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New York City Department of Health and Mental Hygiene

Bureau of Vital Statistics

Dear New Mother/Parent (woman giving birth),

The New York City Department of Health and Mental Hygiene issues your child’s birth certificate. A birth certificate is the permanent legal record of your child’s birth and is used as proof of your child’s age, citizenship and parentage. The information you provide is required by law. Unless you complete this form correctly, we cannot create an accurate birth certificate for your child.

Information about education, race, smoking, height and your weight before pregnancy are collected for public health purposes. Additional questions labeled “QI” (Quality Improvement) are requested by the New York State Department of Health. New York City and State laws protect against the unlawful release of birth certificate information to ensure the confidentiality of you and your child.

•It is extremely important that you provide complete and accurate information to ALL questions. Please print all information clearly.

•The worksheet MUST be completed in English. If you are not able to complete it in English by yourself please call the hospital Birth Registrar at __________________________.

•The completed worksheet MUST be completed and returned to the Birth Registrar within 24 hours of the birth of your child.

•If you have any questions, please call the hospital Birth Registrar.

For Facility Birth Registration Tracking Purposes

MOTHER/PARENT WORKSHEET - DATA COLLECTED FOR REGISTRATION OF NEWBORN BIRTH CERTIFICATE

Mother/Parent’s MRN:		Mother/Parent’s Name:


Child’s MRN:		Child’s DOB:


	Number delivered this pregnancy	If more than one, birth order of this child

VR-203 (Rev. 01/14)

Please print all names exactly as you would like them to appear on the birth certificate.

To change this information in the future, you will be required to submit a correction application to the Health Department.

CHILD	If more than one child delivered, birth order of this child: _____

1. What will be your		Child’s FIRST Name	Child’s MIDDLE Name(s)	Child’s LAST Name			Suffix
							(Jr., III, etc.)
baby’s LEGAL NAME?


2. Do you want a Social Security number and card for your child?					Yes	No

As long as you have provided the legal first and last name of your newborn child above, you may request a Social Security number (SSN) for your child. The Health

	Department will send the request to the Social Security Administration at the time the certificate is filed. If you do not request this now, you will need to contact	If yes, the card will be mailed to Mother/Parent’s
		Mailing Address by the Social Security Administration.
	Social Security directly to obtain an SSN for your child. The hospital, birth facility and Health Department will not be responsible for making the request on your behalf.	Mailing Address by the Social Security Administration.


	MOTHER/PARENT (WOMAN GIVING BIRTH)

3.What is your CURRENT LEGAL name?

4.What is your MAIDEN name?

Name prior to first marriage

Mother/Parent’s First Name

Mother/Parent’s Middle Name

Mother/Parent’s Legal Last Name

My maiden name is my current legal name

Mother/Parent’s First Name

Mother/Parent’s Middle Name

Mother/Parent’s Maiden Last Name

5-7. What is your DATE OF BIRTH, current AGE and SEX?

8. What is your SOCIAL SECURITY NUMBER?

Providing parents’ Social Security numbers is required by Federal Law, 42 USC 405(c) (§205 (c) of the Social Security Act). The numbers will be made available to the NYS Office of Temporary and Disability Assistance to assist with child support enforcement activities and to the Internal Revenue Service through the Social Security Administration for the purpose of determining Earned Income Tax Credit compliance.

Date of					Current		Sex		Female
					Current		Sex
					Age
Mother/Parent’s						____ ____
Mother/Parent’s	____ ____ / ____ ____ / ____ ____ ____ ____
Birth	____ ____ / ____ ____ / ____ ____ ____ ____								Male
Birth		Month	Day	Year
		Month	Day	Year

Mother/Parent’s SSN			I don’t have a SSN
Mother/Parent’s SSN			I don’t have a SSN		Father/Parent’s SSN will be requested in the Father/Parent’s

____ ____ ____ – ____ ____ – ____ ____ ____ ____					information section, if applicable.
____ ____ ____ – ____ ____ – ____ ____ ____ ____

Your signature below indicates that the information regarding the Social Security number on this form is correct.
Mother/Parent’s Signature						Date
						__ __ / __ __ / __ __ __ __
						Month		Day		Year

MOTHER/PARENT’S BIRTHPLACE

9.Where were YOU BORN?

10.If you were born outside of the United States, how long have you lived in the U.S.?

City			State (If not in U.S., please indicate foreign country)		Foreign Country

				OR
		Never lived in U.S.	Years lived in U.S.	OR	Months lived in U.S.
	(go to next question)		Years lived in U.S.	If less than one year:	Months lived in U.S.
	(go to next question)		___ ___	If less than one year:	___ ___
			___ ___		___ ___

MOTHER/PARENT’S ADDRESS

11. Where do you USUALLY LIVE?

Street Address (Do NOT enter a PO Box or In Care of (c/o))

Apt. Number

If NYC, County (borough)

Where is your household physically located?

