"Certificate of Live Birth Worksheet" - Indiana

Certificate of Live Birth Worksheet is a legal document that was released by the Indiana State Department of Health - a government authority operating within Indiana.

Form Details:

  • Released on January 27, 2017;
  • The latest edition currently provided by the Indiana State Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Indiana State Department of Health.

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Download "Certificate of Live Birth Worksheet" - Indiana

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Mother’s Name_______________________________________
Mother’s Medical Record #_____________________________
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
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
TYPE OF BIRTH - - - - PICK ONE:
PICK ONE:
TYPE OF BIRTH
TYPE OF BIRTH
PICK ONE:
PICK ONE:
Born at Facility
Born En-Route to Facility
Born at Non Participating Facility
Born En-Route to Non Participating Facility
Home Birth
Foundling
1 1 1 1 . Facility name:*
Facility name:* ____________________________________________________________________
Facility name:*
Facility name:*
(If not institution, give street and number)
2 2 2 2 . City, Town or Location of birth:
City, Town or Location of birth:
City, Town or Location of birth: ______________________________________________________
City, Town or Location of birth:
3 3 3 3 . County of birth:
County of birth:
County of birth: ____________________________________________________________________
County of birth:
4 4 4 4 . P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
Hospital
Freestanding birthing center ( freestanding birthing center is one that has no direct
physical connection to a hospital)
Home birth
Planned to deliver at home?
Yes
No
Clinic/Doctor’s Office
Other (specify, e.g., taxi cab, train, plane __________________________
*Facilities may wish to have pre-set responses (hard-copy and/or electronic) to questions 1-5 for births which occur at their institutions.
5 5 5 5 . Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
AM
AM
AM
AM
PM
PM
PM
PM
NOON
NOON
NOON
NOON
MIDNIGHT
MIDNIGHT
MIDNIGHT
MIDNIGHT
6 6 6 6 . Date of birth:
Date of birth:
Date of birth: ___ ___/___ ___/___ ___ ___ ___
Date of birth:
M M D D Y Y Y Y
7 7 7 7 . Plurality
. Plurality
. Plurality
. Plurality
(Specify SINGLE, TWIN, TRIPLET, QUADRUPLET, QUINTUPLET, SEXTUPLET, SEPTUPLET, or
OCTUPLET for 8 or more. (Include all live births and fetal losses resulting from this pregnancy.):______________
8 8 8 8 . If not
. If not single birth
single birth
. If not
. If not
single birth
single birth
(Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live
births and fetal losses resulting from this pregnancy): ________________________
9. 9. 9. 9. If not single birth, specify number of infants in this
If not single birth, specify number of infants in this delivery born alive:
delivery born alive:_________
If not single birth, specify number of infants in this
If not single birth, specify number of infants in this
delivery born alive:
delivery born alive:
10. Sex (Male, Female, or Not yet determined): __________________________________
1/27/2017
PAGE 1
VERSION 29 INDIANA'S BIRTH WORKSHEET
Mother’s Name_______________________________________
Mother’s Medical Record #_____________________________
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
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
TYPE OF BIRTH - - - - PICK ONE:
PICK ONE:
TYPE OF BIRTH
TYPE OF BIRTH
PICK ONE:
PICK ONE:
Born at Facility
Born En-Route to Facility
Born at Non Participating Facility
Born En-Route to Non Participating Facility
Home Birth
Foundling
1 1 1 1 . Facility name:*
Facility name:* ____________________________________________________________________
Facility name:*
Facility name:*
(If not institution, give street and number)
2 2 2 2 . City, Town or Location of birth:
City, Town or Location of birth:
City, Town or Location of birth: ______________________________________________________
City, Town or Location of birth:
3 3 3 3 . County of birth:
County of birth:
County of birth: ____________________________________________________________________
County of birth:
4 4 4 4 . P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
Hospital
Freestanding birthing center ( freestanding birthing center is one that has no direct
physical connection to a hospital)
Home birth
Planned to deliver at home?
Yes
No
Clinic/Doctor’s Office
Other (specify, e.g., taxi cab, train, plane __________________________
*Facilities may wish to have pre-set responses (hard-copy and/or electronic) to questions 1-5 for births which occur at their institutions.
