The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the birth of a child in the United States. This form collects essential information about the newborn, including details about the parents, birth circumstances, and the medical provider involved. Understanding how to accurately fill out this form is crucial for new parents and guardians, ensuring proper documentation for legal and health purposes.
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When a new life enters the world, one of the first steps in celebrating that arrival is completing the CDC U.S. Standard Certificate of Live Birth form. This essential document captures critical information about the newborn, ensuring that their existence is officially recognized. The form collects details such as the baby’s name, date of birth, place of birth, and the names and addresses of the parents. It also includes vital statistics, like the baby’s sex and the mother’s prenatal care, which help public health officials track trends in maternal and child health. Beyond its bureaucratic purpose, this certificate serves as a key piece of identity for the child, laying the groundwork for future enrollment in school, obtaining a Social Security number, and more. By understanding the intricacies of this form, parents can navigate the requirements with confidence while ensuring that they fulfill important legal obligations surrounding their child's birth.
U.S. STANDARD CERTIFICATE OF LIVE BIRTH
LOCAL FILE NO.
BIRTH NUMBER:
C H I L D
1. CHILD’S NAME (First, Middle, Last, Suffix)
2. TIME OF BIRTH
3. SEX
4. DATE OF BIRTH (Mo/Day/Yr)
(24 hr)
5. FACILITY NAME (If not institution, give street and number)
6. CITY, TOWN, OR LOCATION OF BIRTH
7. COUNTY OF BIRTH
8b. DATE OF BIRTH (Mo/Day/Yr)
M O T H E R
8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)
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
F A T H E R
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: _______________________________________________
12. DATE CERTIFIED
13. DATE FILED BY REGISTRAR
TITLE: □ MD □ DO □ HOSPITAL ADMIN. □ CNM/CM □ OTHER MIDWIFE
______/ ______ / __________
□ OTHER (Specify)_____________________________
MM
DD
YYYY
MM DD
INFORMATION FOR ADMINISTRATIVE
USE
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
16. SOCIAL SECURITY NUMBER REQUESTED
17. FACILITY ID. (NPI)
IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? □ Yes
FOR CHILD?
18. MOTHER’S SOCIAL SECURITY NUMBER:
19. FATHER’S SOCIAL SECURITY NUMBER:
INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY
Mother’s Name ________________
Mother’s Medical Record No. _________________________
20. MOTHER’S EDUCATION (Check the
21. MOTHER OF HISPANIC ORIGIN? (Check
box that best describes the highest
the box that best describes whether the
degree or level of school completed at
mother is Spanish/Hispanic/Latina. Check the
the time of delivery)
“No” box if mother is not Spanish/Hispanic/Latina)
□
8th grade or less
No, not Spanish/Hispanic/Latina
□ Yes, Mexican, Mexican American, Chicana
9th - 12th grade, no diploma
Yes, Puerto Rican
High school graduate or GED
completed
Yes, Cuban
Some college credit but no degree
Yes, other Spanish/Hispanic/Latina
□ Associate degree (e.g., AA, AS)
(Specify)_____________________________
□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)
23. FATHER’S EDUCATION (Check the
24. FATHER OF HISPANIC ORIGIN? (Check
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, other Spanish/Hispanic/Latino
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)___________________________________
25.FATHER’S RACE (Check one or more races to indicate what the father considers himself to be)
26. PLACE WHERE BIRTH OCCURRED (Check one)
27. ATTENDANT’S NAME, TITLE, AND NPI
28. MOTHER TRANSFERRED FOR MATERNAL
□ Hospital
NAME: _______________________ NPI:_______
MEDICAL OR FETAL INDICATIONS FOR
□ Freestanding birthing center
DELIVERY? □ Yes □ No
IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No
TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE
TRANSFERRED FROM:
□ Clinic/Doctor’s office
□ OTHER (Specify)___________________
_______________________________________
□ Other (Specify)_______________________
REV. 11/2003
MOTHER
29a. DATE OF FIRST PRENATAL CARE VISIT
29b. DATE OF LAST PRENATAL CARE VISIT
30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY
______ /________/ __________ □ No Prenatal Care
______ /________/ __________
M M
D D
_________________________ (If none, enter A0".)
31. MOTHER’S HEIGHT
32. MOTHER’S
PREPREGNANCY WEIGHT
33. MOTHER’S WEIGHT
AT DELIVERY
34. DID MOTHER GET WIC FOOD FOR HERSELF
_______ (feet/inches)
_________ (pounds)
DURING THIS PREGNANCY? □ Yes □ No
35. NUMBER OF PREVIOUS
36. NUMBER OF OTHER
37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY
38. PRINCIPAL SOURCE OF
LIVE BIRTHS (Do not include
PREGNANCY OUTCOMES
For each time period, enter either the number of cigarettes or the
PAYMENT FOR THIS
this child)
(spontaneous or induced
number of packs of cigarettes smoked. IF NONE, ENTER A0".
DELIVERY
losses or ectopic pregnancies)
Average number of cigarettes or packs of cigarettes smoked per day.
□ Private Insurance
35a.
Now Living
35b. Now Dead
36a. Other Outcomes
Number _____
# of cigarettes
# of packs
□ Medicaid
Three Months Before Pregnancy
_________
OR
________
□ Self-pay
First Three Months of Pregnancy
□ Other
□ None
Second Three Months of Pregnancy _________
(Specify) _______________
Third Trimester of Pregnancy
35c. DATE OF LAST LIVE BIRTH
36b. DATE OF LAST OTHER
39. DATE LAST NORMAL MENSES BEGAN
40. MOTHER’S MEDICAL RECORD NUMBER
_______/________
PREGNANCY OUTCOME
Y Y Y Y
MEDICAL
41. RISK FACTORS IN THIS PREGNANCY
43. OBSTETRIC PROCEDURES (Check all that apply)
46. METHOD OF DELIVERY
(Check all that apply)
AND
Diabetes
□ Cervical cerclage
A. Was delivery with forceps attempted but
HEALTH
Prepregnancy
(Diagnosis prior to this pregnancy)
□ Tocolysis
unsuccessful?
Gestational
(Diagnosis in this pregnancy)
External cephalic version:
INFORMATION
B. Was delivery with vacuum extraction attempted
Hypertension
□ Successful
(Chronic)
□ Failed
but unsuccessful?
(PIH, preeclampsia)
□ None of the above
Eclampsia
C. Fetal presentation at birth
□ Previous preterm birth
Cephalic
44. ONSET OF LABOR (Check all that apply)
Breech
□ Other previous poor pregnancy outcome (Includes
□ Premature Rupture of the Membranes (prolonged, ∃12 hrs.)
Other
perinatal death, small-for-gestational age/intrauterine
D. Final route and method of delivery (Check one)
growth restricted birth)
□ Precipitous Labor (<3 hrs.)
□ Vaginal/Spontaneous
□ Pregnancy resulted from infertility treatment-If yes,
□ Prolonged Labor (∃ 20 hrs.)
□ Vaginal/Forceps
check all that apply:
□ Vaginal/Vacuum
□ Fertility-enhancing drugs, Artificial insemination or
□ Cesarean
Intrauterine insemination
If cesarean, was a trial of labor attempted?
