your baby within 21 days of
register my the birth (Health and Safety Code Section 102400). There is no fee
baby’s birth? to register the birth within the first year.

Any birth registered on or after the child’s first birthday must be

processed by CDPH-VR as a Delayed Registration of Birth. If you cannot
meet the requirements for a Delayed Registration of Birth, you will have to
apply to your local Superior Court for a Court Order Delayed Registration of
Birth. Out-of-hospital births are harder to register the longer you wait after
the date of the birth.

Who should When a baby is born at home or elsewhere outside a hospital, the
register my baby’s physician or midwife who attended the birth – or in the absence of a
birth? physician or midwife, either one of the parents – is responsible for
registering the birth with the local Health Department in the county where
the birth occurred.

-4-
How can I make Please review your baby’s birth certificate for accuracy before
sure the certificate is signing it. Never sign a blank birth certificate – the person completing it
completed correctly? may make errors. Once the record has been registered, any corrections
(such as misspellings or omissions) must be made through CDPH-VR,
and a fee may be charged. The processing time for amendments can be
located on the CDPH-VR website at: Vital Records Processing Times
(ca.gov)

What if there is an After your baby’s birth certificate has been registered, the original
error on the birth certificate (with the exception of gender error) cannot be changed. Errors
certificate? can only be corrected by filing an Affidavit to Amend a Record (VS 24
form), which is available from the local Health Department or from
(Refer to the CDPH-VR.
attached flyer,
“What You Need When accepted, the affidavit will be attached to the original certificate
to Know About and will become part of the legal birth record (the birth certificate will
Your Child’s become a two-page document – the original birth certificate, and the
Birth Certificate”) affidavit). The original certificate is not changed.

If there is a gender error on the birth certificate, contact the local Health
Department for instructions on how to correct the error.

What if part (or all) After your baby’s birth certificate has been registered, the original
of my baby’s name certificate cannot be changed. If part (or all) of the baby’s name was
was left off the birth left off the birth certificate, and you want to add the baby’s name, you
certificate? must complete either a Supplemental Name Report – Birth (VS 107 form),
or an Affidavit to Amend a Record (VS 24 form). These forms are
available from the local Health Department, or from CDPH-VR.

When accepted, the application or affidavit will be attached to the original

certificate and will become part of the legal birth record (the birth
certificate will become a two-page document). The original certificate is
not changed.

Note: If you want to change your child’s name after the birth has been
registered, you may need to obtain a court order.

For amendments made within one year of the child’s birth, there is no
processing fee. For amendments made one year or more after the
child’s birth, there is a processing fee.

-5-
How can I get a You will not automatically receive a copy of your baby’s birth certificate.
certified copy of the Once the birth is registered, you can request a certified copy of the birth
birth certificate? certificate from the local Health Department or County Recorder in the
county where your child was born, or from CDPH-VR.

A fee is charged for each certified copy requested.

How can I get a You can get a Social Security number for your child by contacting the
Social Security nearest Social Security office. There is never a charge for a social
number for my security number and card from the Social Security Administration. For
child? more information about Social Security, contact your nearest Social
Security Office or call (800) 772-1213 (toll-free). This phone number will
provide you with prerecorded information at any time – attendants are
available only from 7 a.m. to 7 p.m. (Pacific Standard Time) on any
business day. You can also access Social Security’s website at:
www.socialsecurity.gov.

Who collects the The information you enter on the enclosed worksheet will be transferred
information on the to the Certificate of Live Birth (VS 10D) and collected by CDPH-VR. This
birth certificate? information is required by Division 102 of the Health and Safety Code.
(Please refer to the attachment, “Importance of Collecting Complete and
Accurate Birth Certificate Information.”)

Am I required to You must complete each field of information on the Worksheet for
complete every part Out-of-Hospital Births, except for the fields between the double bold lines
of the worksheet? in the center of the front page. CDPH-VR asks that you provide this
optional information as well, so that the records are complete – but you
are not required to do so. The information marked “medical data” will not
be transcribed onto the actual hard copy of the birth certificate. This
information will also not be disclosed or available to anyone except to
CDPH and the federal government and will be used for demographic and
statistical analysis only without any personal identifying information.
(Health and Safety Code Section 102426.)

