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 such as the baby's name, date of birth, and parental details. Completing this form is crucial for establishing identity and securing vital records, so make sure to fill it out accurately by clicking the button below.
The CDC U.S. Standard Certificate of Live Birth form serves as a crucial document in the realm of public health and vital statistics. This form captures essential information about a newborn, including details such as the child's name, date and place of birth, and the parents' information. It plays a significant role in establishing the identity of the child and is often required for various legal and administrative purposes, including obtaining a Social Security number and enrolling in school. The form also collects data on the mother's health during pregnancy, the type of delivery, and any complications that may have occurred. By standardizing the information collected across states, the CDC ensures consistency and accuracy in birth records, which are vital for tracking demographic trends and public health initiatives. Understanding the importance and requirements of this form is essential for new parents and healthcare providers alike, as it lays the foundation for the child's legal identity and access to essential services.
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The CDC U.S. Standard Certificate of Live Birth form is an essential document for recording the birth of a child in the United States. Understanding how to fill it out correctly ensures that vital information is accurately captured. Here are some key takeaways about this important form:
Filling out the CDC U.S. Standard Certificate of Live Birth form accurately is a vital step in the birth registration process. Following these guidelines can help ensure that the birth is officially recognized and that parents have access to necessary documentation in the future.
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.