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Fill Out a Valid CDC U.S. Standard Certificate of Live Birth Form

The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the birth of a child in the United States. This form captures essential details such as the baby's name, date of birth, and parents' information. To ensure accurate record-keeping, it’s important to fill out this form correctly; click the button below to get started.

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Structure

The CDC U.S. Standard Certificate of Live Birth form is a crucial document that plays a significant role in the lives of families and individuals across the United States. This form serves as an official record of a child's birth and contains essential information, including the baby's name, date and place of birth, and the names of the parents. It also captures vital statistics such as the baby's sex, weight, and length at birth. Accurate completion of this form is vital, as it not only provides legal recognition of the child but also facilitates access to various services, including healthcare and education. Furthermore, the data collected through these certificates contribute to public health statistics, helping authorities monitor and improve maternal and infant health outcomes. Understanding the components and importance of the U.S. Standard Certificate of Live Birth is essential for new parents and guardians, ensuring they can navigate the process smoothly and fulfill their responsibilities in documenting their child's entry into the world.

Common mistakes

Incorrect Personal Information: Individuals often make mistakes when entering the names of the parents. Common errors include misspellings or incorrect order of first, middle, and last names.
Missing Signatures: It is essential for both parents to sign the form. Omitting one or both signatures can lead to delays in processing the birth certificate.
Inaccurate Dates: Mistakes in recording the date of birth, date of parents' marriage, or other significant dates can result in complications. Double-checking these details is crucial.
Improper Use of Abbreviations: Some individuals use abbreviations for names or places. The form requires full names and complete addresses to avoid confusion.
Failure to Include All Required Information: Each section of the form must be filled out completely. Leaving sections blank can cause delays or rejection of the application.
Incorrect Birthplace Details: Providing inaccurate information about the place of birth can lead to issues with the registration process. Ensure that the city and state are correctly identified.
Not Following Submission Guidelines: Each state may have specific submission requirements. Not adhering to these can result in delays or the need to resubmit the form.

Preview - CDC U.S. Standard Certificate of Live Birth Form

U.S. STANDARD CERTIFICATE OF LIVE BIRTH

LOCAL FILE NO.							BIRTH NUMBER:
C H I L D	1. CHILD’S NAME (First, Middle, Last, Suffix)			2. TIME OF BIRTH	3. SEX			4. DATE OF BIRTH (Mo/Day/Yr)
C H I L D				(24 hr)
	5. FACILITY NAME (If not institution, give street and number)	6. CITY, TOWN, OR LOCATION OF BIRTH				7. COUNTY OF BIRTH
			8b. DATE OF BIRTH (Mo/Day/Yr)
M O T H E R	8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)		8b. DATE OF BIRTH (Mo/Day/Yr)

8c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix)

8d. BIRTHPLACE (State, Territory, or Foreign Country)

9a. RESIDENCE OF MOTHER-STATE

9b. COUNTY

9c. CITY, TOWN, OR LOCATION

9d. STREET AND NUMBER

9e. APT.

NO.

9f. ZIP CODE

9g. INSIDE CITY

LIMITS?

□ Yes □ No

F A T H E R

10a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)

10b. DATE OF BIRTH (Mo/Day/Yr)

10c. BIRTHPLACE (State, Territory, or Foreign Country)

CERTIFIER

11. CERTIFIER’S NAME: _______________________________________________

12. DATE CERTIFIED

13. DATE FILED BY REGISTRAR

TITLE: □ MD □ DO □ HOSPITAL ADMIN. □ CNM/CM □ OTHER MIDWIFE

______/ ______ / __________

□ OTHER (Specify)_____________________________

YYYY

MM DD

YYYY

INFORMATION FOR ADMINISTRATIVE

USE

M O T H E R

14. MOTHER’S MAILING ADDRESS:

9 Same as residence, or: State:

City, Town, or Location:

Street & Number:

Apartment No.:

Zip Code:

15. MOTHER MARRIED? (At birth, conception, or any time between)

□ Yes

□ No

16. SOCIAL SECURITY NUMBER REQUESTED

17. FACILITY ID. (NPI)

IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? □ Yes

□ No

FOR CHILD?