The voluntary fields, which apply to information for both the genetic
mother and genetic father, are:

 Race and Ethnicity  Usual Occupation

 Education  Social Security Numbers
 Usual Kind of Business or Industry  Date Last Worked

(Continued)

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Am I required to For births not attended by a physician or midwife, there are also three
complete every part voluntary fields (see asterisks on the worksheet) which apply to medical
of the worksheet? data:

(Continued)  Complications and procedures of pregnancy and concurrent illnesses

 Complications and procedures of labor and delivery, and

 Abnormal conditions and clinical procedures related to the newborn

These three fields are required for physician- or midwife-attended births.

They are, however, voluntary if the parents are registering the birth.

What is the CDPH-VR collects birth information for conducting research relating to the
information on health status of California’s population.
the birth certificate
used for?

Who should appear at In order to register an out-of-hospital birth, the local Health Department
the Health Department must require the personal appearance of:
to register the birth
certificate?  The physician and parent(s), or parent(s) with the physician’s signed
Affidavit, for physician attended births

 The midwife and parent(s), or parent(s) with the midwife’s signed

Affidavit, for midwife attended births, or

 The parent(s) and attendant (if appropriate), for non-physician, non-

midwife attended births.

Note: They do not necessarily need to come in to the office at the same
time.

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 Instructions for Registering the Birth

Action required Complete the enclosed “Worksheet for Out-of-Hospital Births”

before appointment before your appointment with the local Health Department.
with the local Health
Department The enclosed worksheet will be used to register the baby’s birth and
prepare the birth certificate. Fill out the worksheet accurately with facts
as of the day the baby was born. CDPH-VR prefers that all items be
completed or accounted for, including the public health data portion of the
worksheet.

If the birth was attended by a physician or midwife, they should complete

form VS 10A (attached), which provides supplemental medical
information.

Contact the local Health Department if you have any questions regarding
registering your baby’s birth (the phone number is on the cover of this
pamphlet).

Declaration of If the person giving birth is not married or in a State Registered Domestic
Paternity Partnership (SRDP), the other parent’s name shall not be listed in Items
6A-6C unless both are biological parents and both sign a voluntary
Declaration of Paternity (CS 909).

Call the Paternity Opportunity Program at (916) 464-1982 or the local

Health Department if you have any questions or need to obtain forms.

Evidence This section applies only if a physician or midwife was not in

required attendance at the birth, and the parents are registering the birth.

Please bring to your appointment evidence to prove five facts:

1. Identity of the parent(s)

2. Pregnancy of the person giving birth
3. Baby was born alive
4. Birth occurred in California
5. Identity of the witness

Note: If a physician or midwife attended the birth, their signed Affidavit is

sufficient evidence to prove 2, 4, and 5 above, but the parents always
need to provide evidence for facts 1 and 3.

Additional information about these five items is provided below.

(Continued)
-8-
Evidence Identity of the Parents
required
A valid picture identification card issued to the parents by a government
(Continued) agency must be provided to prove identity. Following are some
recommended documents that can be used (only the original or a
certified copy is acceptable):

 A driver’s license or identification card issued by a United States

(U.S.) Department of Motor Vehicles Office.

 U.S. passport.

 U.S. military identification card.

 Temporary resident identification card (green card).

 Other valid picture identification card issued by a foreign

government. (If the parents gave birth in California but are not
here legally, they may be able to get identification verification
from their consulate.)

Pregnancy of the Person Giving Birth

To prove the pregnancy of the person giving birth, provide a pregnancy

test verification form or a letter that meets all of the following conditions:
 From a doctor, midwife, or clinic.

 Written on the doctor’s, midwife’s, or clinic’s official stationery

(not on a prescription pad).

 Signed (not stamped) by the doctor, midwife, or clinic

representative or nurse.

 Contains the current issued professional license number of the

physician or midwife who signed the letter.

The pregnancy test verification form or letter must include all of the
following information:

 The name of person giving birth.

 The date when the person giving birth was first seen by the doctor
or midwife (this date may be after the date of birth).

 The results of the person giving birth’s prenatal or postpartum

exams or pregnancy tests.

(Continued)

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Evidence  The date of the person giving birth’s last menstrual period.
required
 The date the baby was born, or was expected to be born (due
(Continued) date).

Baby was Born Alive

 Bring the baby to the appointment.

 The appointment will not be conducted if the baby is not

present.

Birth Occurred in California

CDPH-VR needs information showing that the person giving birth was in
California on the date that the birth occurred. Documentation to confirm
the person giving birth’s presence in California on the date the birth
occurred may include any of the following:

 If the birth occurred at the person giving birth’s residence, provide

an electric power, natural gas, or water bill for the period when the
birth occurred. The copy of the bill (or statement from the
company) must include the name of the utility company, the
address of the residence where the birth occurred, and the name of
either parent who is listed on the birth certificate.

 An affidavit from someone who was with the person giving birth at
the time of the baby’s birth. The affidavit must contain the address
of the person with the person giving birth, and the location of the
birth.

 A current rent receipt or other similar document that shows the

name of either parent and current address.

 A statement from a state or local government agency that requires

proof of residency in California that the person giving birth was
receiving services on the date of the baby’s birth (e.g., WIC or
Medi-Cal).

Identity of the Witness

If a physician or midwife did not attend the birth, and if a witness did
attend, the witness should accompany you to the appointment.
A witness may include any of the following:

 Spouse or other family member.

(Continued)
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Evidence  Friend.
required
 Paramedic or fire department staff.
(Continued)
If a paramedic or fire department staff was present at the birth,
you can get a copy of the official report stating the treatment or
service they provided (there may be a fee for the report). The
staff does not have to be present at the appointment, nor do you
have to bring a copy of their identification.

If the paramedic arrived after the baby’s birth, bring a copy of the
911 call or an official report of the contents of the 911 call, along
with a copy of the paramedic’s report.

■ If the paramedic cut the cord, or was present when the

cord was cut, the report should so state.
■ If the paramedic delivered the placenta, the report should
so state.

Valid ID for Witness: A valid picture identification card issued to the

witness by a government agency must be provided to prove identity.
Following are some recommended documents that can be used (only
the original or a certified copy is acceptable):
 A driver’s license or identification card issued by a United States
(U.S.) Department of Motor Vehicles Office.
 U.S. passport.
 U.S. military identification card.
 Temporary resident identification card (green card).
 Other valid picture identification card issued by a foreign
government. (If the witness is not in California legally, they may be
able to get identification verification from their consulate.)

Verification The local Health Department may verify the accuracy of all information
provided to register an out-of-hospital birth.

Registrar’s right If the requirements of Health and Safety Code Section 102415 and of
to refuse to register the enclosed registration packet or other bona fide evidence are not
birth presented to the registrar, then the registrar must refuse to register the
birth certificate. In these cases, the birth certificate may be registered
only by authority of a Superior Court. (Health and Safety Code Section
103450.)

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Valid ID for The physician or midwife must provide written documentation of their
physician/midwife identity at the time they sign the birth certificate.

A valid picture identification card issued by a government agency

must be provided to prove identity. Following are some recommended
documents that can be used (only the original or a certified copy is
acceptable):

 A driver’s license or identification card issued by a United States

(U.S.) Department of Motor Vehicles Office.

 U.S. passport.

 U.S. military identification card.

The physician or midwife must also provide their professional license

number for verification purposes.

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 Worksheet for Out-of-Hospital Births

Please Bring This Completed Form to Register This Child’s Out-of-Hospital Birth
Child’s First Name Middle Last (Birth)
Information
Sex This Birth Specify 1=Single, 2=Twin, 3=Triplet, Etc.

Date of Birth Time of Birth □ a.m. □ p.m.

Place of Birth Street Address

City County Zip Code

Parent’s First Name Middle Last (Birth) □ Mother

Information □ Father
□ Parent
State of Birth Date of Birth

Parent’s First Name Middle Last (Birth) □ Mother

Information □ Father
□ Parent
(Person State of Birth Date of Birth
Giving Birth)

The Following is Confidential Information and Will be Used for Public Health Purposes Only
Genetic Race (list up to 3) Hispanic: □ Yes □ No Date Last Worked
Father’s
Information See Attached Race/Ethnicity Worksheet Specify:
__________________________________
Usual Occupation Usual Kind of Business or Education – Years Completed Social Security Number
Industry

Genetic Race (list up to 3) Hispanic: □ Yes □ No Date Last Worked

Mother’s
Information
See Attached Race/Ethnicity Worksheet Specify:
__________________________________
Usual Occupation Usual Kind of Business or Education – Years Completed Social Security Number
Industry

Person Residence – Street Name and Number County

Giving
Birth’s City State Zip
Address
Mailing Address – If Different From Residence Address County
Street Name and Number or P.O. Box

