Doh 2184E Form – Fill Out and Use This PDF

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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

A child’s birth certificate is a very important document. It is the official record of the child’s full name, date of birth and place of birth. Throughout the child’s lifetime, it provides proof of identity and age. As a child grows from childhood to adulthood, information in the birth certificate will be needed for many important events such as: entrance to school, obtaining a work permit, driver’s license or marriage license, entrance in the Armed Forces, employment, collection of Social Security and retirement benefits, and for a passport to travel in foreign lands.

Because the birth certificate is such an important document, great care must be taken to make certain that it is correct in every detail. By completing this work booklet carefully, you can help assure the accuracy of the child’s birth certificate.

New York State Birth Certificate:

PARENTS, for the birth certificate, you must complete the unshaded portions of this work booklet, see pages 3 - 5, 10 - 12 & 14 (the shaded portions will be completed by hospital staff).

Information that is not labeled “QI”, “IMM” or “NBS” in the work booklet will be used to prepare the official birth certificate. The completed birth certificate is filed with the Local Registrar of Vital Statistics of the municipality where the child was born within five (5) business days after the birth and with the New York State Department of Health. When the filing process is completed, the mother will receive a Certified Copy of the birth certificate. This is an official form that may be used as proof of age, parentage, and identity. Receiving it confirms that the child’s birth certificate is officially registered in the State of New York. Additional copies of the birth certificate may be obtained from the Local Registrar or the New York State Department of Health, P.O. Box 2602, Albany, New York 12220-2602. For further information about obtaining copies, please call (518) 474-3077 or visit the New York State Department of Health web site at: http://www.nyhealth.gov/vital_records/.

All information (including personal/identifying information) is shared with the County Health Departments or other Local Health Units where the child was born and where the mother resides, if different. County Health Departments and Local Health Units may use this data for Public Health Programs. The Social Security Administration receives a minimal set of data ONLY when the parents have indicated, in this work booklet, that they wish to participate in the Social Security Administration’s Enumeration at Birth program.

While individual information is important, public health workers will use medical and demographic data in their efforts to identify, monitor, and reduce maternal and newborn risk factors. This information also provides physicians and medical scientists with the basis to develop new maternal and childcare programs for New York State residents.

Statewide Perinatal Data System (SPDS) – Quality Improvement (QI), Immunization Registry (IMM) and Newborn Screening Program (NBS) Information:

The information labeled “QI” collected in this work booklet will be used by medical providers and scientists to perform data analyses aimed at improving services provided to pregnant women and their babies. Information labeled “IMM” will be used by New York State’s Immunization Information System (NYSIIS). A birthing hospital’s obligation to report immunizations for newborns can be met by recording all the information in SPDS. This includes the manufacturer and lot number as required by law. Information labeled “NBS” will result in significant improvements in the Newborn Screening Program such as better identification and earlier treatment of infants at risk for a variety of disorders.

ATTENTION HOSPITAL STAFF:

This work booklet has been designed to obtain information relating to the pregnancy and birth during the 72-hour period immediately following the birth of a live born child in New York State. Hospital staff, please complete the shaded portions of the work booklet.

New York State Public Health Law provides the basis for the collection of the birth certificate data. For pertinent information about the New York State Public Health Laws refer to sections 206(1)(e), 4102, 4130.5, 4132 and 4135. These laws are also described in the New York State Birth Certificate Guidelines. The Guidelines are available to SPDS users on the Help tab of the SPDS Core Module.

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 1 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 2 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Help for Parents Completing This Work Booklet

Page 4: Last Name on Mother’s Birth Certificate

This is commonly referred to as “maiden name.” If the mother was adopted, it would be the last name on her birth certificate after the adoption.

Page 4: Infant’s Pediatrician/Family Practitioner

Enter the name of the doctor who will care for the infant after he/she is released from the hospital. This may or may not be the same as the doctor who cared for the infant while in the hospital.

Page 11: Last Name on Father’s / Second Parent’s Birth Certificate

Father: This is usually the same as his current last name. In the event that a man has changed his last name through marriage, the name on his birth certificate should be entered here. This may or may not be the same as his current last name depending on whether his name was changed by marriage only or changed through a court proceeding which resulted in an amendment to his birth certificate.

Mother (Second Parent): This is commonly referred to as maiden name and is the name on her birth certificate.