New York (Manhattan)

Bronx

If not in U.S., please indicate foreign address, city and country.

City

State

ZIP Code

Country

Kings (Brooklyn)

Queens

Richmond (Staten Island)

Do you live within the city limits specified above?

Yes

Outside NYC (Specify County): _____________________________________

12. What is your MAILING address?

Same as my USUAL residence above

This is where the birth certificate will be MAILED.

If no mailing address, certificate will NOT be mailed; you will need to pick it up at the Health Department.

No mailing address

The first copy of the birth certificate is FREE.

If mailing address is In Care of (c/o), please indicate here:

In Care of (another person or organization/agency)

Street Address (PO Box is not permitted in a NYC mailing address)

Apt. Number

City

State

ZIP Code

Country

13. What are your TELEPHONE numbers?

Day

Evening

( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___ Ext. _____________

( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___

MOTHER/PARENT’S ATTRIBUTES

14.EDUCATION: What is the highest level of school that you COMPLETED at the time of your baby’s delivery?

Check (8) ONE box only

15.Were you EMPLOYED during the pregnancy?

16.What is your current/most recent OCCUPATION (job)?

17.What INDUSTRY did you perform this occupation (job)?

Do not give the name of the business, but write what type of business it is.

18. What is your ANCESTRY?

Check (8) ONE box and specify what you most consider yourself to be.

19. What is your RACE?

Race is defined by U.S. Census. Hispanic is not a race according to the U.S. Census. For Hispanic ancestry, please use Question 18.

Check (8) ALL that apply and specify where indicated.

8th grade or less; none		Associate degree (e.g. AA, AS)
		Bachelor’s degree (e.g. BA, AB, BS)
9th-12th grade, no diploma		Bachelor’s degree (e.g. BA, AB, BS)
High school graduate or GED		Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
High school graduate or GED		Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
Some college credit, but no degree		Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)




Yes	No
Yes	No

Occupation (For example: cashier, bank teller, nurse, attorney, etc.)

Industry (For example: restaurant, banking, health care, legal, etc.)

Hispanic (For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)

Specify: _____________________________________________________________________

NOT Hispanic (For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)

Specify: _____________________________________________________________________

White	Filipino		Native Hawaiian
Black or African American	Japanese		Guamanian or Chamorro
American Indian or Alaska Native	Korean		Samoan
(name of enrolled or principal tribe)
(name of enrolled or principal tribe)	Vietnamese	Other Pacific Islander (specify)
______________________	Other Asian (specify)		________________________
Asian Indian	______________________		Other (specify)
Chinese			________________________
			________________________

MOTHER/PARENT’S HEALTH

20. Did you participate in WIC during this pregnancy?	Yes	No
(Special supplemental nutrition for Woman, Infants and Children.)
21. What is your HEIGHT?
21. What is your HEIGHT?	Height		Pre-Pregnancy Weight
22. What was your PRE-PREGNANCY WEIGHT?	____ ____ Feet ____ ____ Inches			____ ____ ____ lbs.
23. Did you smoke CIGARETTES in the three months
23. Did you smoke CIGARETTES in the three months	No	Yes If yes, what was the average number of cigarettes/day or packs/day you smoked during the following times?
before or during this pregnancy?		Please answer below. Enter 0 if NONE during any of these periods
before or during this pregnancy?		Time Period	Number of Cigarettes per day OR	Number of Packs per day
		Time Period	Number of Cigarettes per day OR	Number of Packs per day
		3 months before your pregnancy	___ ___	_____
		First 3 months of your pregnancy	___ ___	_____
		Second 3 months of your pregnancy	___ ___	_____
		Third 3 months of your pregnancy	___ ___	_____
24. Did you use ALCOHOL during this pregnancy?
24. Did you use ALCOHOL during this pregnancy?	Yes	No

Quality Improvement (QI) questions are asked for the New York State Department of Health. They are designed to learn more about the quality of prenatal care New Yorkers are receiving. All answers will be used for public health purposes only.

25.(QI) Did you receive PRENATAL CARE (medical care for this pregnancy) before admission for this delivery?

No Skip to Question 26

Yes If yes, please answer the following: 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?

a) How smoking during pregnancy could affect your baby?		Yes		No	e) Birth control methods to use after your pregnancy?		Yes	No
b) How drinking alcohol during your pregnancy could affect your baby?					f) What to do if your labor starts early?
	Yes			No	f) What to do if your labor starts early?	Yes		No
c) How using illegal drugs could affect your baby?	Yes			No	g) How to keep from getting HIV (the virus that causes AIDS)?		Yes		No
d) How long to wait before having another baby?					h) Physical abuse to women by their husbands or partners?
d) How long to wait before having another baby?	Yes		No		h) Physical abuse to women by their husbands or partners?		Yes		No

26.(QI) How many times per week during your current pregnancy did you EXERCISE for 30 minutes or more, above your usual activities?