City State/Foreign County Zip

Continued on Back
 Worksheet for Out-of-Hospital Births (Continued)

The Following is Confidential Information and Will be Used for Public Health Purposes Only
Medical Did Person Giving Birth Receive WIC (Womens, Infants & Children) Food While Pregnant?
Data
Average Number of Cigarettes/Packs Per Day Average Number of Cigarettes/Packs Per Day
First Three Months Prior to Pregnancy First Trimester

Average Number of Cigarettes/Packs Per Day Average Number of Cigarettes/Packs Per Day
Second Trimester Third Trimester

Prepregnancy Weight in Pounds Delivery Weight in Pounds Height Feet Height Inches

APGAR Score at 1 Minute APGAR Score at 5 Minutes APGAR Score at 10 Minutes Date Last Normal Menses Began
(00-10, Unknown, or Not Taken) (00-10, Unknown, or Not (00-10, Unknown, or Not
Taken) Taken)

Date First Prenatal Care Visit Month Prenatal Care Began Date Last Prenatal Care Visit Number of Prenatal Visits

Obstetric Estimate of Gestation at Delivery Hearing Screening: (Pass (Both Ears); Refer (One Ear); Refer
(Completed Weeks) (Both Ears); Results Pending; Waived; Not Medically Indicated;
Test Not Available)

PREGNANCY HISTORY (Complete Each Section)

Live Births (Do not count this child) Other Terminations (Exclude induced abortions)

Now Living Now Dead Before 20 Weeks After 20 Weeks

Date of Last Live Birth Date of Last Other Termination

Enter Principal Source of Payment Birthweight in Grams (See attached Method of Delivery (See attached VS 10A
Appropriate for Prenatal Care birth weight conversion table) worksheet)
Codes From
Worksheets
Principal Source of Payment * Complications and Procedures of Pregnancy and Concurrent Illnesses (See attached VS 10A
for Delivery worksheet) Enter 00 for NONE

* Complications and Procedures of Labor and Delivery * Abnormal Conditions and Clinical Procedures Related to the
(See attached VS 10A worksheet) Enter 00 for NONE Newborn (See attached VS 10A worksheet) Enter 00 for NONE

* The attending physician or midwife shall complete these three fields for physician- or midwife-attended out-of-hospital births.
These three fields are optional for non-physician- or non-midwife-attended out-of-hospital births.
 Affidavit of Birth Information for Out-of-Hospital Births

This Affidavit is to be Completed at the Local Health Office

I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the
child named herein was born alive to the stated parent at the place, date, and time shown on this worksheet.
This worksheet was completed with the understanding that the facts so stated herein afford a full, complete, and truthful
representation of facts and what my testimony shall be should I be asked or directed to testify to the facts herein in a court
of law. I realize that any false statement of facts or information made herein could subject me to the risk of criminal
liability, including, but not limited to, prosecution for perjury.
Parent Printed Name Written Signature
Verification ►
Relationship to Child Date Signed Phone Number
( )
□ Mother
□ Father
□ Parent
Witness Printed Name Written Signature
Verification ►
Address – Street Name and Number County

City State Zip

Relationship to Child Date Signed Phone Number

( )

Attendant Printed Name Written Signature

Verification ►
Address – Street Name and Number County
(Physician,
Certified Nurse- City State Zip
Midwife, or
Licensed State License Number Date Signed Phone Number
Midwife) ( )

Local Printed Name Written Signature

Registration ►
District Staff Date Signed Inventory Control Number
Verification □ Registered □ Denied ___________________

Privacy Notification

The information entered on the worksheet will be transferred to the Certificate of Live Birth (VS 10D) and will be collected
by California Department of Public Health-Vital Records, M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410,
telephone number (916) 445-2684. This information is required by Division 102 of the Health and Safety Code. Every
element on the worksheet is mandatory, except the items between the double bold lines on the first page of the worksheet.
Failure to comply by every person, except a parent informant, is a misdemeanor. The Certificate of Live Birth is open to
public access except where prohibited by statute. The principal purposes of this record are to: 1) Establish a legal record of
each vital event, 2) Provide certified copies for personal use, 3) Furnish information for demographic and epidemiological
studies, and 4) Supply data to the National Center for Health Statistics for federal reports. The parents’ Social Security
numbers are included pursuant to Section 102425 (b) (15) of the Health and Safety Code, and may be used for child support
enforcement purposes.
 CERTIFICATES OF LIVE BIRTH AND FETAL DEATH
MEDICAL DATA SUPPLEMENTAL WORKSHEET
VS 10A (Rev. 1/2006)