In either case: If the parent was adopted it would be the last name on his or her birth certificate after the adoption.

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 3 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

New Birth Registration

Parents

Mother’s First Name:

Mother’s Middle Name:

Mother’s Current Last Name :

Last Name on Mother’s Birth Certificate:

Mother

Social Security Number:

Mother’s Date of Birth: (MM/DD/YYYY)

–

Infant’s First Name:

Infant’s Middle Name:

Infant’s Last Name:

Infant’s Name Suffix

(e.g. Jr., 2nd, III):

Infant

Sex:

 Male  Female

Plurality:

Birth Order:

Medical Record No.:

 Undetermined

Date of Birth:

TIME OF BIRTH: (HH:MM)

 am  pm  military (24-hour time)

(MM/DD/YYYY)

Was child born in this facility?

 Yes

 No If child was not born in this facility, please answer the following questions:

Infant

In what type of place was the infant born?

If New York State Birthing Center, enter its name:

 Freestanding Birth Center

 Home (unknown intent)

(regulated by DOH)

 Clinic / Doctor’s Office

 Home (intended)

In what county was the child born?

(not regulated by DOH)

 Home (unintended)

 Other

Institution

Birthplace

Site of Birth, If Other Type of Place:

Street Address – if other than Hospital / Birthing Center:

If place of infant’s birth was other than Hospital or Birthing Center:

City, town or village where birth occurred:

Zip / Postal Code:

Infant’s Pediatrician/Family Practitioner:

NBS

Attendant

Attendant’s Information:

License Number:

Name:

First

Middle

Last

Title:

(Select one)

 Medical Doctor  Doctor of Osteopathy

 Licensed Midwife (CNM)

 Licensed Midwife (CM)

 Other

Certifier’s Information:

Check here if the Certifier is the same as the Attendant (otherwise enter information below)

Certifier	License Number:	Name:	First		Middle	Last




	Title: (Select one)
	 Medical Doctor	 Doctor of Osteopathy		 Licensed Midwife (CNM)	 Licensed Midwife (CM)	 Other

		Primary Payor for this Delivery:
		Select one:
Parents	Payor	 Medicaid / Family Health Plus	 Private Insurance		 Indian Health Service
		 CHAMPUS / TRICARE	 Other Government / Child Health Plus B		 Other
		 Self-pay
		 Self-pay

		If Medicaid is not the primary payor, is it a secondary		Is the mother enrolled in an HMO or other managed care
		payor for this delivery?	 Yes  No	plan?	 Yes  No	QI

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 4 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:	First	Middle	Last	Mother’s Med. Rec. Number:

Father / Second Parent Name: First		Middle	Last		Suffix

Infant’s Name:	First	Middle	Last	Suffix	Date of Birth

To the hospital:

1.Obtain the parent(s) signature(s).

2.File the original Release Form in the mother's hospital record. Note: It is not necessary to file the remainder of the Work Booklet.

3.Provide a copy to the parent(s).

4.Do not send copies to the New York State Department of Health or to any Social Security office, unless specifically requested by such agency.

To the parent(s):

1.Please read the following notice about the collection and use of Social Security Numbers on your child's birth certificate.

2.Please check "Yes" or "No" to indicate if you wish to participate in the Social Security Administration’s Enumeration at Birth program.

NOTICE REGARDING COLLECTION OF PARENTS' SOCIAL SECURITY NUMBERS: The collection of parents' Social Security Numbers on the New York State Certificate of Live Birth is mandatory. They are required by Public Health Law Section 4132(1) and may be used for child support enforcement, public health related purposes, when requested by State, federal and municipal governments for official purposes, when required by Public Health Law Section 4173 or 4174, and when otherwise required or authorized by law.

Social Security Release

The Social Security Administration offers the parents of newborns an opportunity to apply for a Social Security Number for their child through the birth certificate registration process. This is referred to by the Social Security Administration as Enumeration at Birth (EAB). If you participate in the EAB, the New York State Department of Health will forward to the Social Security Administration information from your child’s birth certificate. Please note that the Social Security Administration will not process your EAB request unless, the birth certificate includes your child’s full name. If you participate in the EAB, disclosure of parents’ Social Security Numbers is mandated by 42 U.S.C. 405(c)(2). The Social Security Number(s) will be used by the Internal Revenue Service (IRS) solely for the purpose of determining Earned Income Tax Credit compliance. If you wish to participate in the Social Security Administration EAB program check “Yes” below.

