California Birth Certificate Editable Free Form – Fill Out and Use This PDF

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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"#$% 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 Time	___________
AM	PM	NOON MIDNIGHT
6Date of birth: $$			%%&&''''

7.Plurality (()* +, +*+ -./&.*+ -.+.*+ (0+.*+ (+.*+

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8.If not single birth 1! 5 6 7 8 9 : ; #!

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9. If not single birth, specify number of infants in this delivery born alive:

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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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6.	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?
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(@signthI requestSocial.)thatSecuritythe SocialAdministrationSecurity Administratiwith the infonrmassigntionfroma Socialthis formSecuritywhichnumberis neededto thetochildassignnamednumberon this.(Eitherformandparent,authorizethethel galStateguardian,to providemay

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20. Will infant be placed fo Adoption?

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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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Unemployed

Unknown

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

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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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<>(Mother's name prior to her first marriage, (Maiden Name)

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		If Yes Date Affidavit was signed: ____ ____/____ ____/____ ____ ____ ____
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If No please go to question 53

39. FATHER'S CURRENT LEGAL NAME

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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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Unemployed

Unknown

45. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If

Spanish/Hispanic/Latino, check all that apply.

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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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=?(5,Other,2!Specify:

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	Antiretrovirals administered during pregnancy or at delivery
	Group B Strep
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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
			unknown)		Insurance would not pay
Other (specify): _______________________________________________________
	Unknown (Reason why there was no est is

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70.Onset of Labor 2A#4

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71. Characteristics of labor and delivery 2A#4

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83. Attendant’s name, title, and N.P.I

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88.Infant’s medical record number:

89. Newborn Screening Number: _________________________________________

If Unknown check reason why

	Religious Waiver

90. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? + " #

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