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 captures essential information about the newborn, including details about the parents and the birth itself. To ensure accurate documentation, it is important to fill out this form correctly; click the button below to get started.
The CDC U.S. Standard Certificate of Live Birth form is a crucial document that plays a significant role in recording the birth of a child in the United States. This form captures essential information about the newborn, including details such as the baby's name, date and place of birth, and the parents' names and addresses. It also includes important medical information, like the birth weight and any complications during delivery. Each section of the form is designed to ensure that all relevant details are accurately documented, which is vital for both public health records and the issuance of a birth certificate. Parents or guardians must fill out this form promptly after the birth, as it serves not only as a legal record but also as a key document for obtaining social security numbers and other benefits. Understanding how to complete the form correctly can help ease the process during a time that is often filled with joy and excitement, while also ensuring that all necessary information is captured for future reference.
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.
Completing the CDC U.S. Standard Certificate of Live Birth form is an important step after the birth of a child. This form must be filled out accurately to ensure that all necessary information is recorded. Follow the steps below to complete the form correctly.
After completing the form, it will need to be submitted to the appropriate state office for processing. Make sure to keep a copy for your records.
What is the CDC U.S. Standard Certificate of Live Birth form?
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. It serves as a vital record that provides essential information about the newborn, including details about the parents, the place of birth, and the time of birth. This form is crucial for obtaining a birth certificate, which is often required for various legal and administrative purposes.
Who is responsible for completing the form?
The form is typically completed by the attending physician, nurse, or midwife who was present at the birth. However, parents or guardians may also be involved in providing information, particularly regarding personal details and the child’s name. Accuracy is important, as the information will be used to create the official birth certificate.
What information is required on the form?
Several key pieces of information are required on the form. This includes the child's full name, date and time of birth, sex, and place of birth. Additionally, the form collects information about the parents, such as their names, addresses, and dates of birth. It may also ask for details regarding the mother's pregnancy and delivery, as well as any complications that may have occurred.
How is the form submitted?
After the form is completed, it must be submitted to the local vital records office. This is often done electronically, but some hospitals may still use paper forms. It is essential to ensure that the form is submitted promptly, as there are time limits for registering a birth, which can vary by state.
Why is it important to have a birth certificate?
A birth certificate is a vital document that serves many purposes. It is often required for enrolling a child in school, obtaining a Social Security number, applying for health insurance, and establishing citizenship. Additionally, a birth certificate can be necessary for legal matters, such as inheritance and custody disputes.
Can the information on the form be corrected after submission?
Yes, corrections can be made to the information on the birth certificate after it has been issued. However, the process for making changes varies by state and may require specific documentation or a formal request. It is advisable to contact the local vital records office for guidance on how to proceed with any necessary corrections.
Is there a fee associated with obtaining a birth certificate?
Yes, there is usually a fee for obtaining a certified copy of a birth certificate. The amount can vary by state and the specific vital records office. It is important to check with the local office for the exact fee and accepted payment methods.
How long does it take to receive a birth certificate?
The time it takes to receive a birth certificate can vary depending on the state and the method of application. In some cases, it may be issued within a few days if requested in person, while mail requests can take several weeks. It is advisable to plan ahead and request the birth certificate as soon as possible after the birth.
Where can I find more information about the form?
For more information about the CDC U.S. Standard Certificate of Live Birth form, you can visit the CDC's official website or contact your local vital records office. They can provide guidance on the completion of the form, submission procedures, and any other questions you may have regarding birth registration.
Filling out the CDC U.S. Standard Certificate of Live Birth form is a crucial step in documenting the birth of a child. However, many people make common mistakes that can lead to delays or complications. One frequent error occurs when parents fail to provide accurate information about the child's name. It’s essential to double-check the spelling and ensure that the name matches the desired name on the birth certificate. Any discrepancies can result in additional paperwork and frustration.
Another mistake often made is not including the correct date and time of birth. This information is vital for legal purposes and can affect the child's eligibility for certain benefits. Parents should take care to confirm the details with the medical staff present at the birth. Inaccuracies in this section can lead to complications in obtaining a social security number later on.
Many individuals overlook the importance of providing complete information about the parents. Omitting details such as the parents' full names, addresses, or dates of birth can create issues. Each piece of information is necessary for the identification of the parents and may be required for various legal documents in the future. Ensuring that all fields are filled out completely helps to avoid unnecessary delays.
Additionally, some parents mistakenly believe that they can leave certain sections blank if they do not apply to their situation. For instance, if a parent is unsure about their occupation or education level, they might choose to skip those questions. However, it is important to provide as much information as possible, even if it means indicating "unknown" or "not applicable." This approach helps maintain the integrity of the record.
Another common error is not signing the form correctly. Both parents typically need to sign the certificate, and if one signature is missing, the form may be deemed incomplete. It’s advisable to review the signature requirements carefully and ensure that all necessary parties have signed before submission.
Finally, many individuals fail to submit the form within the required timeframe. Each state has its own rules regarding how soon a birth certificate must be filed after a child is born. Delaying this process can lead to complications, including fines or difficulties in obtaining the birth certificate later. Parents should familiarize themselves with their state’s regulations to avoid this pitfall.
The CDC U.S. Standard Certificate of Live Birth is a crucial document that serves as the official record of a child's birth in the United States. Alongside this form, several other documents may be needed for various legal and administrative purposes. Below is a list of commonly used forms and documents that complement the birth certificate.
Understanding the various documents that accompany the CDC U.S. Standard Certificate of Live Birth can simplify the process of securing essential services and benefits for your child. Each document serves a specific purpose and helps to establish legal identity and rights, ensuring that parents can navigate their responsibilities with confidence.
The CDC U.S. Standard Certificate of Live Birth form serves as a crucial document in the realm of vital records. Several other documents share similarities with it, each playing a significant role in the documentation of personal identity and vital statistics. Below is a list of documents that are comparable to the birth certificate:
Each of these documents plays a vital role in the legal and personal identification processes, reflecting the importance of accurate record-keeping in society.
When filling out the CDC U.S. Standard Certificate of Live Birth form, attention to detail is crucial. Here are five important dos and don'ts to keep in mind:
Understanding the CDC U.S. Standard Certificate of Live Birth form is crucial for new parents and anyone involved in birth registration. However, several misconceptions surround this important document. Here are seven common misunderstandings:
The CDC form is not a birth certificate. It is a standardized document used to collect information about a birth, which is then used to create the official birth certificate issued by the state.
While the CDC provides a standard format, each state may have variations in how they implement the form or additional requirements for registration.
Though hospitals typically handle the filing, parents can also submit the form directly in some states, especially if the birth occurs outside a medical facility.
While timely completion is encouraged, states often allow a window of time for parents to provide the necessary information.
Not all details on the form are publicly accessible. Certain information is protected and only available to authorized individuals or entities.
The form is used for all live births occurring in the U.S., regardless of the citizenship status of the parents.
Corrections can be made if errors are identified. Each state has procedures in place for amending the information on the birth certificate.
By clarifying these misconceptions, parents can better navigate the process of birth registration and ensure that their child's vital records are accurate and complete.
Filling out the CDC U.S. Standard Certificate of Live Birth form is an important process for documenting a newborn's arrival. Here are some key takeaways to keep in mind:
Understanding these key points can help streamline the process of obtaining a birth certificate and ensure that all necessary information is accurately documented.