May the Social Security Administration be furnished with information from this form to issue your child a social security number?

Yes	
No	
Mother’s Signature 		Date
Father’s or Second
Parent’s Signature 		Date

Either parent's signature applies to the above release.

If neither box is checked for the release, a ‘No’ response will be assumed.

Hospital Name:

Signature of Hospital Representative:



Date:

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 5 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 6 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Infant

	Infant

If Multiple Births:		Birth Weight:
Number of Live Births:	Number of Fetal Deaths:

	grams	lbs.	oz.

If birth weight < 1250 grams (2 lbs. 12 oz.), reason(s) for delivery at a less than level III hospital: (Only if applicable)

 None  Unknown at this time	QI
Select all that apply:	QI
 Rapid / Advanced Labor	 Bleeding		 Fetus at Risk	 Severe pre-eclampsia
 Woman Refused Transfer	 Other (specify)
Infant Transferred:		NYS Hospital Infant Transferred To:			State/Terr./Province:

Within 24 hrs  After 24 hrs.  Not transferred

Birth Information

Apgar			Is the Infant Alive?	Clinical Estimate
Scores	5 minutes:	10 minutes:	 Yes  No	of Gestation:
1 minute:			 Infant Transferred /	(Weeks)
1 minute:			 Infant Transferred /
			Status Unknown

How is infant being fed at discharge? (Select one)

 Breast Milk Only	 Formula Only	 Both Breast Milk and Formula
 Other	 Do Not Know

Newborn

Treatment

Given:

Conjunctivitis only

Vitamin K only

Both

Neither

Abnormal ConditionsHepatitis BNewborn Screening

Newborn Blood-Spot Screening

Reason if Lab ID is not submitted:

Screening Lab ID Number: (9-digits)

 No NBS Lab ID because infant died prior to test

 No NBS Lab ID because infant transferred prior to test

___ ___ ___ ___ ___ ___ ___ ___ ___

 Lab ID is unknown / illegible

NBS



Refused NBS

Hepatitis B Inoculation

Immunization Administered:

 Yes

 No

Immunoglobulin Administered:  Yes

 No

Date: (MM/DD/YYYY)

Mfr:

Lot:

Abnormal Conditions of the Newborn:

Newborn

 None  Unknown at this time

Select all that apply

 Assisted ventilation required immediately following delivery

 Assisted ventilation required for more than six hours

the

 NICU Admission

 Newborn given surfactant replacement therapy

 Antibiotics received by the newborn for suspected neonatal sepsis

 Seizures or serious neurologic dysfunction

Significant birth injury (skeletal fx, peripheral nerve injury, soft tissue/solid organ hemorrhage which requires intervention)

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 7 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Congenital Anomalies

 None of the listed  Unknown at this time

Diagnosed

If Yes, please indicate all methods used:

Select all that apply

Prenatally?

Yes No

Anencephaly

Yes No

 Level II Ultrasound  MSAFP / Triple Screen

 Amniocentesis

 

 Other

 Unknown

Yes No

Meningomyelocele/Spina Bifida

Yes No

 Level II Ultrasound  MSAFP / Triple Screen

 Amniocentesis

 

 Other

 Unknown

Yes No

Cyanotic Congenital Heart

Yes No

 Level II Ultrasound

 

Disease

 

 Other

 Unknown

Yes No

Congenital Diaphragmatic

Yes No

 Level II Ultrasound

 

Hernia

 

 Other

 Unknown

Yes No

Omphalocele

Yes No

 Level II Ultrasound

Anomalies

 

 Other

 Unknown

Yes No

 Level II Ultrasound

Yes No

Gastroschisis

Yes No

 Level II Ultrasound

 

 Other

 Unknown

Congenital

 

Limb Reduction Defect

 

 Other

 Unknown

Yes No

Cleft lip with or without Cleft

Yes No

 Level II Ultrasound

 

Palate

 

 Other

 Unknown

Yes No

Cleft Palate Alone

Yes No

 Level II Ultrasound

 

 Other

 Unknown

Yes No

Down Syndrome

Yes No

 Level II Ultrasound  MSAFP / Triple Screen

 CVS

 Amniocentesis

 Karyotype confirmed

 

 Other

 Unknown

 Karyotype pending

Yes No

Other Chromosomal Disorder

Yes No

 Level II Ultrasound  MSAFP / Triple Screen

 CVS

 Amniocentesis

 Karyotype confirmed

 

 Other

 Unknown

 Karyotype pending

Yes No

Hypospadias

Yes No

 Level II Ultrasound

 

 Other

 Unknown

Labor &

Delivery

Method of Delivery

Labor & Delivery

Mother Transferred in Antepartum:

NYS Facility Mother Transferred From:

State/Terr./Province:

 Yes  No

Mother’s Weight at Delivery:

lbs.