□ Assisted reproductive technology (e.g., in vitro
45. CHARACTERISTICS OF LABOR AND DELIVERY
fertilization (IVF), gamete intrafallopian
(Check all that
apply)
transfer
(GIFT))
Induction of labor
47. MATERNAL MORBIDITY (Check all that apply)
□ Mother had a previous cesarean delivery
(Complications associated with labor and
Augmentation of labor
If yes, how many __________
delivery)
Non-vertex presentation
Maternal transfusion
□ Steroids (glucocorticoids) for fetal lung maturation
□ Third or fourth degree perineal laceration
42. INFECTIONS PRESENT AND/OR TREATED
received by the mother prior to delivery
Ruptured uterus
DURING THIS
PREGNANCY (Check all that apply)
□ Antibiotics received by the mother during labor
Unplanned hysterectomy
□ Clinical chorioamnionitis diagnosed during labor or
□ Admission to intensive care unit
Gonorrhea
maternal temperature >38°C (100.4°F)
□ Unplanned operating room procedure
Syphilis
□ Moderate/heavy meconium staining of the amniotic fluid
following delivery
Chlamydia
□ Fetal intolerance of labor such that one or more of the
Hepatitis B
following actions was taken: in-utero resuscitative
Hepatitis C
measures, further fetal assessment, or operative delivery
□ Epidural or spinal anesthesia during labor
NEWBORN
Mother’s Medical Record No. ____________________
NEWBORN INFORMATION
48. NEWBORN MEDICAL RECORD NUMBER
54. ABNORMAL CONDITIONS OF THE NEWBORN
55. CONGENITAL ANOMALIES OF THE NEWBORN
49. BIRTHWEIGHT (grams preferred, specify unit)
Assisted ventilation required immediately
Anencephaly
Meningomyelocele/Spina bifida
______________________
Cyanotic congenital heart disease
9 grams 9 lb/oz
Congenital diaphragmatic hernia
Assisted ventilation required for more than
Omphalocele
six hours
50. OBSTETRIC ESTIMATE OF GESTATION:
Gastroschisis
_________________ (completed weeks)
NICU admission
Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
Newborn given surfactant replacement
□ Cleft Lip with or without Cleft Palate
Cleft Palate alone
therapy
51. APGAR SCORE:
Down Syndrome
Score at 5 minutes:________________________
Antibiotics received by the newborn for
Karyotype confirmed
If 5 minute score is less than 6,
Score at 10 minutes: _______________________
suspected neonatal sepsis
Karyotype pending
Seizure or serious neurologic dysfunction
Suspected chromosomal disorder
52. PLURALITY - Single, Twin, Triplet, etc.
□ Significant birth injury (skeletal fracture(s), peripheral
Hypospadias
(Specify)________________________
nerve
injury, and/or soft tissue/solid organ hemorrhage
None of the anomalies listed above
which
requires intervention)
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________
9 None of the above
56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No
57. IS INFANT LIVING AT TIME OF REPORT?
58. IS THE INFANT BEING
IF YES, NAME OF FACILITY INFANT TRANSFERRED
□ Yes □ No □ Infant transferred, status unknown
BREASTFED AT DISCHARGE?
TO:______________________________________________________
Rev. 11/2003
NOTE: This recommended standard birth certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future
activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.
Filling out the CDC U.S. Standard Certificate of Live Birth form is a vital step in officially recording a new birth. Make sure to have all the necessary information ready, as this will smooth the process. Once completed, you will submit the form to the appropriate local authorities to ensure the birth is legally documented.
Once submitted, the local office will process the certificate and provide you with a copy for your records.
The CDC U.S. Standard Certificate of Live Birth is an official document issued to record the birth of a child in the United States. This certificate includes details such as the child's name, date of birth, place of birth, and parental information. It serves as proof of identity and citizenship and is often required for school enrollment, obtaining a driver's license, and applying for passports.
The form must be completed by the attending physician, midwife, or hospital staff immediately following the birth. It ensures that all necessary information is accurately recorded. Parents may need to verify certain details and provide information about themselves and the child.
Yes, the Certificate of Live Birth is the document used to produce the official birth certificate. After the information is collected and verified, the state vital records office will issue the official birth certificate based on the completed certificate.
The form requests several key pieces of information, including:
Additional questions about the pregnancy, delivery, and medical information may also be included.
Filing the Certificate of Live Birth promptly is crucial because it helps ensure that the child's birth is officially recorded in the state vital records system. Delays can complicate obtaining an official birth certificate and may affect the child's legal status, citizenship confirmation, and access to services such as education and healthcare.
If errors are found after the form has been filed, it is essential to contact the local vital records office as soon as possible. They provide guidance on the correction process, which may involve completing a form or submitting other identifying information. Timeliness is important to ensure records are accurate.
Yes, the Certificate of Live Birth can be used to apply for various government benefits. It serves as proof of birth for programs such as Social Security, Medicaid, and other assistance programs. Ensure that all information is correct, as discrepancies may delay applications.
To obtain a copy of the official birth certificate, you typically must request it from the vital records office in the state where the birth occurred. Requirements may include providing identification, filling out a request form, and paying a fee. Procedures may vary by state, so it’s best to check the local regulations.
