Welcoming a new baby is a joyful event that comes with a variety of responsibilities, including legal documentation to officially record the birth. The H00184 form, also known as the Birth Certificate Worksheet, is a critical document for parents at District One Hospital. This form gathers exhaustive details necessary to create your baby's official birth certificate, covering everything from the baby's and parents' full legal names to intricate demographic information. Parents are urged to fill out as much information as possible to ensure accuracy and completeness. Additionally, the form accommodates the collection of social security numbers for the child, if desired, and specifies parents' education levels, previous children, and detailed racial and ethnic background. This document is not only about capturing the joyous arrival but also on ensuring all legal and statistical aspects are thoroughly and accurately documented. It includes a section for single mothers regarding the confidentiality of the birth record, an option to publicize the birth through local news, and requires the signatures of both parents as a certification of the accuracy of the information provided. It's essential to return this form with any pre-admission paperwork and to reach out to the Women’s Health Unit with any questions or concerns about the process.
| Question | Answer |
|---|---|
| Form Name | Form H00184 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 12th, Somali, 9th, 3BC |
Patient Identification Sticker
Goes Here
BIRTH CERTIFICATE WORKSHEET
This form will be used to create your baby’s official birth certificate. Complete as much of the information as possible, including full legal names. Return this form along with your
PLEASE PRINT |
DUE DATE _______________________ |
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MOTHER |
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NAME: ________________________________________________________ Maiden Surname: _____________________
(First) |
(Middle) |
(Last) |
Date of Birth: _____________ |
Birth Place (City/State/Country): _________________________ Marital Status: ________ |
|
Address: _____________________________________________________________________________________________
(Street)(City)(State) (ZIP) (County)
Mailing Address: ______________________________________________________________________________________
(if different) |
(Street) |
(City) |
(State) (ZIP) |
(County) |
Do you live inside the city limits? Yes |
No - Name of Township: ___________________________________ |
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Social Security Number: _______________________ I don’t have a Social Security Number |
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Education (Highest grade completed) Up to 8th grade |
9th |
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Some college but no degree College degree ____________________
Live Births (do not include this child): Number of children: Living: __________ Deceased ____________
Date of last live birth (month/year): __________________________
Other Terminations (spontaneous and/or induced at any time after conception):
Number of terminations: ____________ Date of last termination (month/year): ________________
** Single mothers do not complete this area unless completing the Recognition of Parentage. **
FATHER
NAME: _____________________________________________________________________________________________
(First) |
(Middle) |
(Last) |
Date of Birth: _____________ |
Birth Place (City/State/Country): _________________________ Marital Status: _________ |
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Address: _____________________________________________________________________________________________
(Street)
(City) |
(State) |
(ZIP) |
(County) |
Social Security Number: _______________________ I don’t have a Social Security Number
Education (Highest grade completed): Up to 8th grade 9th
Some college but no degree College degree ____________________
Form Number: H00184
Revision Date: 2/10
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Birth Certificate Worksheet
*3BC*
3BC
Patient Identification Sticker
Goes Here
CHILD
NAME: _____________________________________________________________________________SEX: Male / Female
(First) |
(Middle) |
(Last) |
|
DOB: __________________ |
Time of Birth: ___________ |
Birth Weight: ___________ Delivered by:____________ |
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Do you want the hospital to file for a Social Security Number for this child? |
Yes No |
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WHAT IS YOUR RACE?
MOTHER
White (Caucasian)
Black or African
Somali
Sudanese
Other African – Please Specify: _________________
American Indian or Alaska Native
Name of Enrolled or Principal Tribe: _____________
Pacific Islander – Please Specify: ____________________
Asian
Chinese
Filipino
Japanese
Korean
Vietnamese
Cambodian
Other Asian – Please Specify: ___________________
Other Race – Please Specify: ________________________
Are you Spanish/Hispanic/Latina? If Yes:
Mexican, Mexican American, Chicana
Puerto Rican
Other Spanish/Hispanic/Latina – Please Specify:
________________________________
FATHER
White (Caucasian)
Black or African
Somali
Sudanese
Other African – Please Specify: _________________
American Indian or Alaska Native
Name of Enrolled or Principal Tribe: _____________
Pacific Islander – Please Specify: ____________________
Asian
Chinese
Filipino
Japanese
Korean
Vietnamese
Cambodian
Other Asian – Please Specify: ___________________
Other Race – Please Specify: ________________________
Are you Spanish/Hispanic/Latina? If Yes:
Mexican, Mexican American, Chicana
Puerto Rican
Other Spanish/Hispanic/Latina – Please Specify:
________________________________
** FOR SINGLE MOTHERS ONLY **
Your baby’s birth record is considered confidential unless you request the information to be public. A confidential birth record may be given only to the parent(s) or guardian of the child, to the child at age 16 or older, or disclosed according to law or a court order. What choice would you like to make?
Yes, change the birth record to a public record |
No, leave the birth record a confidential record |
I give my permission for the following birth announcement information to be released to the Faribault Daily News for
publication: Parents’ names, City of residence, Date of baby’s birth and Sex of baby. |
Yes No |
I certify that the information provided on this worksheet is correct. I understand that this information will be used to create the official birth certificate with the Minnesota Department of Health.
_________________________________________________ |
________________________________________________ |
Mother’s Signature |
Father’s Signature |
Form #: H00184 |
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Birth Certificate Worksheet