Use the codes on this Worksheet to report the appropriate entry in items numbered 25D and 28A through 31 on the
“Certificate of Live Birth” and for items 29D and 32B through 35 on the “Certificate of Fetal Death.”
Item 25D. (Birth) PRINCIPAL SOURCE OF PAYMENT FOR PRENATAL CARE
Item 29D. (Fetal Death) (Enter only 1 code)
02 Medi-Cal, without CPSP Support Services 07 Private Insurance Company
99 Unknown
13 Medi-Cal, with CPSP Support Services 09 Self Pay
00 No Prenatal Care
05 Other Government Programs (Federal, State, Local) 14 Other
Item 28A. (Birth) METHOD OF DELIVERY
Item 32A (Fetal Death) (Enter only 1 code/number under each section, separated by commas: A,B,C,D,E,F)
A. Final delivery route B. If mother had a previous Cesarean—How many? _______
01 Cesarean—primary (Enter 0 – 9, or U if Unknown)
11 Cesarean—primary, with trial of labor attempted C. Fetal presentation at birth
21 Cesarean—primary, with vacuum
31 Cesarean—primary, with vacuum & trial of labor attempted 20 Cephalic fetal presentation at delivery
02 Cesarean—repeat 30 Breech fetal presentation at delivery
12 Cesarean—repeat, with trial of labor attempted 40 Other fetal presentation at delivery
22 Cesarean—repeat, with vacuum 90 Unknown
32 Cesarean—repeat, with vacuum & trial of labor attempted
03 Vaginal—spontaneous D. Was vaginal delivery with forceps attempted, but unsuccessful?
04 Vaginal—spontaneous, after previous Cesarean 50 Yes 58 No 59 Unknown
05 Vaginal—forceps E. Was vaginal delivery with vacuum attempted, but unsuccessful?
15 Vaginal—forceps, after previous Cesarean 60 Yes 68 No 69 Unknown
06 Vaginal—vacuum
16 Vaginal—vacuum, after previous Cesarean
F. Hysterotomy/Hysterectomy (Fetal Death Only)
88 Not Delivered (Fetal Death Only) 70 Yes 78 No
Item 28B. (Birth) EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY
Item 32B (Fetal Death) (Enter only 1 code)
02 Medi-Cal 05 Other Government Programs (Federal, State, Local) 14 Other
15 Indian Health Service 07 Private Insurance 99 Unknown
16 CHAMPUS/TRICARE 09 Self Pay 00 Medically Unattended Birth
Item 29. (Birth) COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES
Item 33. (Fetal Death) (Enter up to 16 codes, separated by commas, for the most important complications/procedures.)
DIABETES INFECTIONS PRESENT AND/OR TREATED DURING THIS
09 Prepregnancy (Diagnosis prior to this pregnancy) PREGNANCY
31 Gestational (Diagnosis in this pregnancy) 42 Chlamydia
43 Gonorrhea
HYPERTENSION
44 Group B streptococcus
03 Prepregnancy (Chronic)
18 Hepatitis B (acute infection or carrier)
01 Gestational (PIH, Preeclampsia)
45 Hepatitis C
02 Eclampsia
16 Herpes simplex virus (HSV)
OTHER COMPLICATIONS/PREGNANCIES 46 Syphilis
32 Large fibroids 47 Cytomegalovirus (Fetal Death Only)
33 Asthma 48 Listeria (Fetal Death Only)
34 Multiple pregnancy (more than 1 fetus this pregnancy) 49 Parvovirus (Fetal Death Only)
35 Intrauterine growth restricted birth this pregnancy 50 Toxoplasmosis (Fetal Death Only)
23 Previous preterm birth (<37 weeks gestation)
PRENATAL SCREENING DONE FOR INFECTIOUS DISEASES
36 Other previous poor pregnancy outcomes (Includes
51 Chlamydia
perinatal death, small-for-gestational age/intrauterine
52 Gonorrhea
growth restricted birth, large for gestational age, etc.)
53 Group B streptococcal infection
OBSTETRIC PROCEDURES
54 Hepatitis B
24 Cervical cerclage
55 Human immunodeficiency virus (offered)
28 Tocolysis
56 Syphilis
37 External cephalic version—Successful
NONE OR OTHER COMPLICATIONS/PROCEDURES NOT LISTED
38 External cephalic version—Failed
COMPLICATIONS/PROCEDU
00 None
39 Consultation with specialist for high risk obstetric services 30 Other Pregnancy Complications/Procedures not Listed
PREGNANCY RESULTED FROM INFERTILITY TREATMENT
40 Fertility-enhancing drugs, artificial insemination or
TREATMENT
intrauterine insemination
RES NOT LISTED
41 Assisted reproductive technology (e.g., in vitro fertilization
(IVF), gamete intrafallopian transfer (GIFT)
See reverse side for codes to Birth Items 30 and 31 and Fetal Death Items 34 and 35.
Do not enter any identification by patient name or number on this worksheet. Discard after use.
Do not retain the worksheet in the medical records or submit with the “Certificates of Live Birth or Fetal Death.”
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH —MEDICAL DATA SUPPLEMENTAL WORKSHEET (Continued)
Item 30 (Birth) COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY
Item 34 (Fetal Death) (Enter up to 9 codes, separated by commas, for the most important complications/procedures.)
ONSET OF LABOR COMPLICATIONS OF PLACENTA, CORD, AND MEMBRANES
10 Premature rupture of membranes ( 12 hours) 38 Rupture of membranes prior to onset of labor
07 Precipitous labor (< 3 hours) 13 Abruptio placenta
08 Prolonged labor ( 20 hours) 39 Placental insufficiency
CHARACTERISTICS OF LABOR AND DELIVERY 20 Prolapsed cord
11 Induction of labor 17 Chorioamnionitis
12 Augmentation of labor MATERNAL MORBIDITY
32 Non-vertex presentation 24 Maternal blood transfusion
33 Steroids (glucocorticoids) for fetal lung maturation received 40 Third or fourth degree perineal laceration
by the mother prior to delivery 41 Ruptured uterus
34 Antibiotics received by the mother during labor 42 Unplanned hysterectomy
35 Clinical chorioamnionitis diagnosed during labor or maternal 43 Admission to ICU
temperature  38°C (100.4°F) 44 Unplanned operating room procedure following delivery
19 Moderate/heavy meconium staining of the amniotic fluid NONE OR OTHER COMPLICATIONS/PROCEDURES NOT LISTED
36 Fetal intolerance of labor such that one or more of the 00 None
following actions was taken: in-utero resuscitative measures,
further fetal assessment, or operative delivery 31 Other Labor/Delivery Complications/Procedures not Listed