Fetal Presentation: (select one)

 Cephalic  Breech Other

Route & Method: (select one)

 Spontaneous  Forceps – Mid  Forceps – Low / Outlet  Vacuum  Cesarean  Unknown

Cesarean Section History:

 Previous C-Section	Number

Attempted Procedures:
Was delivery with forceps attempted but unsuccessful?		 Yes	 No
Was delivery with vacuum extraction attempted but unsuccessful?		 Yes	 No

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 8 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

		Labor & Delivery
	Trial Labor:
	If Cesarean section, was trial labor attempted?	 Yes  No

of Delivery

Indications for C-Section:

Unknown

Select all that apply

Failure to progress

Fetus at Risk / NFS

Refused VBAC

Malpresentation

Maternal Condition – Not Pregnancy Related

Elective

Previous C-Section

Maternal Condition – Pregnancy Related

Other

Method

Labor

Indications for Vacuum:

Indications for Forceps:

 Unknown

Select all that apply

 Failure to progress

 Fetus at Risk

 Failure to progress

 Fetus at Risk

 Other

Onset of Labor

 None  Unknown at this time

Select all that apply

 Prolonged Rupture of Membranes --

 Premature Rupture of Membranes --

 Precipitous Labor -- (less than 3 hours)

(12 or more hours)

(prior to labor)

Prolonged Labor (20 or more hours)

Characteristics of Labor & Delivery

Characteristics

None  Unknown at this time Select all that apply

Induction of Labor – AROM

Steroids

Meconium Staining

Internal Electronic Fetal Monitoring

Induction of Labor – Medicinal

Antibiotics

Fetal Intolerance

Augmentation of Labor

Chorioamnionitis

External Electronic Fetal Monitoring

Maternal Morbidity

None  Unknown at this time

Select all that apply

Maternal Transfusion

Unplanned Hysterectomy

Postpartum transfer to a higher level QI of care

Perineal Laceration (3rd / 4th Degree)

Admit to ICU

Ruptured Uterus

Unplanned Operating Room Procedure Following Delivery

Procedures Anesthesia / Analgesia

Anesthesia / Analgesia

None  Unknown at this time

Yes  No

Other Procedures Performed at Delivery

None  Unknown at this time

Select all that apply
 Episiotomy and Repair	 Sterilization

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 9 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Mother’s Demographics

Mother

Medical Record Number:

Mother’s Education: (select one)

 8th grade or less	 Some college credit, but no degree		 Master’s degree
 9th – 12th grade; no diploma	 Associate’s degree		 Doctorate degree
 High school graduate; or GED	 Bachelor’s degree

City of Birth:		State/Terr./Province of Birth:			Country of Birth, if not USA:

Hispanic Origin:
Select all that apply
 No, not Spanish/Hispanic/Latina	 Yes, Mexican, Mexican American, Chicana			 Yes, Puerto Rican
 Yes, Cuban	 Yes, Other Spanish/Hispanic/Latina

Specify:

Race:

Parents

Mother’s Demographics

Select all that apply

White/Caucasian

Chinese

Korean

Guamanian or Chamorro

 American Indian or Alaska Native Tribe:

 Other Asian	Specify:
 Other Pacific Islander	Specify:
 Other	Specify:

Black or African American

Filipino

Vietnamese

Samoan

Asian Indian

Japanese

Native Hawaiian

Mother’s Residence
Mother’s Mailing	Address
Mother’s Mailing	Address

	Employment

Residence Address

Street Address:

State/Terr./Province:		County:	City, Town or Village:

Zip/Postal Code:	Mother’s Country of Residence, if not USA:			U.S./Canadian Phone Number:
				(	)	–
Mailing Address – Most Recent

Check here if the mailing address is the same as the residence address (otherwise enter information below)

Mailing Address:

City, Town or Village:		State/Terr./Province:			Country, if not USA:		Zip/Postal Code:

Employment History
Employed while Pregnant:	Current / Most Recent Occupation:					Kind of Business / Industry:
 Yes  No

Name of Company or Firm:			Address:

City:				State/Territory/Province:			Zip / Postal Code:

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 10 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Father or Second Parent

or Second Parent’s Demographics

Will the mother and father be executing an							What type of certificate is required?
Acknowledgement of Paternity?		 Yes  No  Not required						 Mother / Father		 Mother / Mother

Parent’s First Name:					Parent’s Middle Name:

Parent’s Current Last Name:					Last Name on Parent’s Birth Certificate:

Parent’s Name Suffix			Social Security Number:
(e.g. Jr., 2nd, III):				–		–
Demographics
Parent’s Date of Birth:		Education: (select one)
(MM/DD/YYYY)		 8th grade or less					 Some college credit, but no degree			 Master’s degree
/	/	 9th – 12th grade; no diploma					 Associate’s degree			 Doctorate degree
/	/	 High school graduate; or GED					 Bachelor’s degree
		 High school graduate; or GED					 Bachelor’s degree

City of Birth:				State/Terr./Province of Birth:					Country of Birth, if not USA:

Hispanic Origin:
Select all that apply
 No, not Spanish/Hispanic/Latino		 Yes, Mexican, Mexican American, Chicano						 Yes, Puerto Rican
 Yes, Cuban		 Yes, Other Spanish/Hispanic/Latino

Specify:

Race:

Parents

Father‘s

Select all that apply

White/Caucasian

Chinese

Korean

Guamanian or Chamorro

American Indian or Alaska Native Tribe:

 Other Asian	Specify:
 Other Pacific Islander	Specify:
 Other	Specify:

Black or African American

Filipino

Vietnamese

Samoan

Asian Indian

Japanese

Native Hawaiian

EmploymentParent’s Residence

Residence Address

Check here if the parent’s residence address is the same as the mother’s address

(otherwise enter information below)

Street Address:

City, Town or Village:				State / Territory / Province:

Parent’s Country of Residence, if not USA:					Zip / Postal Code:
Employment History
Employment History
Current / Most Recent Occupation:			Kind of Business / Industry:

Name of Company or Firm:	Address:

City:		State / Territory / Province:				Zip / Postal Code:

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 11 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Parents

Prenatal History

Pregnancy History

Prenatal History

Did mother receive	Primary Prenatal Care Provider Type:		Did mother participate in WIC?
prenatal care?	 MD / DO / C(N)M / HMO	 No Information
 Yes  No	 Clinic	 No Provider	 Yes  No

Other

Key Pregnancy Dates (MM/DD/YYYY)

Date of Last Menses:

Estimated Due Date:

Date of First Prenatal Visit:

Date of Last Prenatal Visit:

Prenatal Visits

Total Number of Prenatal Visits:

Pregnancy History

Previous Live Births:

Previous Spontaneous

Previous Induced

Total Prior

Terminations:

Pregnancies:

Now Living

Now Dead

Less than 20 Weeks

20 Weeks or More

None or Number



First Live Birth:

Last Live Birth:

Last Other Pregnancy

Prepregnancy

Height:

(MM / YYYY)

Outcome: (MM / YYYY)

Weight:

lbs.

ft.

in.

Prenatal Care

Risk Factors in this Pregnancy

 None  Unknown at this time

Select all that apply

Factors

 Prepregnancy Diabetes

 Gestational Diabetes

 Prepregnancy Hypertension

 Gestational hypertension

 Other Poor Pregnancy Outcomes

 Prelabor Referred for High Risk Care

 Other Vaginal Bleeding

 PreviousBirthweightLowInfant QI

 Other Serious Chronic Illnesses

 Previous Preterm Births

 Abruptio Placenta

 Eclampsia

Risk

 Pregnancy resulted from infertility treatment (if yes, check all that apply)

 Fertility-enhancing drugs, artificial or intrauterine insemination

 Assisted reproductive technology (e.g. IVF, GIFT) Number of Embryos Implanted: (if applicable)

Infections Present and/or Treated During Pregnancy

Infections

 None  Unknown at this time

Select all that apply

 Gonorrhea

 Syphilis

 Herpes Simplex Virus (HSV)

