Birth Certificate Worksheet

Birth Certificate Worksheet

Please complete this information to prepare your child's birth certificate.
Child's Name: If a name has not been determined when the birth certificate is created, a dash (-)can be entered for the first, middle, and last names. The birth certificate can be amended later to add the child's name.

First NameMiddle NameLast NameSuffix
Sex:
Plurality
Number of Babies in Current Pregnancy
Birth Order:
Date of Birth:

MonthDayYear
Date
Time of Birth:
Planned Place of Birth:

Place of birth and planned place of birth refer to categories and do not refer to specific addresses. Categories include: Hospital, Freestanding Birth Center, Home Delivery, Clinic/Doctor's Office, Other, and Unknown.
Did the place of birth category match the planned place of birth category?

YesNo
If the place of birth category did not match the planned place of birth category, where did you plan for this birth to take place?

HospitalFreestanding Birth CenterHome DeliveryClinic/Doctor's OfficeUnknownOther
The birth maiden name of the patient giving birth

Fields 9A, 9B, 9C on child's birth certificate, unless a certified copy of a surrogate court order is presented. If only one parent is listed on the birth certificate, they must be listed in fields 9A, 9B, 9C.
Name

First NameMiddle NameLast NameSuffix
Birth Date

MonthDayYear
Date
Relationship to Child (Optional)

MotherFatherParent
Birth State/Foreign Country
State/Territory/Province Name:
If the parents are not married or in an SRDP

Then the biological or intended parents may sign the Voluntary Declaration of Parentage (VDOP) form to list the biological parent not giving birth or intended parent in fields 6A, 6B, 6C at the time of birth. If the parents are not married or in an SRDP, do not have a surrogate court order, and do not complete the VDOP, the second parent cannot be listed or have additional information collected for the birth certificate. Reference Health and Safety Code Section 102425(a)(4). Additional parents may be added through the amendment process after the certificate is registered.
Are the Parents Married and/or in a State Registered Partnership (SRDP), or is there a certified surrogate court order?

YesNoUnknown
Has a voluntary Declaration of Parentage (VDOP) form been completed and signed?

YesNoUnknown
Scholarshare Contact Information for Parent Giving Birth.

This information is for Scholarshare use only. This information is not printed on the birth certificate and is not included with any data collected on the birth certificate.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth name of Parent Not Giving Birth or Intended Parent

Fields 6A, 6B, and 6C, on child's birth certificate.
Name

First NameMiddle NameLast NameSuffix
Relationship to Child (Optional)

MotherFatherParent
Birth State/Foreign Country
State/Territory/Province Name:
Birth Date

MonthDayYear
Date
Scholarshare Contact Information for Parent Not Giving Birth or Intended Parent (Person listed in 6A-6C)

This contact information is for Scholarshare use only. This information is not printed on the birth certificate nor included with any data collected on the birth certificate. Do not collect this information if no parent is listed in fields 6A-6C.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Names of Parent(s)/Informant(s) Signing the Birth Certificate:
Name of Parent/Informant 1 who will sign the Birth Certificate (Required)
Your name should be written as you want it to appear in field 12A in lieu of an ink signature.
Relationship of Parent/Informant 1:

MotherFatherParentOther
Name of Parent/Informant 2 who will sign the Birth Certificate (Optional)
Your name should be written as you want it to appear in field 12A in lieu of an ink signature.
Relationship of Parent/Informant 2:

MotherFatherParentOther
Confidential Data Section
Is the mother or parent Hispanic, Latina, or Spanish?

YesNoUnknownWithheld
If Yes, please specify:

CubanMexicanPuerto RicanOther
Is the father or parent Hispanic, Latino, or Spanish?

YesNoUnknownWithheld
If Yes, please specify:

CubanMexicanPuerto RicanOther
Up to three races may be entered for each parent on the birth certificate.

Unless otherwise specified, the selected race(s) will be printed on the certificate. If the parent(s) would like a different description printed on the certificate, enter them at the bottom of this section.
Mother (Select up to three)

WhiteCaucasianBlackAfrican AmericanMexicanMexican AmericanAlaska NativeEskimoAleutNative AmericanAmerican IndianChineseJapaneseFilipinoKoreanVietnameseAsian IndianCambodianThaiLaotianHmongNative HawaiianGuamanianSamoanUnknownWithheldOther
Custom Description (Optional)
If the mother wants a different description printed on the certificate, enter them here.
Father or Parent (Select up to three)

WhiteCaucasianBlackAfrican AmericanMexicanMexican AmericanAlaska NativeEskimoAleutNative AmericanAmerican IndianChineseJapaneseFilipinoKoreanVietnameseAsian IndianCambodianThaiLaotianHmongNative HawaiianGuamanianSamoanUnknownWithheldOther
Custom Description (Optional)
If the father or parent wants a different description printed on the certificate, enter them here.
Education:
Mother - Enter the highest level or Degree of School Completed. Does not include trade schools/occupation-specific certificate programs.

