VS-109: Texas Birth Worksheet for Child's Birth Certificate

Record Type: Born at this facility, Born en-route to facility, Foundling/ Safe Haven, Home birth-Intended, Home birth-Intent unknown, Home birth-Unintended, Surrogacy-1 Parent or Surrogacy-2 Parent.

Enter Plurality and Birth Order.

Is Child Unnamed? Yes or No. Enter First Name, Middle Name, Last Name and Suffix.

Enter Date of Birth, Time of Birth (AM or PM), Sex (Female, Male or Unknown/ Not yet Determined) and Infant's Medical Record Number.

Parents Authorize Release of Information to Social Security Administration to Issue this Child a SSN: Yes, No or Unknown.

Mother's Information, Title Preference: Mother, Father or Parent. Enter Legal First Name, Legal Middle Name, Legal Last Name, Legal Suffix and Medical Record Number.

Mother's Name Prior to First Marriage: Same as Mother's Legal Name?

Facility Information & Place of Birth: Facility Name or Other Facility Name, Type and Address.

Mother's Miscellaneous Information, Education Level: 8th Grade or Less, 9th-12th Grade No Diploma, Doctorate or Professional Degree, Unknown/Not stated or the other Education Levels.

Enter Occupation, Kind of Business or Industry and Email.

Mother's Residence Address Information: Withheld by Request on AOP. Address, Apt, County, City/Town, Zip and Inside City Limits (Yes, No or Unknown).

Mother's Mailing Address Information: Same as Residence?

Father's Legal Name: Title Preference (Mother, Father or Parent), First Name, Middle Name, Last Name and Suffix. Father's Maiden Name: Same as Father's Legal Name?

Father's Miscellaneous Information, Education Level: 8th Grade or Less, 9th-12th Grade No Diploma, Unknown/Not stated or the other Education Levels.

Enter Occupation and Kind of Business or Industry.

Father's Mailing Address Information: Withheld by Request on AOP. Same as Mother's Mailing?, or Address.

Father Demographics, Father's Ethnicity: No, Not Spanish/Hispanic/Latino, Yes (Mexican, Puerto Rican or Other Hispanic (Specify)), Unknown or Refused. Father's Race: White, Black or African-American, American Indian or Alaska Native, Unknown or Refused, or the other race boxes the form prints.

The Presumed Father tab displays when AOP = yes on Mother's Tab and marital status = yes: Presumed Father's Legal Name, First Name, Middle Name, Last Name and Suffix.

Presumed Father's Information: Date of Birth and SSN.

Presumed Father's Mailing Address Information: Withheld by Request on AOP. Same as Mother's Mailing?, or Address.

Intended Father's Legal Name: Title Preference, First Name, Middle Name, Last Name and Suffix. Father's Maiden Name: Same as Intended Father's Legal Name? Yes or No. Intended Father's Information: Date of Birth, Age, Birthplace (Click Checkbox to Filter Foreign Countries Only) and SSN.

Mother Medical - 1 General: Mother Transferred for Delivery? Yes or No. If Yes, from What Location.

Principal Source of Payment: Private Insurance, Medicaid/Chip (Pending or Not), Self Pay, Other Government or Other (Specify).

Did Mother Get WIC Food for Herself during This Pregnancy? Yes or No. Mother's Medicaid Chip Name and Mother's Medicaid Chip Number.

Newborn Medical - 1 General: Is Infant Living at Time of Report? Yes, No or Infant Transferred, Status Unknown. Is Infant Being Breast Fed, Even Partially? Yes or No. Obstetric Estimate of Gestation (completed weeks). Apgar Score (at 5 min. and at 10 min.): 1 - 10, Not Taken or Unknown.

Was Infant Transferred within 24 Hours of Delivery? Yes or No. If YES Where. Was Infant Vaccinated with Hepatitis B Vaccine? Yes, No, Unknown or Information Unavailable. Enter Infant Primary Care Physician and the Child's Weight Information.

Immtrac Consent: Please Indicate the Parent's Choice Regarding Consent for Immtrac Participation. The Birth Registrar Will be Required to Affirm that this Information Accurately Reflects the Parent's Choice.

If the Parent Has Not Yet Been Offered the Option to Consent for Immtrac Participation, You May Skip this Section and Answer at a Later Time.

This Section Must Be Completed for Legal Release of the Birth Registration. Parent Has GRANTED CONSENT or DENIED CONSENT for Immtrac Participation by Signing DSHS Immtrac Newborn Registration Form # (Immtrac NB-2) and Marking the Option. Parent Has Not Signed a Properly Completed DSHS Immtrac Newborn Registration Form # (Immtrac NB-2).

Certifier Information: Certifier Same as Attendant? First Name, Middle Name, Last Name, Title, Address and Date Certified.

Ensure the information you report in TxEVER is correct so that an accurate birth certificate is created.