U.S. STANDARD CERTIFICATE OF LIVE BIRTH
LOCAL FILE NO. BIRTH NUMBER:
CHILD
1. CHILD’S NAME (First, Middle, Last, Suffix)
2. TIME OF BIRTH
(24 hr)
3. SEX
4. DATE OF BIRTH (Mo/Day/Yr)
5. FACILITY NAME
(If not institution, give street and number)
6. CITY, TOWN, OR LOCATION OF BIRTH
7. COUNTY OF BIRTH
MOTHER
8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
8b. DATE OF BIRTH (Mo/Day/Yr)
8c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) 8d. BIRTHPLACE (State, Territory, or Foreign Country)
9a. RESIDENCE OF MOTHER-STATE
9b. COUNTY 9c. CITY, TOWN, OR LOCATION
9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE
9g. INSIDE CITY
LIMITS?
□ Yes □ No
FATHER
10a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
10b. DATE OF BIRTH (Mo/Day/Yr) 10c. BIRTHPLACE (State, Territory, or Foreign Country)
CERTIFIER
11. CERTIFIER’S NAME: _______________________________________________
TITLE: □ MD □ DO □ HOSPITAL ADMIN. □ CNM/CM □ OTHER MIDWIFE
□ OTHER (Specify)_____________________________
12. DATE CERTIFIED
______/ ______ / __________
MM DD YYYY
13. DATE FILED BY REGISTRAR
______/ ______ / __________
MM DD YYYY
INFORMATION FOR ADMINISTRATIVE USE
MOTHER
14. MOTHER’S MAILING ADDRESS: 9 Same as residence, or: State: City, Town, or Location:
Street & Number: Apartment No.: Zip Code:
15. MOTHER MARRIED? (At birth, conception, or any time between) □ Yes □ No
IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? □ Yes □ No
16. SOCIAL SECURITY NUMBER REQUESTED
FOR CHILD? □ Yes □ No
17. FACILITY ID. (NPI)
18. MOTHER’S SOCIAL SECURITY NUMBER:
19. FATHER’S SOCIAL SECURITY NUMBER:
INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY
MOTHER
20. MOTHER’S EDUCATION (Check the
box that best describes the highest
degree or level of school completed at
the time of delivery)
□ 8th grade or less
□ 9th - 12th grade, no diploma
□ High school graduate or GED
completed
□ Some college credit but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS,
MEng, MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
21. MOTHER OF HISPANIC ORIGIN? (Check
the box that best describes whether the
mother is Spanish/Hispanic/Latina. Check the
“No” box if mother is not Spanish/Hispanic/Latina)
□ No, not Spanish/Hispanic/Latina
□ Yes, Mexican, Mexican American, Chicana
□ Yes, Puerto Rican
□ Yes, Cuban
□ Yes, other Spanish/Hispanic/Latina
(Specify)_____________________________
22. MOTHER’S RACE (Check one or more races to indicate
what the mother considers herself to be)
□ White
□ Black or African American
□ American Indian or Alaska Native
(Name of the enrolled or principal tribe)________________
□ Asian Indian
□ Chinese
□ Filipino
□ Japanese
□ Korean
□ Vietnamese
□ Other Asian (Specify)______________________________
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander (Specify)______________________
□ Other (Specify)___________________________________
FATHER
Mother’s Name
________________
Mother’s Medical Record
No.