____ ____ Times per week

27. (QI) Did you have any problems with your GUMS at any time during pregnancy, for example, swollen or bleeding gums?

Yes

28. (QI) During your pregnancy, would you say that you were:

Check (8) ONE box only

29.(QI) Thinking back to just before you were pregnant, how did you feel about becoming pregnant? Check (8) ONE box only

Not depressed at all	A little depressed	Very depressed and did not receive help
	Moderately depressed	Very depressed and did receive help

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

If you want the name of the child’s father/parent to appear on the birth certificate you must provide accurate and complete information below and submit completed form to the hospital Birth Registrar.

AND

1)If married, ask the hospital what is necessary to ensure your spouse’s name appears as the legal father/parent of your child on the birth certificate; OR

2)If married and your spouse is NOT the father/parent of the child, speak with the hospital Birth Registrar; OR

3)If you are not married, both you and the father must sign an ACKNOWLEDGMENT OF PATERNITY in the presence of two unrelated witnesses; OR

4)If your circumstances are not covered by the above, speak with the hospital Birth Registrar.

FATHER/PARENT’S INFORMATION FOR LIVE BIRTH

To be Completed by Mother/Parent or Father/Parent

FATHER/PARENT

30. What is the NAME of your baby’s father/parent Father/Parent’s First Name	Father/Parent’s Middle Name(s)	Father/Parent’s Last Name	Suffix
prior to first marriage?			(Jr., III, etc.)
Please write Father/Parent’s name exactly as you would like it to appear on
the certificate. To change this information in the future, you will be required

to submit a correction application to the Health Department.
31-33. What is the father/parent’s DATE OF BIRTH,	Date of				Current		Sex	Female
	Father/Parent’s				Age	____ ____		Female
	Father/Parent’s	____ ____ / ____ ____ / ____ ____ ____ ____			Age
current AGE, and SEX?	Birth	____ ____ / ____ ____ / ____ ____ ____ ____						Male
	Birth	Month	Day	Year
		Month	Day	Year

34. What is the father/parent’s SOCIAL SECURITY NUMBER?

Father/Parent’s SSN

Father/Parent does not have a SSN

____ ____ ____ – ____ ____ – ____ ____ ____ ____

Mother/Parent’s signature on previous page confirms that the above SSN is correct

FATHER/PARENT’S BIRTHPLACE

35. Where was the father/parent BORN?	City	State (If not in US, please indicate foreign country)		Foreign Country
36. If the father/parent was born outside of the United
36. If the father/parent was born outside of the United	Never lived in U.S.	Years lived in U.S.	OR	Months lived in U.S.
States, how long has he/she lived in the U.S.?	(go to next question)	Years lived in U.S.	If less than one year:	Months lived in U.S.
	(go to next question)		If less than one year:
			___ ___	___ ___

FATHER/PARENT’S ATTRIBUTES

37.EDUCATION: What is the highest level of school that the father/parent COMPLETED at the time of your baby’s delivery?

Check (8) ONE box only

38.What is the father/parent’s current/most recent OCCUPATION (job)?

39.In what INDUSTRY did he/she perform this occupation (job)?

Do not give the name of the business, but write what type of business it is.

40. What is the father/parent’s ANCESTRY?

Check (8) ONE box only and specify what father/parent most considers himself/herself to be.

41. What is the father/parent’s RACE?

Race is defined by U.S. Census. Hispanic is not a race according to the U.S. Census. For Hispanic ancestry, please use Question 40.

Check (8) ALL that apply and specify where indicated.

		8th grade or less; none			Associate degree (e.g. AA, AS)
		9th-12th grade, no diploma			Bachelor’s degree (e.g. BA, AB, BS)
		High school graduate or GED			Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)


		Some college credit, but no degree			Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)

Occupation (For example: cashier, bank teller, nurse, attorney, etc.)

Industry (For example: restaurant, banking, health care, legal, etc.)

Hispanic (For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)

Specify: _____________________________________________________________________

NOT Hispanic (For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)

Specify: _____________________________________________________________________

White	Filipino		Native Hawaiian
Black or African American	Japanese		Guamanian or Chamorro
American Indian or Alaska Native	Korean		Samoan
(name of enrolled or principal tribe)
(name of enrolled or principal tribe)	Vietnamese	Other Pacific Islander (specify)
______________________	Other Asian (specify)		________________________
Asian Indian	______________________		Other (specify)
Chinese			________________________
			________________________

Question	Answer
Form Name	Vr 203 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	ny vr 203, worksheet certificate blank, parent worksheet, vr 203 russian form

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