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Misconceptions

Understanding the CDC U.S. Standard Certificate of Live Birth form can be challenging. Many people hold misconceptions about this important document. Here are nine common misunderstandings:

  1. It is the same as a birth certificate issued by the state. Many believe that the CDC form is the official birth certificate. However, it is a standard form used to collect data that states then use to create the official birth certificate.
  2. All states use the same version of the form. While the CDC provides a standard template, each state may modify the form to meet local laws and requirements. Therefore, variations exist across different states.
  3. Only hospitals can fill out the form. This is not entirely accurate. While hospitals typically complete the form, parents can also provide necessary information, especially if the birth occurs outside a medical facility.
  4. The form is only necessary for legal purposes. Some people think the form is solely for legal documentation. In reality, it also serves public health purposes, helping to track birth statistics and health trends.
  5. Once submitted, the information cannot be changed. This is a misconception. Parents can request corrections to the information on the form if they discover errors after submission.
  6. There is a strict deadline for submitting the form. While timely submission is encouraged, states often allow a grace period for parents to submit the form after the birth of their child.
  7. All information on the form is public. Many assume that all details on the birth certificate are accessible to anyone. However, access to this information is restricted to protect privacy.
  8. The form is only for newborns. Some individuals think the form only applies to infants. However, it can also be used for children adopted or born through surrogacy.
  9. Filling out the form is optional. This is not true. In most states, completing and submitting the birth certificate form is a legal requirement after a child is born.

These misconceptions can lead to confusion and misinformation. Understanding the facts surrounding the CDC U.S. Standard Certificate of Live Birth form is crucial for parents and guardians navigating the birth registration process.

File Details

Fact Name Description
Purpose The CDC U.S. Standard Certificate of Live Birth form is used to officially document the birth of a child in the United States.
Standardization This form is standardized across states to ensure uniformity in birth data collection and reporting.
Data Collection Information collected includes the baby's name, date and place of birth, and details about the parents.
Legal Requirement All states require the completion of this form for legal recognition of a birth.
State-Specific Forms While the CDC form is standardized, each state may have additional requirements governed by state laws.
Filing Deadline Most states require the birth certificate to be filed within a specific timeframe, often within 30 days of birth.
Access to Records Birth certificates are typically accessible to parents and legal guardians, with certain restrictions on public access.

Key takeaways

When filling out and using the CDC U.S. Standard Certificate of Live Birth form, consider these key takeaways:

  1. Accuracy is essential. Ensure all information is correct to avoid complications in obtaining a birth certificate.
  2. Use clear handwriting. If filling out the form by hand, print legibly to ensure that all details are easily readable.
  3. Provide complete information. Fill in all required fields, including details about the parents, to prevent delays in processing.
  4. Check for specific state requirements. Some states may have additional information or documentation needed, so verify local guidelines.
  5. Submit promptly. File the completed form as soon as possible after the birth to ensure timely issuance of the birth certificate.
  6. Keep a copy. Retain a copy of the completed form for your records before submitting it to the appropriate office.
  7. Understand the purpose. The birth certificate serves as an official record and is often required for identification, school enrollment, and other legal purposes.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Live Birth form, it is important to ensure accuracy and completeness. Here are some guidelines to help you through the process:

  • Do read the instructions carefully before starting.
  • Do use black or blue ink for clarity.
  • Do provide all required information, including the full names of both parents.
  • Do double-check all entries for spelling and accuracy.
  • Don't leave any required fields blank.
  • Don't use correction fluid or tape on the form.
  • Don't sign the form until all information is complete.
  • Don't submit the form without a witness if required.
  • Don't forget to keep a copy for your records.

Following these guidelines will help ensure that the form is processed smoothly. If you have questions, consider reaching out to your local vital records office for assistance.

Common mistakes

  1. Failing to provide accurate parental information. This includes names, addresses, and dates of birth. Inaccuracies can lead to delays in processing.

  2. Not including the time of birth. This detail is crucial for the official record and can sometimes be overlooked.

  3. Leaving out the place of birth. The specific location, including the hospital or facility name, is necessary for the certificate.

  4. Using incorrect spelling for names. Names should be spelled correctly to avoid issues in identification and legal matters.

  5. Not signing the form. Both parents must provide their signatures; otherwise, the application will be incomplete.

  6. Forgetting to include the mother's maiden name. This detail helps establish lineage and is a required piece of information.

  7. Using illegible handwriting. Clear and readable handwriting is essential to ensure that all information is correctly interpreted.

  8. Neglecting to check for additional requirements specific to their state. Some states may have unique documentation needs.

  9. Not providing contact information for follow-up. Including a phone number or email can help resolve any questions that may arise.

  10. Submitting the form without double-checking for errors. A thorough review can prevent minor mistakes from causing significant delays.

What You Should Know About This Form

  1. 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. This form captures essential information about the newborn, including the child's name, date of birth, place of birth, and details about the parents.

  2. Who needs to complete the birth certificate form?

    The birth certificate form should be completed by the parents or guardians of the newborn. In some cases, hospital staff may assist in filling out the form. It's important to ensure that all information is accurate and complete to avoid issues later.

  3. How do I obtain a copy of the birth certificate?

    To obtain a copy of the birth certificate, you must contact the vital records office in the state where the birth occurred. Each state has its own process, which may include submitting a request form, providing identification, and paying a fee.

  4. What information is required on the form?

    The form requires various details, including:

    • Child's full name
    • Date and time of birth
    • Place of birth (hospital or home address)
    • Parents' names and addresses
    • Parents' dates of birth
    • Parents' places of birth
  5. Can the information on the birth certificate be changed later?

    Yes, certain information on the birth certificate can be amended after it is filed. Common changes include correcting spelling errors or updating parental information. Each state has specific procedures for making these changes, often requiring documentation to support the request.

  6. How long does it take to receive the birth certificate?

    The time it takes to receive a birth certificate can vary by state and the method of request. Typically, it can take anywhere from a few days to several weeks. Expedited services may be available for an additional fee.

  7. Is the birth certificate necessary for other legal processes?

    Yes, a birth certificate is often required for various legal processes. It may be needed for obtaining a Social Security number, enrolling in school, applying for a passport, or proving identity. Keeping a copy on hand is advisable.

  8. What should I do if I lose the birth certificate?

    If the birth certificate is lost, you can request a replacement from the vital records office in the state where the birth occurred. You will need to provide identification and may need to fill out a request form. There may also be a fee for the replacement certificate.

CDC U.S. Standard Certificate of Live Birth Example

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.

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