5 5 5 5 . Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
AM
AM
AM
AM
PM
PM
PM
PM
NOON
NOON
NOON
NOON
MIDNIGHT
MIDNIGHT
MIDNIGHT
MIDNIGHT
6 6 6 6 . Date of birth:
Date of birth:
Date of birth: ___ ___/___ ___/___ ___ ___ ___
Date of birth:
M M D D Y Y Y Y
7 7 7 7 . Plurality
. Plurality
. Plurality
. Plurality
(Specify SINGLE, TWIN, TRIPLET, QUADRUPLET, QUINTUPLET, SEXTUPLET, SEPTUPLET, or
OCTUPLET for 8 or more. (Include all live births and fetal losses resulting from this pregnancy.):______________
8 8 8 8 . If not
. If not single birth
single birth
. If not
. If not
single birth
single birth
(Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live
births and fetal losses resulting from this pregnancy): ________________________
9. 9. 9. 9. If not single birth, specify number of infants in this
If not single birth, specify number of infants in this delivery born alive:
delivery born alive:_________
If not single birth, specify number of infants in this
If not single birth, specify number of infants in this
delivery born alive:
delivery born alive:
10. Sex (Male, Female, or Not yet determined): __________________________________
1/27/2017
PAGE 1
VERSION 29 INDIANA'S BIRTH WORKSHEET
1 1 1 1 1 1 1 1 . What will be your
. What will be your BABY
BABY’ ’ ’ ’ S S S S legal name (as it should appear on the birth certificate)?
legal name (as it should appear on the birth certificate)?
. What will be your
. What will be your
BABY
BABY
legal name (as it should appear on the birth certificate)?
legal name (as it should appear on the birth certificate)?
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
First
Middle
Last
Suffix (Jr., III, etc.)
1 1 1 1 2 2 2 2 . MOTHER: What is your current legal name?
. MOTHER: What is your current legal name?
. MOTHER: What is your current legal name?
. MOTHER: What is your current legal name?
_______________________ _________________ _______________________ ____________
First
Middle
Last
Suffix (Jr., III, etc.)
1 1 1 1 3 3 3 3 . . . . MOTHER: Where do you usually live
MOTHER: Where do you usually live
MOTHER: Where do you usually live-- -- -- --that is
MOTHER: Where do you usually live
that is
that is-- -- -- --where is your household/residence located?
that is
where is your household/residence located?
where is your household/residence located?
where is your household/residence located?
Building number: ______________________ Pre-directional ___________________________________
Name of street _______________________________________________________________________
Street Designator, eg Street, Avenue, etc. _______________________________
Post Directional __________________________________ Apartment Number _____________
State: _______________________(or U.S. Territory, Canadian Province)
If not United States, Country ________________________________________
City, Town, or Location:_______________________________ County: _______________________ Zip: _______________
1 1 1 1 4 4 4 4 . Is
. Is
. Is this household inside city limits (inside the incorporated limits of the city, town or location
. Is
this household inside city limits (inside the incorporated limits of the city, town or location
this household inside city limits (inside the incorporated limits of the city, town or location
this household inside city limits (inside the incorporated limits of the city, town or location
where you
where you
where you
where you live)?
live)?
live)?
live)?
Yes
No
Don’t know
Same as residence [Go to next question]
1 1 1 1 5 5 5 5 . M O T H E R :
. M O T H E R :
. M O T H E R :
. M O T H E R :
W h a t i s y o u r m a i l i n g a d d r e s s ?
W h a t i s y o u r m a i l i n g a d d r e s s ?
W h a t i s y o u r m a i l i n g a d d r e s s ?
W h a t i s y o u r m a i l i n g a d d r e s s ?
Building number: ______________________ Pre-directional ___________________________________
Name of street _______________________________________________________________________
Street Designator, eg Street, Avenue, etc. _______________________________
Post Directional __________________________________ Apartment Number _____________
State: _______________________(or U.S. Territory, Canadian Province)
If not United States, Country ________________________________________
City, Town, or Location:_______________________________ County: _______________________ Zip: _______________
1 1 1 1 6 6 6 6 . MOTHER: What is your date of birth? (Example: 03
. MOTHER: What is your date of birth? (Example: 03- - - - 04
04- - - - 1977)
1977)
. MOTHER: What is your date of birth? (Example: 03
. MOTHER: What is your date of birth? (Example: 03
04
04
1977)
1977)
___ ___/___ ___/___ ___ ___ ___
M M D D Y Y Y Y
AGE: ________________
1 1 1 1 7 7 7 7 . MOTHER: In
. MOTHER: In what State, U.S. territory, or foreign country were you born?
what State, U.S. territory, or foreign country were you born? Please specify one
Please specify one
. MOTHER: In
. MOTHER: In
what State, U.S. territory, or foreign country were you born?
what State, U.S. territory, or foreign country were you born?
Please specify one
Please specify one
of the following:
of the following:
of the following:
of the following:
State ___________________________________County ____________________________ City ___________________________
OR U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Northern Marianas
___________________________ OR Foreign country ___________________________________________
MOTHER: If you were born in the U.S. please answer the next two questions as well.
In What County were you born? ___________________________________________
In What City were you born? ______________________________________________
UNKNOWN
1 1 1 1 8 8 8 8 . MOTHER: What is your Social Security Number?
. MOTHER: What is your Social Security Number?
. MOTHER: What is your Social Security Number?
. MOTHER: What is your Social Security Number?
__ __ __ ___ _ _ _ __ __ __ ___ _ _ _ ____
____
____
______ __ __ __ ____
____
____
______ __ __ __-- -- -- --- - - - _ _ _ _ ____
____
_____ _
____
_ _
_ _
_ _____
____
____
_____ _ _ _ -- -- -- --- - - - _ _ _ _ ____
____
____
_____ _ _ _ ____
____
______ _
____
__ _
__ _
__ _____
____
_____ _
____
_ _
_ _
_ _____
____
____
_____ _ _ _
1 1 1 1 9 9 9 9 . Do you want a Social Security Number issued for your baby?
. Do you want a Social Security Number issued for your baby?
. Do you want a Social Security Number issued for your baby?
. Do you want a Social Security Number issued for your baby?
1/27/2017
PAGE 2
VERSION 29 INDIANA'S BIRTH WORKSHEET
Yes (Please sign request below)
No (Continue)
I r e q u e s t t h a t t h e S o c i a l S e c u r i t y A d m i n i s t r a t i o n a s s i g n a S o c i a l S e c u r i t y n u m b e r t o t h e c h i l d n a m e d o n t h i s f o r m a n d a u t h o r i z e t h e S t a t e t o p r o v i d e
t h e S o c i a l S e c u r i t y A d m i n i s t r a t i o n w i t h t h e i n f o r m a t i o n f r o m t h i s f o r m w h i c h i s n e e d e d t o a s s i g n a n u m b e r . ( E i t h e r p a r e n t , o r t h e l e g a l g u a r d i a n , m a y
s i g n . )
Signature of infant’s mother or father_____________________________________________________
Date: ___ ___/___ ___/___ ___ ___ ___
M M D D Y Y Y Y
20
20
20
20. Will infant be placed for Adoption?
. Will infant be placed for Adoption?
. Will infant be placed for Adoption?
. Will infant be placed for Adoption?
Yes
No
2 2 2 2 1 1 1 1 . . . . MOTHER:
MOTHER: What is the highest level of schooling that you will have completed at the time of
What is the highest level of schooling that you will have completed at the time of
MOTHER:
MOTHER:
What is the highest level of schooling that you will have completed at the time of
What is the highest level of schooling that you will have completed at the time of
delivery? (Check the box that
delivery? (Check the box that
delivery? (Check the box that
delivery? (Check the box that best describes your education. If you are currently enrolled, check
best describes your education. If you are currently enrolled, check
best describes your education. If you are currently enrolled, check
best describes your education. If you are currently enrolled, check
the box that indicates the previous grade or highest degree received).
the box that indicates the previous grade or highest degree received).
the box that indicates the previous grade or highest degree received).
the box that indicates the previous grade or highest degree received).
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit but no degree
Associate degree (e.g. AA, AS)
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: What is your usual occupation or industry in which you work? Please fill in below. For
example your occupation is Teacher, CPA, Waitress, Clerk, etc., and the industry in which you work is
Department Store, Law Firm, Hospital, Factory, etc.
Usual Occupation: _____________________________________________________________________
Usual Industry: ________________________________________________________________________
Unemployed
Unknown
2 2 2 2 3 3 3 3 . . . . MOTHER:
MOTHER:
MOTHER: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina,
MOTHER:
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina,
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina,
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
check the “No”
check the “No”
check the “No”
box. If
box. If Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check the appropriate box
the appropriate box. . . .
box. If
box. If
Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check
the appropriate box
the appropriate box
No, not Spanish/Hispanic/Latina
Yes, Mexican, Mexican American, Chicana
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latina (e.g. Spaniard, Salvadoran, Dominican, Columbian)
(specify)____________________________________
2 2 2 2 4 4 4 4 . . . . MOTHER:
MOTHER:
MOTHER: What is your race? (Please check
MOTHER:
What is your race? (Please check
What is your race? (Please check
What is your race? (Please check all that apply
all that apply
all that apply). ). ). ).
all that apply
White
Black or African American
American Indian or Alaska Native (name of enrolled or principal tribe(s))
____________________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (specify)______________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (specify)______________________________
Other (specify) ___________________________________________
MOTHER:
MOTHER: Additional Information To Be Filled In
Additional Information To Be Filled In If If If If A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
MOTHER:
MOTHER:
Additional Information To Be Filled In
Additional Information To Be Filled In
A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
FOR THIS BIRTH
FOR THIS BIRTH
FOR THIS BIRTH
FOR THIS BIRTH If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question 30
30
30. . . .
30
2 2 2 2 5. What is Your Phone Number? Required ________________________________________________
5. What is Your Phone Number? Required ________________________________________________
5. What is Your Phone Number? Required ________________________________________________
5. What is Your Phone Number? Required ________________________________________________
2 2 2 2 6 6 6 6 . What is
. What is
. What is the name of your
. What is
the name of your
the name of your
the name of your Employer
Employer
Employer
Employer (Company name)
(Company name)
(Company name)
(Company name)? ? ? ? Optional
Optional
Optional
Optional
_________________________________________________________________________________________
1/27/2017
PAGE 3
VERSION 29 INDIANA'S BIRTH WORKSHEET
2 2 2 2 7. 7. 7. 7. What is
What is your
your Employer's address
Employer's address? ? ? ? Optional
Optional
What is
What is
your
your
Employer's address
Employer's address
Optional
Optional
_________________________________________________________________________________________________
2 2 2 2 8. 8. 8. 8. What is
What is the name of your
the name of your Medical Insurance Company
Medical Insurance Company? ? ? ? Optional
Optional
What is
What is
the name of your
the name of your
Medical Insurance Company
Medical Insurance Company
Optional
Optional
_________________________________________________________________________________________________
2 2 2 2 9. 9. 9. 9. What is
What is your Medical Insurance Policy number?
your Medical Insurance Policy number? Optional
Optional
What is
What is
your Medical Insurance Policy number?
your Medical Insurance Policy number?
Optional
Optional
__________________________________________________________________________________________
30
30. . . . MOTHER:
MOTHER: Did you receive WIC (Women, Infants & Children)
Did you receive WIC (Women, Infants & Children) food for yourself because you
food for yourself because you
30
30
MOTHER:
MOTHER:
Did you receive WIC (Women, Infants & Children)
Did you receive WIC (Women, Infants & Children)
food for yourself because you
food for yourself because you
were pregnant with this child?
were pregnant with this child?
were pregnant with this child?
were pregnant with this child?
Yes
No
Unknown
31
31
31
31. . . . MOTHER:
MOTHER:
MOTHER:
MOTHER: What is your height?
What is your height?
What is your height?
What is your height?
________feet _______ inches
3 3 3 3 2 2 2 2 . . . . MOTHER:
MOTHER: What was your pre
What was your pre- - - - pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you
MOTHER:
MOTHER:
What was your pre
What was your pre
pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you
became pregnan
became pregnant with this child?
t with this child? __________lbs.
became pregnan
became pregnan
t with this child?
t with this child?
3 3 3 3 3 3 3 3 . Mother’s weight at delivery
. Mother’s weight at delivery
. Mother’s weight at delivery
. Mother’s weight at delivery
__________lbs.
3 3 3 3 4 4 4 4 . . . . CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGNA A A A NCY
NCY
NCY
NCY: : : : How many cigarettes OR
How many cigarettes OR
How many cigarettes OR
How many cigarettes OR
following time periods?
following time periods?
following time periods?
following time periods?
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
If If If If you NEVER smoked, enter zero for each time period.
you NEVER smoked, enter zero for each time period.
you NEVER smoked, enter zero for each time period.
you NEVER smoked, enter zero for each time period.
# o f c i g a r e t t e s
# o f c i g a r e t t e s
# o f c i g a r e t t e s
# o f c i g a r e t t e s
# o f p a c k s
# o f p a c k s
# o f p a c k s
# o f p a c k s
Three months before pregnancy
__________
OR ____________
First three months of pregnancy
__________
OR ____________
Second three months of pregnancy __________
OR ____________
Last three months of pregnancy
__________
OR ____________
35. CURRENT MARITAL STATUS
Never Married
Widowed
Divorced
Currently Married
Married, but refusing Father’s Information
Unknown
36. Mother's name prior to her first
Mother's name prior to her first marriage, (Maiden Name)
marriage, (Maiden Name)
Mother's name prior to her first
Mother's name prior to her first
marriage, (Maiden Name)
marriage, (Maiden Name)
_________________________________________________________________________________
First
Middle
Last
Suffix
37. MOTHER'S Marital Status, ARE YOU MARRIED TO THE FATHER OF YOUR CHILD?
[Please go to question 39
Y e s
[Please go to question 38
N o
38. If not married, has a Paternity Affidavit been completed for this child?
Yes, a paternity affidavit has been completed
I f Y e s D a t e A f f i d a v i t w a s s i g n e d : _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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No, a paternity affidavit has not been completed
I f I f I f I f N o
N o p l e a s e g o t o q u e s t i o n
p l e a s e g o t o q u e s t i o n 5 3
5 3
N o
N o
p l e a s e g o t o q u e s t i o n
p l e a s e g o t o q u e s t i o n
5 3
5 3
3 3 3 3 9 9 9 9 . . . . FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
_______________________ _________________ _______________________ ______________
First
Middle
Last
Suffix(Jr., III, etc.)
40
40
40
40. . . . FATHER: What is
FATHER: What is
FATHER: What is the father's
FATHER: What is
the father's
the father's
the father's date of birth? (Example: 03
date of birth? (Example: 03
date of birth? (Example: 03- - - - 04
date of birth? (Example: 03
04
04
04- - - - 1977)
1977)
1977)
1977)
___ ___/___ ___/___ ___ ___ ___ M M D D Y Y Y Y
AGE: ________________
4 4 4 4 1 1 1 1 . FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born? Please specify one of
Please specify one of
. FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born?
Please specify one of
Please specify one of
the following:
the following:
the following:
the following:
State __________________________________ County ____________________________ City ___________________________
OR U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Northern Marianas
____________________________ OR Foreign country ___________________________________________
FATHER: If the father was born in the U.S. please answer the next two questions as well.
In What County was he born? ___________________________________________
In What City was he born? ______________________________________________
UNKNOWN
4 4 4 4 2 2 2 2 . What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
. 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.
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- - -
- - - _ _ _ _ _ _
- - -
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _
_ _ _ _ _ _ - - -
- - -
- - -
- - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4 4 4 4 3 3 3 3 . What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
. 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
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
box that indicates the pr
box that indicates the pr
box that indicates the pr
box that indicates the previous grade or highest degree received).
evious grade or highest degree received).
evious grade or highest degree received).
evious grade or highest degree received).
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit but no degree
Associate degree (e.g. AA, AS)
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)
44. What is the father's usual occupation or industry. Please fill in below. For example his occupation is
Photographer, Farmer, Nurse, etc., and the industry in which he works is Factory, Skating Rink, Army,
etc.
Usual Occupation: _____________________________________________________________________
Usual Industry: ________________________________________________________________________
Unemployed
Unknown
4 4 4 4 5 5 5 5 . Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
No, not Spanish/Hispanic/Latino
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