□ Yes

□ No

18. MOTHER’S SOCIAL SECURITY NUMBER:

19. FATHER’S SOCIAL SECURITY NUMBER:

INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY

M O T H E R

F A T H E R

Mother’s Name ________________

Mother’s Medical Record No. _________________________

20. MOTHER’S EDUCATION (Check the		21. MOTHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		mother is Spanish/Hispanic/Latina. Check the
	the time of delivery)		“No” box if mother is not Spanish/Hispanic/Latina)
□	8th grade or less	□	No, not Spanish/Hispanic/Latina
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latina
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

23. FATHER’S EDUCATION (Check the		24. FATHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		father is Spanish/Hispanic/Latino. Check the
	the time of delivery)		“No” box if father is not Spanish/Hispanic/Latino)
□	8th grade or less	□	No, not Spanish/Hispanic/Latino
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latino
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

22.MOTHER’S RACE (Check one or more races to indicate what the mother considers herself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

25.FATHER’S RACE (Check one or more races to indicate what the father considers himself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

26. PLACE WHERE BIRTH OCCURRED (Check one)	27. ATTENDANT’S NAME, TITLE, AND NPI	28. MOTHER TRANSFERRED FOR MATERNAL
□ Hospital	NAME: _______________________ NPI:_______	MEDICAL OR FETAL INDICATIONS FOR
□ Freestanding birthing center	NAME: _______________________ NPI:_______	DELIVERY? □ Yes □ No
□ Freestanding birthing center		IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	TRANSFERRED FROM:
□ Clinic/Doctor’s office	□ OTHER (Specify)___________________	_______________________________________
□ Other (Specify)_______________________	□ OTHER (Specify)___________________
□ Other (Specify)_______________________

REV. 11/2003

MOTHER

29a. DATE OF FIRST PRENATAL CARE VISIT

29b. DATE OF LAST PRENATAL CARE VISIT

30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

______ /________/ __________ □ No Prenatal Care

______ /________/ __________

M M

D D

YYYY

M M

D D

YYYY

_________________________ (If none, enter A0".)

31. MOTHER’S HEIGHT

32. MOTHER’S

PREPREGNANCY WEIGHT

33. MOTHER’S WEIGHT

AT DELIVERY

34. DID MOTHER GET WIC FOOD FOR HERSELF

_______ (feet/inches)

_________ (pounds)

DURING THIS PREGNANCY? □ Yes □ No

35. NUMBER OF PREVIOUS

36. NUMBER OF OTHER

37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

38. PRINCIPAL SOURCE OF

LIVE BIRTHS (Do not include

PREGNANCY OUTCOMES

For each time period, enter either the number of cigarettes or the

PAYMENT FOR THIS

this child)

(spontaneous or induced

number of packs of cigarettes smoked. IF NONE, ENTER A0".

DELIVERY

losses or ectopic pregnancies)

Average number of cigarettes or packs of cigarettes smoked per day.

□ Private Insurance

35a.

Now Living

35b. Now Dead

36a. Other Outcomes

Number _____

# of cigarettes

# of packs

□ Medicaid

Three Months Before Pregnancy

_________

________

□ Self-pay

First Three Months of Pregnancy

_________

________

□ Other

□ None

Second Three Months of Pregnancy _________

________

(Specify) _______________

Third Trimester of Pregnancy

_________

________

35c. DATE OF LAST LIVE BIRTH

36b. DATE OF LAST OTHER

39. DATE LAST NORMAL MENSES BEGAN

40. MOTHER’S MEDICAL RECORD NUMBER

_______/________

PREGNANCY OUTCOME

______ /________/ __________

Y Y Y Y

_______/________

M M

D D

YYYY

Y Y Y Y

MEDICAL

41. RISK FACTORS IN THIS PREGNANCY

43. OBSTETRIC PROCEDURES (Check all that apply)

46. METHOD OF DELIVERY

(Check all that apply)

AND

Diabetes

□ Cervical cerclage

A. Was delivery with forceps attempted but

HEALTH

□

Prepregnancy

(Diagnosis prior to this pregnancy)

□ Tocolysis

unsuccessful?

□

Gestational

(Diagnosis in this pregnancy)

External cephalic version:

□ Yes

□ No

INFORMATION

B. Was delivery with vacuum extraction attempted

Hypertension

□ Successful

□

Prepregnancy

(Chronic)

□ Failed

but unsuccessful?

□

Gestational

(PIH, preeclampsia)

□ None of the above

□ Yes

□ No

□

Eclampsia

C. Fetal presentation at birth

□ Previous preterm birth

□

Cephalic

44. ONSET OF LABOR (Check all that apply)

□

Breech

□ Other previous poor pregnancy outcome (Includes

□ Premature Rupture of the Membranes (prolonged, ∃12 hrs.)

□

Other

perinatal death, small-for-gestational age/intrauterine

D. Final route and method of delivery (Check one)

growth restricted birth)

□ Precipitous Labor (<3 hrs.)

□ Vaginal/Spontaneous

□ Pregnancy resulted from infertility treatment-If yes,

□ Prolonged Labor (∃ 20 hrs.)