0-11th Grade12th Grade with No DiplomaHigh School DiplomaGeneral Equivalency Diploma (GED)Some College (No Degree)Associate's Degree (e.g., AA, AS, AAS, AAB)Bachelor's Degree (e.g., BA, BSc, BEng)Master's Degree (e.g., MA, MSc, MBA, MSW)Doctorate Degree (e.g., PhD, EdD)Professional Degree (e.g., MD, JD, DDS, LLB)
If 0-11th Grade, Enter Highest Grade Completed:
Mother Usual Occupation:
Work done for the most extended period. Please don't enter the company name.
Mother Kind of Business/Industry:
Do not enter the company name.
Father/Parent - Enter the highest level or Degree of School Completed. Does not include trade schools/occupation-specific certificate programs.

0-11th Grade12th Grade with No DiplomaHigh School DiplomaGeneral Equivalency Diploma (GED)Some College (No Degree)Associate's Degree (e.g., AA, AS, AAS, AAB)Bachelor's Degree (e.g., BA, BSc, BEng)Master's Degree (e.g., MA, MSc, MBA, MSW)Doctorate Degree (e.g., PhD, EdD)Professional Degree (e.g., MD, JD, DDS, LLB)
If 0-11th Grade, Enter Highest Grade Completed:
Father/Parent Usual Occupation:
Work done for the most extended period. Please don't enter the company name.
Father/Parent Kind of Business/Industry:
Do not enter the company name.
Sexual Orientation/Gender Identity

This information is optional and should only be provided by the parent identified in the above fields. This information is confidential and is not printed on the birth certificate.
Mother - What sex appears on your original birth certificate?

MaleFemaleUnknownDecline to respond
Mother - How do you describe your gender identity?

MaleFemaleFemale-to-Male (FTM)/Transgender Male/Trans ManMale-to-Female (MTF)/Transgender Female/Trans WomanNonbinary, Genderqueer, neither exclusively male nor famaleDo not knowDecline to respondOther
Mother - How do you describe your sexual orientation? (If more than one orientation, select the orientation with which you identify most)

Straight or heterosexualLesbian, gay, or homosexualBisexualPansexualDo not knowDecline to respondOther
Father or Parent - What sex appears on your original birth certificate?

MaleFemaleUnknownDecline to respond
Father or Parent - How do you describe your gender identity?

MaleFemaleFemale-to-Male (FTM)/Transgender Male/Trans ManMale-to-Female (MTF)/Transgender Female/Trans WomanNonbinary, Genderqueer, neither exclusively male nor famaleDo not knowDecline to respondOther
Father or Parent - How do you describe your sexual orientation? (If more than one orientation, select the orientation with which you identify most)

Straight or heterosexualLesbian, gay, or homosexualBisexualPansexualDo not knowDecline to respondOther
Parent Giving Birth Residence Address (Required). P.O. Boxes Are Not Acceptable.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County
Medical and Health Data: Birth Parent and Newborn
Did the person giving birth receive Women, Infants, and Children (WIC) food while pregnant?

YesNoUnknown
Did the person giving birth smoke before or during the pregnancy?

YesNo
How many cigarettes per day three months before becoming pregnant?
How many cigarettes during the first three months of pregnancy?
How many cigarettes during the second three months of pregnancy?
How many cigarettes during the last three months of pregnancy?
Birth Parent:
Prepregnancy Weight (LBs)
Delivery Weight (LBs)
Height:
APGAR score (5 minute):
APGAR score (10 minute):
Date Last Normal Menses Began:

MonthDayYear
Date
Date of First Prenatal Care Visit:

MonthDayYear
Date
Month Prenatal Care Began
(e.g., 1st, 2nd, 3rd, Unknown, Etc.)
Date of Last Prenatal Care Visit:

MonthDayYear
Do not enter the delivery date
Number of Prenatal Visits:
Count only visits recorded in the most current record available. Do not estimate additional prenatal visits when the prenatal record is not current. Do not include non-pregnancy-related visits to the ER, visits to confirm pregnancy, nutritionist, dietitian, health educator, etc. Average prenatal visits are approximately 16.
Principal Source of Payment for Prenatal Care:

