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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

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION FOR ADMINISTRATIVE

USE

 

 

 

 

 

 

 

 

 

M O T H E R

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

□ No

 

FOR CHILD?

□ Yes

□ No

 

 

 

18. MOTHER’S SOCIAL SECURITY NUMBER:

 

 

19. FATHER’S SOCIAL SECURITY NUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY

 

 

 

 

 

 

 

 

 

M O T H E R

F A T H E R

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

 

box that best describes the highest

 

the box that best describes whether the

 

degree or level of school completed at

 

father is Spanish/Hispanic/Latino. Check the

 

the time of delivery)

 

“No” box if father is not Spanish/Hispanic/Latino)

□

8th grade or less

□

No, not Spanish/Hispanic/Latino

□ Yes, Mexican, Mexican American, Chicano

□

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/Latino

□ 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)

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)

□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)

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

 

 

 

YYYY

 

 

 

M M

D D

YYYY

 

 

_________________________ (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)

 

 

_________ (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 _____

 

 

Number _____

Number _____

 

 

 

 

 

 

 

# of cigarettes

# of packs

□ Medicaid

 

 

 

 

 

 

 

Three Months Before Pregnancy

_________

 

OR

________

□ Self-pay

 

 

 

 

 

 

 

 

 

 

 

 

 

First Three Months of Pregnancy

_________

 

OR

________

□ Other

 

 

□ None

 

 

 

□ None

□ None

 

 

 

Second Three Months of Pregnancy _________

OR

________

 

 

 

 

 

 

 

 

(Specify) _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

Third Trimester of Pregnancy

_________

OR

________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

______ /________/ __________

 

 

 

 

 

 

 

 

 

 

MM

Y Y Y Y

_______/________

M M

D D

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

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:

 

 

 

 

 

 

□ Yes

□ No

 

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Was delivery with vacuum extraction attempted

 

Hypertension

 

 

 

 

 

 

 

□ Successful

 

 

 

 

 

 

 

 

□

 

Prepregnancy

(Chronic)

 

 

 

□ Failed

 

 

 

 

 

 

 

but unsuccessful?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□

 

Gestational

(PIH, preeclampsia)

 

 

□ None of the above

 

 

 

 

 

 

 

□ Yes

□ No

 

 

□

 

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

□ None of the above

 

 

 

 

 

 

□ Cesarean

 

 

 

 

 

Intrauterine insemination

 

 

 

 

 

 

 

 

 

 

 

 

If cesarean, was a trial of labor attempted?

 

 

□ Assisted reproductive technology (e.g., in vitro

 

 

 

 

 

 

 

 

 

 

 

□ Yes

 

 

 

 

 

45. CHARACTERISTICS OF LABOR AND DELIVERY

 

 

 

 

 

 

 

 

 

fertilization (IVF), gamete intrafallopian

 

 

 

 

□ No

 

 

 

 

 

 

 

 

 

(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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□ None of the above

 

 

□ 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

□ None of the above

 

 

□

Hepatitis B

 

 

 

 

 

following actions was taken: in-utero resuscitative

 

 

 

 

 

 

□

Hepatitis C

 

 

 

 

 

measures, further fetal assessment, or operative delivery

 

 

 

 

 

 

 

 

 

 

□ Epidural or spinal anesthesia during labor

 

 

 

 

 

 

 

 

□ None of the above

 

 

 

 

 

 

 

 

 

 

 

 

□ None of the above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEWBORN

Mother’s Name ________________

Mother’s Medical Record No. ____________________

NEWBORN INFORMATION

48. NEWBORN MEDICAL RECORD NUMBER

54. ABNORMAL CONDITIONS OF THE NEWBORN

55. CONGENITAL ANOMALIES OF THE NEWBORN

 

 

 

(Check all that apply)

□

 

(Check all that apply)

49. BIRTHWEIGHT (grams preferred, specify unit)

□

Assisted ventilation required immediately

Anencephaly

 

 

□

Meningomyelocele/Spina bifida

______________________

 

following delivery

□

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

 

 

□

Karyotype confirmed

52. PLURALITY - Single, Twin, Triplet, etc.

□ Significant birth injury (skeletal fracture(s), peripheral

□

□

Karyotype pending

 

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:______________________________________________________

 

 

 

 

□ Yes □ No

 

 

 

 

 

 

 

 

 

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.

Common mistakes

Filling out the CDC U.S. Standard Certificate of Live Birth form is a crucial step in documenting a newborn's arrival. However, many people make common mistakes that can lead to delays or complications. One frequent error is providing inaccurate personal information. Parents may overlook details such as the correct spelling of names or the precise date of birth, which can cause issues later when obtaining official documents.

Another common mistake is failing to include all required signatures. The form typically requires signatures from both parents. Omitting one can result in the form being rejected. It's essential to double-check that all necessary parties have signed before submission.

Some individuals mistakenly think that the order of information doesn’t matter. However, the form has a specific structure that must be followed. Filling out sections out of order can create confusion and lead to processing delays. Always adhere to the sequence laid out in the form.

People often forget to provide the mother's maiden name. This information is critical for identification purposes and may be used in various legal contexts. Leaving it blank can complicate future requests for documents or services.

Another mistake is using abbreviations or nicknames. While it may seem harmless to write "Liz" instead of "Elizabeth," official documents require full legal names. Abbreviations can lead to discrepancies that might need correction later.

Inaccurate information about the parents' places of birth is also a common error. Some individuals may not know the exact location or may provide outdated information. It's important to verify these details to ensure accuracy.

Many people overlook the importance of the attending physician's information. This section should be filled out completely, including the name, address, and contact information of the healthcare provider. Incomplete information can hinder the registration process.

Another mistake is not checking for consistency across all sections of the form. For example, if the mother's name is written differently in one area than another, it can raise questions during processing. Consistency is key to avoiding complications.

Some parents may rush through the form, leading to careless errors. Taking the time to read through the instructions and double-check all entries can prevent many issues. A thorough review can save time and frustration in the long run.

Lastly, failing to submit the form within the required timeframe is a significant oversight. Each state has specific deadlines for registering a birth. Missing these deadlines can lead to additional complications, including fines or the inability to obtain a birth certificate. Always be aware of your state's requirements and act promptly.

Dos and Don'ts

Filling out the CDC U.S. Standard Certificate of Live Birth form requires attention to detail. Here are some guidelines to follow and avoid:

  • Do: Use black or blue ink when filling out the form.
  • Do: Print clearly to ensure all information is legible.
  • Do: Provide accurate information regarding the child's name and date of birth.
  • Do: Include the parents' full names as they appear on legal documents.
  • Do: Double-check all entries for spelling and accuracy before submission.
  • Don't: Leave any required fields blank; all sections must be completed.
  • Don't: Use correction fluid or tape on the form; it may invalidate the document.
  • Don't: Provide nicknames or informal names; use legal names only.
  • Don't: Forget to sign and date the form where indicated.

Following these guidelines will help ensure that your form is processed smoothly and efficiently.

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