□ Vaginal/Forceps

check all that apply:

□ Vaginal/Vacuum

□ Fertility-enhancing drugs, Artificial insemination or

□ None of the above

□ Cesarean

Intrauterine insemination

If cesarean, was a trial of labor attempted?

□ Assisted reproductive technology (e.g., in vitro

□ Yes

45. CHARACTERISTICS OF LABOR AND DELIVERY

fertilization (IVF), gamete intrafallopian

□ No

(Check all that

apply)

transfer

(GIFT))

□

Induction of labor

47. MATERNAL MORBIDITY (Check all that apply)

□ Mother had a previous cesarean delivery

(Complications associated with labor and

□

Augmentation of labor

If yes, how many __________

delivery)

□

Non-vertex presentation

□

Maternal transfusion

□ None of the above

□ Steroids (glucocorticoids) for fetal lung maturation

□ Third or fourth degree perineal laceration

42. INFECTIONS PRESENT AND/OR TREATED

received by the mother prior to delivery

□

Ruptured uterus

DURING THIS

PREGNANCY (Check all that apply)

□ Antibiotics received by the mother during labor

□

Unplanned hysterectomy

□ Clinical chorioamnionitis diagnosed during labor or

□ Admission to intensive care unit

□

Gonorrhea

maternal temperature >38°C (100.4°F)

□ Unplanned operating room procedure

□

Syphilis

□ Moderate/heavy meconium staining of the amniotic fluid

following delivery

□

Chlamydia

□ Fetal intolerance of labor such that one or more of the

□ None of the above

□

Hepatitis B

following actions was taken: in-utero resuscitative

□

Hepatitis C

measures, further fetal assessment, or operative delivery

□ Epidural or spinal anesthesia during labor

□ None of the above

NEWBORN

Mother’s Name ________________

Mother’s Medical Record No. ____________________

NEWBORN INFORMATION

48. NEWBORN MEDICAL RECORD NUMBER	54. ABNORMAL CONDITIONS OF THE NEWBORN				55. CONGENITAL ANOMALIES OF THE NEWBORN
			(Check all that apply)		□		(Check all that apply)
49. BIRTHWEIGHT (grams preferred, specify unit)	□	Assisted ventilation required immediately				Anencephaly
					□	Meningomyelocele/Spina bifida
______________________		following delivery			□	Cyanotic congenital heart disease
9 grams 9 lb/oz	□				□	Congenital diaphragmatic hernia
		Assisted ventilation required for more than
					□	Omphalocele
		six hours
50. OBSTETRIC ESTIMATE OF GESTATION:					□	Gastroschisis

_________________ (completed weeks)	□	NICU admission			□	Limb reduction defect (excluding congenital
						amputation and dwarfing syndromes)
	□	Newborn given surfactant replacement			□ Cleft Lip with or without Cleft Palate
					□	Cleft Palate alone
		therapy
51. APGAR SCORE:
					□	Down Syndrome
Score at 5 minutes:________________________
	□	Antibiotics received by the newborn for				□	Karyotype confirmed
If 5 minute score is less than 6,
Score at 10 minutes: _______________________		suspected neonatal sepsis			□	□	Karyotype pending
	□	Seizure or serious neurologic dysfunction				Suspected chromosomal disorder
						□	Karyotype confirmed
52. PLURALITY - Single, Twin, Triplet, etc.	□ Significant birth injury (skeletal fracture(s), peripheral				□	□	Karyotype pending
						Hypospadias
(Specify)________________________		nerve	injury, and/or soft tissue/solid organ hemorrhage
					□	None of the anomalies listed above
		which	requires intervention)
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________	9 None of the above


56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No				57. IS INFANT LIVING AT TIME OF REPORT?				58. IS THE INFANT BEING
IF YES, NAME OF FACILITY INFANT TRANSFERRED				□ Yes □ No □ Infant transferred, status unknown				BREASTFED AT DISCHARGE?
TO:______________________________________________________								□ Yes □ No

Rev. 11/2003

NOTE: This recommended standard birth certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future

activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.

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Documents used along the form

The CDC U.S. Standard Certificate of Live Birth is a crucial document for establishing a person's identity and citizenship. However, there are several other forms and documents that are often used in conjunction with this certificate. Each serves a specific purpose in the process of documenting a birth and ensuring that all legal and administrative requirements are met.