No Prenatal Care (00)Medi-Cal, without CPSP Support Services (02)Other Governmental PRograms (Federal, State, Local) (05)Private Insurance Company (07)Self Pay (09)Medi-Cal, with CPSP Support Services (13)Unknown (99)Other
Birthweight in Grams:
Obstetric Estimate of Gestation (Completed Weeks)
Hearing Screening

Pass BothRefer OneRefer BothResults PendingWaivedNot Med IndicatedTest Not Available
Number of Previous Live Births Now Living:
Number of Previous Live Births Now Dead:
Date of Last Live Birth (Do not count this child)

MonthDayYear
Date
Number of Miscarriages Before 20 Weeks (Do not count abortions)
Number of Miscarriages After 20 Weeks (Do not count abortions)
Date of Last Miscarriage:

MonthDayYear
Date
Method of Delivery
Final Delivery Route:
Number of Previous Cesarean(s):
Fetal Presentation:
Forceps Attempted But Unsuccessful:

YesNoUnknown
Vacuum Attempted But Unsuccessful:

YesNoUnknown
Expected Source of Payment for Delivery:

Medically Unattended Birth (00)Medi-Cal (02)Other Governmental Programs (Federal, State, Local) (05)Private Insurance (07)Self Pay (09)Other (14)Indian Health Services (15)CHAMPUS/TRICARE (16)Unknown (99)
Mother - Social Security Number
Father/Parent - Social Security Number
Social Security Number Requested for Child:

YesNo
Birth Parent Mailing Address - This is the address where the Child's Social Security Card will be mailed. This mailing address will also be shrared with the Scholarshare Investment Board. P.O. Boxes are allowed. The Social Security Administration guidance limits the Enumeration at Birth programs to hospital births.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County
Requesting The Child's Social Security Number Through The Birth Certificate Process:

NOTICE TO PARENTS: The Social Security Administration guidance limits the Enumeration at Birth program to hospital births. Completion of this form in the hospital will enable you to receive a valuable service from the federal government. Federal law requires that a Social Security Number be provided for all dependents listed on federal tax forms. A Social Security Number is also necessary when applying for welfare or other public assistance benefits for your child. By completing this form and requesting a Social Security Number for your new baby, the California Department of Public Health will transmit your request to the Social Security Administration, and a card will be mailed to you usually within six weeks, eliminating the need for you to personally visit a Social Security office with evidence of your child’s identity, birth date, and citizenship.For certified copies of your child’s birth certificate, contact the health department or the recorder’s office of the county where the birth occurred. You may also obtain an application for a certified copy through the California Department of Public Health by calling (916) 445-2684 or by visiting the web site (https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records.aspx).
Baby's Name as Reported on Birth Certificate
A Social Security Number Cannot Be Issued For a Child That Has Not Been Named
Do you want a Social Security Number (SSN) for your new baby?

YesNo
Please contact the Social Security Administration at 1-800-772-1213 or online at www.ssa.gov for questions or concerns regarding the issuance of your child’s Social Security number or Social Security card.
I acknowledge that I am responsible for reviewing my child’s birth certificate for accuracy and that the birth certificate worksheet is only retained for a limited time period. Beyond that, it will not be the responsibility of the hospital to amend the birth certificate for anything other than an incorrect date of birth, time of birth, sex of infant, or hospital error. All other amendments to the birth certificate are the responsibility of the parent.
Parent's Printed Name
Date Signed

MonthDayYear
Date
Should be Empty:

Birth Certificate Worksheet

Planned Place of Birth:

The birth maiden name of the patient giving birth

If the parents are not married or in an SRDP

Scholarshare Contact Information for Parent Giving Birth.

Birth name of Parent Not Giving Birth or Intended Parent

Scholarshare Contact Information for Parent Not Giving Birth or Intended Parent (Person listed in 6A-6C)

Names of Parent(s)/Informant(s) Signing the Birth Certificate:

Confidential Data Section

Up to three races may be entered for each parent on the birth certificate.

Education:

Sexual Orientation/Gender Identity

Parent Giving Birth Residence Address (Required). P.O. Boxes Are Not Acceptable.

Medical and Health Data: Birth Parent and Newborn

Birth Parent:

Method of Delivery

Requesting The Child's Social Security Number Through The Birth Certificate Process:

A Social Security Number Cannot Be Issued For a Child That Has Not Been Named

Please contact the Social Security Administration at 1-800-772-1213 or online at www.ssa.gov for questions or concerns regarding the issuance of your child’s Social Security number or Social Security card.