_________________________
23. FATHER’S EDUCATION (Check the
box that best describes the highest
degree or level of school completed at
the time of delivery)
□ 8th grade or less
□ 9th - 12th grade, no diploma
□ High school graduate or GED
completed
□ Some college credit but no degree
□ Associate degree (e.g., AA, AS)
□ Bachelor’s degree (e.g., BA, AB, BS)
□ Master’s degree (e.g., MA, MS,
MEng, MEd, MSW, MBA)
□ Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)
24. FATHER OF HISPANIC ORIGIN? (Check
the box that best describes whether the
father is Spanish/Hispanic/Latino. Check the
“No” box if father is not Spanish/Hispanic/Latino)
□ No, not Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican American, Chicano
□ Yes, Puerto Rican
□ Yes, Cuban
□ Yes, other Spanish/Hispanic/Latino
(Specify)_____________________________
25. FATHER’S RACE (Check one or more races to indicate
what the father considers himself to be)
□ White
□ Black or African American
□ American Indian or Alaska Native
(Name of the enrolled or principal tribe)________________
□ Asian Indian
□ Chinese
□ Filipino
□ Japanese
□ Korean
□ Vietnamese
□ Other Asian (Specify)______________________________
□ Native Hawaiian
□ Guamanian or Chamorro
□ Samoan
□ Other Pacific Islander (Specify)______________________
□ Other (Specify)___________________________________
26. PLACE WHERE BIRTH OCCURRED (Check one)
□ Hospital
□ Freestanding birthing center
□ Home Birth: Planned to deliver at home? 9 Yes 9 No
□ Clinic/Doctor’s office
□ Other (Specify)_______________________
27. ATTENDANT’S NAME, TITLE, AND NPI
NAME: _______________________ NPI:_______
TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE
□ OTHER (Specify)___________________
28. MOTHER TRANSFERRED FOR MATERNAL
MEDICAL OR FETAL INDICATIONS FOR
DELIVERY?
□ Yes □ No
IF YES, ENTER NAME OF FACILITY MOTHER
TRANSFERRED FROM:
_______________________________________
REV. 11/2003
MOTHER
29a. DATE OF FIRST PRENATAL CARE VISIT
______ /________/ __________
□ No Prenatal Care
M M D D YYYY
29b. DATE OF LAST PRENATAL CARE VISIT
______ /________/ __________
M M D D YYYY
30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY
_________________________ (If none, enter A0".)
31. MOTHER’S HEIGHT
_______ (feet/inches)
32. MOTHER’S PREPREGNANCY WEIGHT
_________ (pounds)
33. MOTHER’S WEIGHT AT DELIVERY
_________ (pounds)
34. DID MOTHER GET WIC FOOD FOR HERSELF
DURING THIS PREGNANCY?
□ Yes □ No
35. NUMBER OF PREVIOUS
LIVE BIRTHS (Do not include
this child)
36. NUMBER OF OTHER
PREGNANCY OUTCOMES
(spontaneous or induced
losses or ectopic pregnancies)
35a. Now Living
Number _____
□ None
35b. Now Dead
Number _____
□ None
36a. Other Outcomes
Number _____
□ None
37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY
For each time period, enter either the number of cigarettes or the
number of packs of cigarettes smoked. IF NONE, ENTER A0".
Average number of cigarettes or packs of cigarettes smoked per day.
# of cigarettes # of packs
Three Months Before Pregnancy _________ OR ________
First Three Months of Pregnancy _________ OR ________
Second Three Months of Pregnancy _________ OR ________
Third Trimester of Pregnancy _________ OR ________
38. PRINCIPAL SOURCE OF
PAYMENT FOR THIS
DELIVERY
□ Private Insurance
□ Medicaid
□ Self-pay
□ Other
(Specify) _______________
35c. DATE OF LAST LIVE BIRTH
_______/________
MM Y Y Y Y
36b. DATE OF LAST OTHER
PREGNANCY OUTCOME
_______/________
MM Y Y Y Y
39. DATE LAST NORMAL MENSES BEGAN
______ /________/ __________
M M D D YYYY
40. MOTHER’S MEDICAL RECORD NUMBER
MEDICAL
AND
HEALTH
INFORMATION
43. OBSTETRIC PROCEDURES (Check all that apply)
□ Cervical cerclage
□ Tocolysis
External cephalic version:
□ Successful
□ Failed
□ None of the above
44. ONSET OF LABOR (Check all that apply)
□ Premature Rupture of the Membranes (prolonged, ∃12 hrs.)
□ Precipitous Labor (<3 hrs.)
□ Prolonged Labor (∃ 20 hrs.)
□ None of the above
46. METHOD OF DELIVERY
A. Was delivery with forceps attempted but
unsuccessful?
□ Yes □ No
B. Was delivery with vacuum extraction attempted
but unsuccessful?
□ Yes □ No
C. Fetal presentation at birth
□ Cephalic
□ Breech
□ Other
D. Final route and method of delivery (Check one)
□ Vaginal/Spontaneous
□ Vaginal/Forceps
□ Vaginal/Vacuum
□ Cesarean
If cesarean, was a trial of labor attempted?