Application for a Birth Certificate: This form is typically submitted to the vital records office to officially request a certified copy of the birth certificate.
Affidavit of Parentage: This document is used to establish the legal relationship between a child and their parents, especially in cases where parents are unmarried.
Social Security Number Application: Parents may need to fill out this form to obtain a Social Security number for their newborn, which is essential for tax and identification purposes.
Certificate of Live Birth Registration: In some states, this document serves as a formal record of the birth and may be required for certain legal processes.
Health Insurance Enrollment Form: Parents often complete this form to add their newborn to their health insurance plan, ensuring medical coverage from birth.
Employment Verification Form: For those seeking employment confirmation, the essential Employment Verification form overview provides important insights into its use and significance.
Consent for Medical Treatment: This document allows parents to authorize medical treatment for their newborn, which may be necessary in emergency situations.
Newborn Screening Consent Form: This form is used to obtain consent for the necessary health screenings that are performed shortly after birth to detect potential health issues.

These documents play an important role in the administrative process following a birth. Understanding each form's purpose can help parents navigate the necessary steps to secure their child's legal identity and rights.

Similar forms

The CDC U.S. Standard Certificate of Live Birth form is similar to the Certificate of Death. Both documents serve as vital records that officially document significant life events. While the birth certificate records the arrival of a new individual into the world, the death certificate marks the end of life. Each document includes essential information such as names, dates, and places, ensuring that they are both legally recognized and can be used for various administrative purposes. They are crucial for establishing identity and lineage, and they play important roles in public health statistics and legal matters.

In today's world, various forms play critical roles in validating personal information, including the Top Forms Online which provides an Employment Verification Form. This document is essential for confirming an individual's background and can vastly influence an individual's prospects in employment, housing, and finance. Understanding these forms ensures individuals can provide the necessary information when required, whether for job applications or securing loans.

Another document comparable to the Certificate of Live Birth is the Marriage Certificate. This document signifies the legal union between two individuals. Like the birth certificate, it contains vital information, including the names of the parties involved, the date of the marriage, and the location where the marriage took place. Both certificates are foundational for establishing family relationships and are often required for legal processes, such as applying for spousal benefits or changing one’s name.

The Adoption Certificate also shares similarities with the Certificate of Live Birth. This document formalizes the legal relationship between an adoptive parent and a child. It serves as proof of the adoption and includes details such as the names of the adoptive parents, the adopted child's name, and the date of adoption. Both certificates are essential for legal identification and can affect inheritance rights, access to medical history, and other legal matters related to family dynamics.

Lastly, the Social Security Card is another document that relates closely to the Certificate of Live Birth. While the birth certificate establishes an individual’s identity at birth, the Social Security Card provides a unique identification number used for various purposes throughout a person’s life. Both documents are vital for accessing government services, employment, and benefits. They work together to ensure that individuals are recognized within the legal and social systems of the United States.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Live Birth form, it is crucial to follow specific guidelines to ensure accuracy and compliance. Below are four essential do's and don'ts to keep in mind.

Do provide accurate information about the newborn's date of birth.
Do include the full names of both parents as they appear on legal documents.
Don't leave any required fields blank; all sections must be completed.
Don't use correction fluid or tape to alter information; if a mistake is made, it is best to draw a single line through the error and write the correct information beside it.

Key takeaways

When filling out and using the CDC U.S. Standard Certificate of Live Birth form, it’s essential to keep several key points in mind. Here are some important takeaways:

Accuracy is crucial: Ensure all information is correct to avoid complications later on.
Provide complete details: Include all required fields, such as the baby's name, date of birth, and parents' information.
Use clear handwriting: If filling out the form by hand, write legibly to prevent misinterpretation.
Check for updates: Be aware that the form may be updated; always use the latest version available.
Know the filing deadlines: Submit the completed form within the timeframe required by your state to ensure timely registration.
Keep copies: Make sure to keep a copy of the completed form for your records.
Consult local guidelines: Different states may have specific requirements or additional forms needed.
Seek assistance if needed: If you have questions, don’t hesitate to ask for help from hospital staff or local health departments.

By following these guidelines, you can ensure a smoother process when registering your child's birth.

How to Use CDC U.S. Standard Certificate of Live Birth

Filling out the CDC U.S. Standard Certificate of Live Birth form is an important step in documenting a new birth. Make sure to gather all necessary information before starting. This will help ensure accuracy and completeness.

Begin with the child's information. Enter the full name, date of birth, and place of birth. Make sure the spelling is correct.
Next, provide the mother's information. Include her full name, date of birth, and place of birth. If applicable, note her maiden name.
Then, fill in the father's information. Include his full name, date of birth, and place of birth.
In the next section, provide details about the parents' marital status at the time of the child's birth.
Complete the section on attendant information. This includes the name and title of the person who assisted with the birth.
Record the hospital or facility name where the birth took place. If the birth occurred at home, indicate that clearly.
Check all entered information for accuracy before submitting. Ensure that every section is filled out completely.

After completing the form, you will need to submit it according to your state’s requirements. This typically involves filing it with the appropriate vital records office. Be sure to keep a copy for your records.