Generally, there is no fee for the immediate filing of the Certificate of Live Birth with the state; however, obtaining copies of the official birth certificate usually incurs a fee. This fee can differ significantly depending on the state and the number of copies requested.
If your child was born outside a hospital, the process for completing the Certificate of Live Birth may differ slightly. Some states allow midwives or parents to complete the form. Contact the local vital records office for specific instructions on how to file a Certificate of Live Birth in such cases.
Completing the CDC U.S. Standard Certificate of Live Birth form can be straightforward, but there are several common mistakes that people often make. First and foremost, ensuring accurate spelling of names is crucial. Mistakes in the name, especially the child’s, can lead to issues later, such as discrepancies on social security documents.
Another frequent error is not providing complete addresses. The residential address of the parents must be included and accurately stated. Missing elements, such as apartment numbers or ZIP codes, can delay processing and verification of the birth record.
Also, some individuals forget to mark the appropriate boxes regarding the parents’ marital status. This step is essential because it can affect the child's legal rights and benefits. Taking the time to review this section can prevent unnecessary complications.
The section for race and ethnicity is sometimes left blank or filled out incorrectly. Accurate data helps in statistical analysis and ensuring that public health policies are effectively tailored to community needs. Considerations around this section can greatly contribute to demographic records.
People often overlook the importance of signatures. Both parents may need to sign the form, and missing signatures can result in a rejection of the application. Make sure each signature is provided in the designated space to avoid delays.
Another common mistake is failing to include the correct date of birth and time. This information is crucial for official records and may impact the issuance of a birth certificate. Double-checking these details can make a difference.
Error in listing the place of birth can also occur. The hospital or facility’s name and address should be accurate. Incorrect information could pose problems when trying to retrieve records in the future.
Moreover, people sometimes provide only one parent's information, which is not sufficient. Both parents' information is typically required, barring certain circumstances, and missing details can hinder the process.
Some don’t realize the importance of including the attending physician’s or midwife's name. This detail is significant for verification purposes and helps ensure that all health care information is documented properly.
Finally, neglecting to read the instructions and guidelines can lead to various errors. Each section of the form should be reviewed with care. Even small oversights can complicate what should be a straightforward process.
The CDC U.S. Standard Certificate of Live Birth form is a vital document that officially records the details of a newborn's birth. While this certificate is essential for legal purposes, several other forms and documents often accompany it to provide additional context or meet regulatory requirements. Below is a list of these documents, each serving a specific role in the birth registration process.
Each of these documents plays a critical role in ensuring that a newborn is officially recognized and provided with important legal benefits. Collecting and completing them accurately helps to establish a solid foundation for the child's future.
The CDC U.S. Standard Certificate of Live Birth form is an important document used to record the birth of an individual in the United States. Several documents serve similar purposes in various contexts. Here are seven such documents, along with a brief explanation of how they are similar:
When filling out the CDC U.S. Standard Certificate of Live Birth form, it is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of ten do's and don'ts to keep in mind.
Understanding the CDC U.S. Standard Certificate of Live Birth form is essential for new parents. However, several misconceptions surround this important document. Here are nine common myths debunked:
The birth certificate serves multiple purposes, including eligibility for school enrollment, obtaining a driver's license, and more.
While parents can complete most sections, certain medical information must be filled out by healthcare providers.
The hospital issues a temporary record; the official birth certificate must be requested separately from the state.
Corrections to the birth certificate can be made, but specific procedures vary by state.
Legal guardians and other authorized individuals can also request copies, depending on state laws.
States usually allow you to file a name change request without issuing a new certificate, depending on local laws.
Each state has its own design and requirements for birth certificates, so they can vary significantly.
This document holds legal significance and is often required for various official processes throughout life.
Hospital documents are not substitutes for the official birth certificate, which is often required by institutions.
The following are key takeaways for filling out and using the CDC U.S. Standard Certificate of Live Birth form:
Immunization Records Florida - Inaccurate information can result in enrollment challenges for the child.
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Towing Laws in Texas - Use a printed name for clarity and official recognition.