 Chlamydia

 Hepatitis B

 Hepatitis C

 Tuberculosis

 Rubella

Bacterial Vaginosis

FactorsRiskOther

Other Risk Factors

Parents

List Number of Packs OR Cigarettes Smoked Per DAY

Smoking Before or

3 Months Prior to Pregnancy

First Three Months

Second Three Months

Third Trimester of Pregnancy

During Pregnancy?

of Pregnancy

Packs

OR Cigarettes

Packs

OR Cigarettes

Packs

OR Cigarettes

Packs

OR Cigarettes

 Yes  No

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 12 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Obstetric Procedures Other Risk

Prenatal Care

Other Risk Factors

Alcohol		Number of Drinks per		Illegal Drugs
Consumed During This		Week:		Used During This
Pregnancy?				Pregnancy?
 Yes  No				 Yes  No
Obstetric Procedures
 None  Unknown at this time
Select all that apply
 Cervical Cerclage			 Tocolysis		 External Cephalic Version —  Successful  Failed
 Fetal Genetic TestingQI
If woman was 35 or over, was fetal genetic testing offered?					QI
 Yes  No, Too Late	 No, Other Reason				QI

Serological Test for Syphilis?

 Yes  No

Date of Test:

(MM/DD/YYYY)

/ /

Reason, if No Test:

Mother refused

Religious reasons

No prenatal care

Other

No time before delivery

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 13 of 14

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records – Birth Registration Unit

Birth Certificate and SPDS Work Booklet

Mother’s Name:

Mother’s Med. Rec. Number:

Parents	Mother (in hospital)
	Survey of

Admission & DischargeChart Review (Prenatal and Medical)

Interview/Records QI

Survey of Mother (in hospital)

Did you receive prenatal care?  Yes  No (If ‘Yes’ please answer question 1. Otherwise skip to question 2.)

1.During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?

	Yes	No
a. How smoking during pregnancy could affect your baby?		
b. How drinking alcohol during your pregnancy could affect your baby?		
c. How using illegal drugs could affect your baby?		
d. How long to wait before having another baby?		
e. Birth control methods to use after your pregnancy?		
f. What to do if your labor starts early?		
g. How to keep from getting HIV (the virus that causes AIDS)?		
h. Physical abuse to women by their husbands or partners?		
2. How many times per week during your current pregnancy did you exercise for 30 minutes or			Times per week:
more, above your usual activities?

3. Did you have any problems with your gums at any time during pregnancy, for example,			 Yes
swollen or bleeding gums?			 No

4. During your pregnancy, would you say that you were: (select one)

 Not depressed at all	 A little depressed
 Moderately depressed	 Very depressed

Very depressed and had to get help

5.Thinking back to just before you were pregnant, how did you feel about becoming pregnant?

 You wanted to be pregnant sooner	 You wanted to be pregnant later
 You wanted to be pregnant then	 You didn’t want to be pregnant then or at any time in the future

Chart Review (Prenatal and Medical)
1a. Copy of prenatal record in chart?
 Yes, Full Record			 Yes, Prenatal Summary Only
 No

1b. Was formal risk assessment in prenatal chart?
 Yes, with Social Assessment			 Yes, without Social Assessment
 No
1c. Was MSAFP / triple screen test offered?
 Yes			 No
 No, Too Late
1d. Was MSAFP / triple screen test done?
 Yes			 No
2. How many times was the mother hospitalized during this
pregnancy, not including hospitalization for delivery?
Admission and Discharge Information
Mother
Admission Date for Delivery (MM/DD/YYYY)		Discharge Date (MM/DD/YYYY)
/	/	/		/
Infant
Discharge Date (MM/DD/YYYY)		 Discharged Home			 Infant Died at Birth Hospital
		 Infant Still in Hospital			 Infant Discharged to Foster Care/Adoption
/	/	 Infant Transferred Out			 Unknown
		 Infant Transferred Out			 Unknown

DOH-2184E (10/09)

New York State Birth Certificate and Statewide Perinatal Data System Work Booklet

Page 14 of 14

Question	Answer
Form Name	Doh 2184E Form
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	1doh 2184e, new york state birth certificate and statewide perinatal data system work booklet spanish, doh 2556i, birth certificate booklet

Select all that apply

 Epidural (Caudal)

 General Inhalation

 General Inhalation

 Paracervical

 General Intravenous

 Pudendal

Was an analgesic administered?