37 Epidural or spinal anesthesia during labor

25 Mother transferred for delivery from another facility for
maternal medical or fetal indications

Item 31 (Birth) ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
Item 35 (Fetal Death) ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE FETUS
(Enter up to 10 codes, separated by commas, for the most important conditions/procedures.)
CONGENITAL ANOMALIES (NEWBORN OR FETUS) ABNORMAL CONDITIONS (NEWBORN OR FETUS)
01 Anencephaly 66 Significant birth injury (skeletal fracture(s), peripheral nerve
injury, and/or soft tissue/solid organ hemorrhage which requires
02 Meningomyelocele/Spina bifida intervention)
76 Cyanotic congenital heart disease ADDITIONAL ABNORMAL CONDITIONS/PROCEDURES
(NEWBORN ONLY)
77 Congenital diaphragmatic hernia
71 Assisted ventilation required immediately following delivery
78 Omphalocele
85 Assisted ventilation required for more than 6 hours
79 Gastroschisis
73 NICU admission
80 Limb reduction defect (excluding congenital amputation and
dwarfing syndromes) 86 Newborn given surfactant replacement therapy
28 Cleft palate alone 87 Antibiotics received by the newborn for suspected neonatal
sepsis
29 Cleft lip alone
70 Seizure or serious neurological dysfunction
30 Cleft palate with cleft lip
57 Down’s Syndrome—Karyotype confirmed 74 Newborn transferred to another facility within 24 hours of
delivery
81 Down’s Syndrome—Karyotype pending
NONE OR OTHER ABNORMAL CONDITIONS/PROCEDURES NOT
82 Suspected chromosomal disorder—Karyotype confirmed LISTED
83 Suspected chromosomal disorder—Karyotype pending 00 None (Newborn or Fetus)
35 Hypospadias 75 Other Conditions/Procedures not Listed (Newborn Only)
88 Aortic stenosis 67 Other Conditions/Procedures not Listed (Fetal Death Only)
89 Pulmonary stenosis
90 Atresia
62 Additional and unspecified congenital anomalies not listed
above
 RACE/ETHNICITY AND EDUCATION WORKSHEET (For Reference Only)
RACE/ETHNICITY (GENETIC FATHER/PARENT) RACE/ETHNICITY (GENETIC MOTHER/PARENT)