□ Yes
□ No
41. RISK FACTORS IN THIS PREGNANCY
(Check all that apply)
Diabetes
□ Prepregnancy (Diagnosis prior to this pregnancy)
□ Gestational (Diagnosis in this pregnancy)
Hypertension
□ Prepregnancy (Chronic)
□ Gestational (PIH, preeclampsia)
□ Eclampsia
□ Previous preterm birth
□ Other previous poor pregnancy outcome (Includes
perinatal death, small-for-gestational age/intrauterine
growth restricted birth)
□ Pregnancy resulted from infertility treatment-If yes,
check all that apply:
□ Fertility-enhancing drugs, Artificial insemination or
Intrauterine insemination
□ Assisted reproductive technology (e.g., in vitro
fertilization (IVF), gamete intrafallopian
transfer (GIFT))
□ Mother had a previous cesarean delivery
If yes, how many __________
□ None of the above
42. INFECTIONS PRESENT AND/OR TREATED
DURING THIS PREGNANCY (Check all that apply)
□ Gonorrhea
□ Syphilis
□ Chlamydia
□ Hepatitis B
□ Hepatitis C
□ None of the above
45. CHARACTERISTICS OF LABOR AND DELIVERY
(Check all that apply)
□ Induction of labor
□ Augmentation of labor
□ Non-vertex presentation
□ Steroids (glucocorticoids) for fetal lung maturation
received by the mother prior to delivery
□ Antibiotics received by the mother during labor
□ Clinical chorioamnionitis diagnosed during labor or
maternal temperature >38°C (100.4°F)
□ Moderate/heavy meconium staining of the amniotic fluid
□ Fetal intolerance of labor such that one or more of the
following actions was taken: in-utero resuscitative
measures, further fetal assessment, or operative delivery
□ Epidural or spinal anesthesia during labor
□ None of the above
47. MATERNAL MORBIDITY (Check all that apply)
(Complications associated with labor and
delivery)
□ Maternal transfusion
□ Third or fourth degree perineal laceration
□ Ruptured uterus
□ Unplanned hysterectomy
□ Admission to intensive care unit
□ Unplanned operating room procedure
following delivery
□ None of the above
NEWBORN INFORMATION
48. NEWBORN MEDICAL RECORD NUMBER
NEWBORN
49. BIRTHWEIGHT (grams preferred, specify unit)
______________________
9 grams 9 lb/oz
50. OBSTETRIC ESTIMATE OF GESTATION:
_________________ (completed weeks)
51. APGAR SCORE:
Score at 5 minutes:________________________
If 5 minute score is less than 6,
Score at 10 minutes: _______________________
52. PLURALITY - Single, Twin, Triplet, etc.
(Specify)________________________
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________
54. ABNORMAL CONDITIONS OF THE NEWBORN
(Check all that apply)
□ Assisted ventilation required immediately
following delivery
□ Assisted ventilation required for more than
six hours
□ NICU admission
□ Newborn given surfactant replacement
therapy
□ Antibiotics received by the newborn for
suspected neonatal sepsis
□ Seizure or serious neurologic dysfunction
□ Significant birth injury (skeletal fracture(s), peripheral
nerve injury, and/or soft tissue/solid organ hemorrhage
which requires intervention)
9 None of the above
55. CONGENITAL ANOMALIES OF THE NEWBORN
(Check all that apply)
□ Anencephaly
□ Meningomyelocele/Spina bifida
□ Cyanotic congenital heart disease
□ Congenital diaphragmatic hernia
□ Omphalocele
□ Gastroschisis
□ Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
□ Cleft Lip with or without Cleft Palate
□ Cleft Palate alone
□ Down Syndrome
□ Karyotype confirmed
□ Karyotype pending
□ Suspected chromosomal disorder
□ Karyotype confirmed
□ Karyotype pending
□ Hypospadias
□ None of the anomalies listed above
Mother’s Name
________________
Mother’s Medical Record
No. ____________________
56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No
IF YES, NAME OF FACILITY INFANT TRANSFERRED
TO:______________________________________________________
57. IS INFANT LIVING AT TIME OF REPORT?
□ Yes □ No □ Infant transferred, status unknown
58. IS THE INFANT BEING
BREASTFED AT DISCHARGE?
□ Yes □ No
