The California Birth Certificate Editable Free form is a document designed to gather essential information needed to create your child’s birth certificate. This certificate serves as a vital record that proves your child's age, citizenship, and parentage, and it will be used throughout their life. Ensuring accuracy in the information provided is crucial, as it not only fulfills legal requirements but also aids health researchers in improving maternal and infant health.
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The California Birth Certificate Editable Free form is an essential tool for parents as they navigate the process of registering their newborn. This form serves as the foundation for creating a legal birth certificate, which is crucial for establishing a child's age, citizenship, and parentage. Parents must provide accurate and complete information, as this document will be referenced throughout the child's life for various legal and administrative purposes. The form includes sections for details such as the place and time of birth, the legal names of the parents, and their educational backgrounds. Additionally, it gathers health-related information that may contribute to research aimed at improving maternal and infant health. Importantly, the form emphasizes the confidentiality of the information provided, ensuring that sensitive details are protected from unauthorized access. Parents will also find inquiries about the issuance of a Social Security number for their child and other optional data, which can aid in future administrative processes. By filling out this form accurately, parents play a vital role in securing their child's identity and rights from the very beginning.
CERTIFICATE OF LIVE BIRTH WORKSHEET
The information you provide below will be used to create your child’s birth certificate. The birth certificate is a document that will be used for legal purposes to prove your child’s age, citizenship and parentage. This document will be used by your child throughout his/her life. State laws provide protection against the unauthorized release of identifying information from the birth certificates to ensure the confidentiality of the parents and their child.
It is very important that you provide complete and accurate information to all of the questions. In addition to information used for legal purposes, other information from the birth certificate is used by health and medical researchers to study and improve the health of mothers and newborn infants. Items such as parent’s education, race, and smoking will be used for studies but will not appear on copies of the birth certificate issued to you or your child.
TYPE OF BIRTH - PICK ONE:
1Facility name:*
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2City, Town or Location of birth:
3County of birth:
4. Placeof birth:
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*Facilities may wish to have pre-set responses (hard-copy and/or electronic) to questions 1-5 for births which occur at their institutions.
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9. If not single birth, specify number of infants in this delivery born alive:
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PAGE 1
VERSION 29 INDIANA'S BIRTH WORKSHEET
11. What will be your BABY’S legal name (as it should appear on the birth certificate)?
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12. MOTHER: What is your current legal name?
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13. MOTHER: Where do you usually live--that is--where is your household/residence located?
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14. Is this household inside city limits (inside the incorporated limits of the city, town or location
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15"4. MOTHER:What is your mailing address?
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What is your date of birth? (Example: 03-04-1977)
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17. MOTHER: In what State, U.S. territory, or foreign country were you born? Please specify one
of the following:
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18. MOTHER: What is your Social Security Number?
______ ______ ______---______ ______---______ ______ ______ ______
19. Do you want a Social Security Number issued for your baby?
PAGE 2
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20. Will infant be placed fo Adoption?
21.MOTHER: What is the highest level of schooling that you will have completed at the time of delivery? (Check the box that best describes your education. If you are cu rently enrolled, check
the box that indicates the previous grade or highest degree received).
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23. MOTHER: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
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24. MOTHER: What is your race? (Please check all that apply).
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MOTHER: Additional Information To Be Filled In If A PATERNITY AFFIDAVIT IS TO BE FILED FOR THIS BIRTH If Not Filing Paternity Affidavit skip to question 30.
25.What is Your Phone Number? Required ________________________________________________
26.What is the name of your Employer (Company name)? Optional
PAGE 3
27. What is your Employer's address? Optional
28. What is the name of your Medical Insurance Company? Optional
29. What is your Medical Insurance Policy number? Optional
30. MOTHER: Did you receive WIC (Women, Infants & Children) food for yourself because you were pregnant with this child?
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31. MOTHER: What is your height?
32. MOTHER: What was your pre-pregnancy weight, that is, your weight immediately before you became pregnant with this child? "
33. Mother’s weight at delivery "
34.CIGARETTE SMOKING BEFORE AND DURING PREGNANCY: How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods?
If you NEVER smoked, enter zero for each time period.
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#of cigarettes
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If Yes Date Affidavit was signed: ____ ____/____ ____/____ ____ ____ ____
PAGE 4
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If No please go to question 53
39. FATHER'S CURRENT LEGAL NAME
40. FATHER: What is the father's date of birth? (Example: 03-04-1977)
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41. FATHER: In what State, U.S. territory, or foreign country was he born? Please specify one of
the following:
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42.What is the father’s Social Security Number? If you are not married, or if a paternity acknowledgment has not been completed, leave this item blank.
43. What is the______highest______level--- of schooling--- that the FATHER will have completed at the time of
delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).
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45. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
Spanish/Hispanic/Latino, check all that apply.
PAGE 5
46. What is the father’s race? Please check one or more races to indicate what he considers himself to be.
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FATHER Additional Information To Be Filled In If A PATERNITY AFFIDAVIT IS TO BE FILED
FOR THIS BIRTH
If Not Filing Paternity Affidavit skip to question 53
47.What is Your Phone Number? Information is required __________________________________
48.What is Your Current AddressNumber, Street, City, State and Zip Information is required
49.What is the name of your Employer (Company name)? Information is optional
50.What is your Employer's address? Information is optional
51. What is the name of your Medical Insurance Company? Information is optional
52. FATHER What is your Medical Insurance Policy Number Information is optional
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56. Source of pre-natal care?
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66. Was a Standard Licensed Diagnostic test for HIV performed for the Mother?
YES
Yes give the date thespecimen was taken:
(MMD YYYY)
If Yes when was the test performed?
During pregnancy
Time of Delivery
NO
If No give reason (checkone below)
Mother's Refusal
HIV Status Know
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Insurance would not pay
Other (specify): _______________________________________________________
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