HISPANIC, LATINO, SPANISH (check 1 box). Enter specific origin on the HISPANIC, LATINA, SPANISH (check 1 box). Enter specific origin on
certificate. the certificate.
Is the GENETIC FATHER/PARENT Hispanic/Latino/Spanish? Is the GENETIC MOTHER/PARENT Hispanic/Latina/Spanish?

No, not Hispanic/Latino/Spanish No, not Hispanic/Latina/Spanish

Yes, Mexican, Mexican American, Chicano Yes, Mexican, Mexican American, Chicana
Yes, Central American Yes, Central American
Yes, South American Yes, South American
Yes, Cuban Yes, Cuban
Yes, Puerto Rican Yes, Puerto Rican
Yes, Other Hispanic/Latino/Spanish (Specify): Yes, Other Hispanic/Latina/Spanish (Specify):

____________________________________ ____________________________________

RACE (check 1, 2 or 3 boxes). Enter up to 3 races on the certificate. RACE (check 1, 2 or 3 boxes). Enter up to 3 races on the certificate.
The GENETIC FATHER/PARENT is: The GENETIC MOTHER/PARENT is:

White Asian Indian White Asian Indian

Black or African American Cambodian Black or African American Cambodian
American Indian or Alaska Native Chinese American Indian or Alaska Native Chinese
(includes North, South, or Central Filipino (includes North, South, or Central Filipino
American Indian, Aleut or American Indian, Aleut or
Hmong Hmong
Alaska Native) Alaska Native)
Specify Tribe(s):______________ Japanese Specify Tribe(s):______________ Japanese
Korean Korean
___________________________ ___________________________
Laotian Laotian
Native Hawaiian Native Hawaiian
Thai Thai
Guamanian Guamanian
Vietnamese Vietnamese
Samoan Samoan
Other Asian (Specify): Other Asian (Specify):
Other Pacific Islander (Specify): Other Pacific Islander (Specify):
_________________________ ________________________ __________________________ __________________________

Other (Specify):______________________________________________ Other (Specify):_____________________________________________

Other (Specify):______________________________________________ Other (Specify):_____________________________________________
Other (Specify):______________________________________________ Other (Specify):_____________________________________________

EDUCATION (GENETIC FATHER/PARENT) EDUCATION (GENETIC MOTHER/PARENT)

Check 1 box that best describes the highest degree or level of school Check 1 box that best describes the highest degree or level of school
completed by the GENETIC FATHER/PARENT at the time of the delivery. completed by the GENETIC MOTHER/PARENT at the time of the delivery.
Enter education degree or level on the certificate. Enter education degree or level on the certificate.

0-11th grade. Enter highest year completed: _____ 0-11th grade. Enter highest year completed: _____
12th grade; no diploma. Enter 12 ND 12th grade; no diploma. Enter 12 ND
High school graduate or GED completed. Enter HS GRADUATE or GED High school graduate or GED completed. Enter HS GRADUATE or GED
Some college credit, but no degree. Enter SOME COLLEGE Some college credit, but no degree. Enter SOME COLLEGE
Associate degree (e.g., AA, AS). Enter ASSOCIATE Associate degree (e.g., AA, AS). Enter ASSOCIATE
Bachelor’s degree (e.g., BA, AB, BS). Enter BACHELOR’S Bachelor’s degree (e.g., BA, AB, BS). Enter BACHELOR’S
Master’s degree (e.g., MA, MS, MEd, MSW, MBA). Enter MASTER’S Master’s degree (e.g., MA, MS, MEd, MSW, MBA). Enter MASTER’S
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS, Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DO, DDS,
DVM, LLB, JD). DVM, LLB, JD).
Enter DOCTORATE or PROFESSIONAL: __________________ Enter DOCTORATE or PROFESSIONAL: __________________