The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the details of a newborn's birth in the United States. This form captures essential information, including the baby's name, date of birth, and parents' details, serving as a vital record for legal and administrative purposes. To ensure accurate documentation, it is important to fill out the form correctly; click the button below to get started.
Da 31 Download - Chargeable leave is tracked for accounting against available leave balances.
Dd 214 - It must not be altered, as changes may void its validity.
Understanding the CDC U.S. Standard Certificate of Live Birth form is essential for accurate record-keeping. Here are some key takeaways:
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.
The CDC U.S. Standard Certificate of Live Birth form serves as a primary record of a person's birth in the United States. Similar to this document, the hospital birth record is created at the time of birth. This document includes essential information such as the baby's name, date of birth, and the names of the parents. Hospitals typically provide a copy to the parents shortly after the birth, making it a vital record for obtaining official documents later in life.
Another document that bears similarities is the Certificate of Live Birth issued by state vital records offices. This certificate is an official state document that confirms the birth of an individual. It often contains similar details to the CDC form, such as the child's name, birth date, and parent information. While the format may vary by state, the purpose remains consistent: to provide legal proof of birth.
The birth announcement, often published in local newspapers, shares characteristics with the CDC form. While it is not an official document, it includes significant details about the birth, such as the baby's name, birth date, and sometimes even the weight and length of the newborn. This announcement serves as a public record and a way for families to celebrate and share their joy with the community.
The Social Security card application is another document that parallels the CDC birth certificate. When parents apply for a Social Security number for their child, they must provide proof of birth, typically using the birth certificate. This application process highlights the importance of the birth certificate in establishing identity and access to government services.
The passport application form also shares similarities with the CDC birth certificate. When applying for a passport, individuals must provide proof of citizenship, and a certified copy of the birth certificate often suffices. This requirement underscores the birth certificate's role as a foundational document for identity verification in various legal contexts.
The adoption certificate is another relevant document. For adopted children, this certificate serves as the legal record of their birth and adoption. It includes similar information, such as the child's name and birth date, but also reflects the legal change in guardianship. This document is crucial for adopted individuals to establish their identity and legal history.
The death certificate, although it marks the end of life, is similar in that it serves as an official record. It contains essential information such as the deceased's name, date of birth, and date of death. Just as the birth certificate is crucial for establishing identity at the beginning of life, the death certificate serves to formally recognize the conclusion of an individual's life.
Finally, the marriage certificate can be considered similar in its function as a legal document. While it does not pertain directly to birth, it often requires proof of identity and sometimes birth information for both parties. This certificate serves to document the legal union between two individuals, much like how the birth certificate documents the beginning of a person’s life.
Completing the CDC U.S. Standard Certificate of Live Birth form is essential for officially documenting the birth of a child. This process ensures that all necessary information is accurately recorded. Follow these steps carefully to fill out the form correctly.
The CDC U.S. Standard Certificate of Live Birth is a crucial document that establishes the legal identity of a newborn. However, several other forms and documents are often used in conjunction with this certificate to provide additional information or fulfill various legal requirements. Below is a list of these documents, each serving its unique purpose.
Understanding these documents and their purposes can help new parents navigate the often complex landscape of legal and administrative requirements following the birth of their child. Being prepared with the right forms ensures a smoother transition into parenthood and protects the rights and well-being of the child.
Incorrect Parent Information: Parents sometimes provide inaccurate names, dates of birth, or places of birth. This can lead to complications when obtaining a birth certificate.
Missing Signatures: Both parents must sign the form. Failing to do so can delay the processing of the birth certificate.
Wrong Birth Date: Entering the incorrect date of birth for the child can result in significant legal issues down the line.
Inaccurate Medical Information: Parents may neglect to provide complete information about the delivery, including the type of birth (e.g., vaginal or cesarean) and any complications.
Omitting the Child’s Gender: Not specifying the gender of the child can lead to confusion and additional steps to correct the record.
Errors in Address: Providing an incorrect address for the parents can complicate future correspondence regarding the birth certificate.
Using Nicknames: Parents sometimes use nicknames instead of legal names for the child, which can create discrepancies in official records.
Failure to Check for Updates: Not reviewing the form for any changes or updates before submission can lead to mistakes that could have been easily corrected.
Not Following Submission Guidelines: Each state may have specific submission requirements. Ignoring these can delay the issuance of the birth certificate.
When filling out the CDC U.S. Standard Certificate of Live Birth form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are some important dos and don’ts to keep in mind: