Outline
The California Birth Certificate Editable Free form serves as a vital tool for parents in documenting their child's birth. This comprehensive worksheet collects essential information that will ultimately be used to create the official birth certificate. Parents must provide accurate details about the birth, including the facility name, location, date, and time of birth. The form also requires personal information about both parents, such as their legal names, addresses, and educational backgrounds. This data is not only crucial for establishing the child's identity, age, and citizenship but also plays a role in public health research, contributing to the understanding of maternal and infant health. Privacy is a key consideration; state laws protect the confidentiality of the information provided, ensuring that sensitive details remain secure. As parents complete this form, they will also be asked to consider additional elements, such as the issuance of a Social Security number for their child and any potential adoption plans. The form is designed to be user-friendly, allowing for easy editing and completion, making the process of obtaining a birth certificate more accessible for families.
Sample - California Birth Certificate Editable Free Form
1/27/2017 PAGE 1
VERSION 29 INDIANA'S BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEETCERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
The information you provide below will be used to create your child’s birth certificate. The birth certificate is a document
that will be used for legal purposes to prove your child’s age, citizenship and parentage. This document will be used by
your child throughout his/her life. State laws provide protection against the unauthorized release of identifying information
from the birth certificates to ensure the confidentiality of the parents and their child.
It is very important that you provide complete and accurate information to all of the questions. In addition to information
used for legal purposes, other information from the birth certificate is used by health and medical researchers to study
and improve the health of mothers and newborn infants. Items such as parent’s education, race, and smoking will be used
for studies but will not appear on copies of the birth certificate issued to you or your child.
____________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________
TYPE OF BIRTH
TYPE OF BIRTH TYPE OF BIRTH
TYPE OF BIRTH -
--
-
PICK ONE:
PICK ONE:PICK ONE:
PICK ONE:
1
11
1Facility name:*
Facility name:* Facility name:*
Facility name:*
!"#
2
22
2City, Town or Location of birth:
City, Town or Location of birth: City, Town or Location of birth:
City, Town or Location of birth:
3
33
3County of birth:
County of birth: County of birth:
County of birth:
4
44
4. Place of birth:
. Place of birth:. Place of birth:
. Place of birth:
!
"#$%
Other (specify, e.g., taxi cab, train, plane __________________________
*Facilities may wish to have pre-set responses (hard-copy and/or electronic) to questions 1-5 for births which occur at their institutions.
5
55
5. Time of birth: ___________
. Time of birth: ___________. Time of birth: ___________
. Time of birth: ___________
AM
AMAM
AM
PM
PMPM
PM
NOON
NOONNOON
NOON
MIDNIGHT
MIDNIGHTMIDNIGHT
MIDNIGHT
6
66
6Date of birth:
Date of birth: Date of birth:
Date of birth: $$ %%&&''''
7
77
7. Plurality
. Plurality. Plurality
. Plurality
(()* +, +*+ -./&.*+ -.+.*+ (0+.*+ (+.*+
12+.*+3!"#4
8
88
8. If not
. If not. If not
. If not
single birth
single birthsingle birth
single birth
1! 5 6 7 8 9 : ; #!
"#4
9.
9. 9.
9. If not single birth, specify number of infants in this
If not single birth, specify number of infants in this If not single birth, specify number of infants in this
If not single birth, specify number of infants in this delivery born alive:
delivery born alive:delivery born alive:
delivery born alive:
&'()*% #4
1/27/2017 PAGE 2
VERSION 29 INDIANA'S BIRTH WORKSHEET
1
11
11
11
1. What will be your
. What will be your . What will be your
. What will be your BABY
BABYBABY
BABY’
’’
’S
SS
S
legal name (as it should appear on the birth certificate)?
legal name (as it should appear on the birth certificate)?legal name (as it should appear on the birth certificate)?
legal name (as it should appear on the birth certificate)?
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
% * (<= #
1
11
12
22
2. MOTHER: What is your current legal name?
. MOTHER: What is your current legal name? . MOTHER: What is your current legal name?
. MOTHER: What is your current legal name?
+ ),*-(.///.(
1
11
13
33
3.
..
.
MOTHER: Where do you usually live
MOTHER: Where do you usually liveMOTHER: Where do you usually live
MOTHER: Where do you usually live--
----
--that is
that isthat is
that is--
----
--where is your household/residence located?
where is your household/residence located?where is your household/residence located?
where is your household/residence located?
"4
(& ( /!
&/"
(4.(+ 2!#
/0)."ountry
2 +> *424?4
1
11
14
44
4. Is
. Is. Is
. Is
this household inside city limits (inside the incorporated limits of the city, town or location
this household inside city limits (inside the incorporated limits of the city, town or location this household inside city limits (inside the incorporated limits of the city, town or location
this household inside city limits (inside the incorporated limits of the city, town or location
where you
where you where you
where you live)?
live)?live)?
live)?
' &@A>
1
11
15
55
5. MOTHER: What is your mailing address?
. MOTHER: What is your mailing address?. MOTHER: What is your mailing address?
. MOTHER: What is your mailing address?
(B)<CD
"4
(& ( /!
&/"
(4.(+ 2!#
/0)."ountry
2 +> *424?4
1
11
16
66
6. MOTHER: What is your date of birth? (Example: 03
. MOTHER: What is your date of birth? (Example: 03. MOTHER: What is your date of birth? (Example: 03
. MOTHER: What is your date of birth? (Example: 03-
--
-04
0404
04-
--
-1977)
1977)1977)
1977)
$$ %%&&'''' 1234
1
11
17
77
7. MOTHER: In
. MOTHER: In. MOTHER: In
. MOTHER: In
what State, U.S. territory, or foreign country were you born?
what State, U.S. territory, or foreign country were you born?what State, U.S. territory, or foreign country were you born?
what State, U.S. territory, or foreign country were you born?
Please specify one
Please specify one Please specify one
Please specify one
of the following:
of the following:of the following:
of the following:
(22
1.( .(E ) /(%
1
%534/,60()(6*67,6(
/8",6,
/8"6,
09%8
1
11
18
88
8. MOTHER: What is your Social Security Number?
. MOTHER: What is your Social Security Number?. MOTHER: What is your Social Security Number?
. MOTHER: What is your Social Security Number?
__
____
___
__
___
____
___
_ _
_ ____
________
______
__ __
__ ____
________
______
____
__--
----
---
--
-_
__
_____
________
_____ _
_ __ _
_ _____
________
_____
__
_--
----
---
--
-_
__
_____
________
_____
_ _
_ ____
________
______ _
__ ___ _
__ _____
________
_____ _
_ __ _
_ _____
________
_____
__
_
1
11
19
99
9. Do you want a Social Security Number issued for your baby?
. Do you want a Social Security Number issued for your baby?. Do you want a Social Security Number issued for your baby?
. Do you want a Social Security Number issued for your baby?
1/27/2017 PAGE 3
VERSION 29 INDIANA'S BIRTH WORKSHEET
!7,6
",
I request that the Social Security Administration assign a Social Security number to the child named on this form and authorize the State to provide
the Social Security Administration with the information from this form which is needed to assign a number. (Either parent, or the legal guardian, may
sign.)
(@
&4$$ %%&&''''
20
2020
20. Will infant be placed for Adoption?
. Will infant be placed for Adoption? . Will infant be placed for Adoption?
. Will infant be placed for Adoption?
!
2
22
21
11
1.
. .
. MOTHER:
MOTHER: MOTHER:
MOTHER: What is the highest level of schooling that you will have completed at the time of
What is the highest level of schooling that you will have completed at the time of What is the highest level of schooling that you will have completed at the time of
What is the highest level of schooling that you will have completed at the time of
delivery? (Check the box that
delivery? (Check the box thatdelivery? (Check the box that
delivery? (Check the box that
best describes your education. If you are currently enrolled, check
best describes your education. If you are currently enrolled, check best describes your education. If you are currently enrolled, check
best describes your education. If you are currently enrolled, check
the box that indicates the previous grade or highest degree received).
the box that indicates the previous grade or highest degree received).the box that indicates the previous grade or highest degree received).
the box that indicates the previous grade or highest degree received).
3 F56
)& ("
/// /(# @/ / (#
%@%/ %( % % %(, %/#
&& &#%& &&( &E% ** =&#
::(%5348,,,,,6,6; 6(
*,,5."1.8.";.(.,6,6;
$).+6...(
0,%,4
0,/,4
Unemployed Unknown
2
22
23
33
3.
. .
. MOTHER:
MOTHER: MOTHER:
MOTHER: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina,
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina,
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
check the “No” check the “No”
check the “No”
box. If
box. Ifbox. If
box. If
Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check the appropriate box
the appropriate boxthe appropriate box
the appropriate box.
..
.
($$*
' %< %</ 2
'
' 2"
' ($$*( (! & 2"#
#
2
22
24
44
4.
. .
. MOTHER:
MOTHER: MOTHER:
MOTHER: What is your race? (Please check
What is your race? (Please check What is your race? (Please check
What is your race? (Please check all that apply
all that applyall that apply
all that apply).
).).
).
, A//
//A!"##
/ 2
= G E
1/#
!> )2 (
1#
1#
MOTHER:
MOTHER: MOTHER:
MOTHER: Additional Information To Be Filled In
Additional Information To Be Filled In Additional Information To Be Filled In
Additional Information To Be Filled In If
IfIf
If
A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
FOR THIS BIRTH
FOR THIS BIRTH FOR THIS BIRTH
FOR THIS BIRTH
If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question 30
3030
30.
..
.
2
22
25. What is Your Phone Number? Required ________________________________________________
5. What is Your Phone Number? Required ________________________________________________5. What is Your Phone Number? Required ________________________________________________
5. What is Your Phone Number? Required ________________________________________________
2
22
26
66
6. What is
. What is . What is
. What is the name of your
the name of yourthe name of your
the name of your
Employer
EmployerEmployer
Employer
(Company name)
(Company name)(Company name)
(Company name)?
? ?
? Optional
OptionalOptional
Optional
1/27/2017 PAGE 4
VERSION 29 INDIANA'S BIRTH WORKSHEET
2
22
27.
7. 7.
7. What is
What is What is
What is your
youryour
your
Employer's address
Employer's addressEmployer's address
Employer's address?
? ?
? Optional
OptionalOptional
Optional
2
22
28.
8. 8.
8. What is
What is What is
What is the name of your
the name of yourthe name of your
the name of your
Medical Insurance Company
Medical Insurance CompanyMedical Insurance Company
Medical Insurance Company?
? ?
? Optional
OptionalOptional
Optional
2
22
29.
9. 9.
9. What is
What is What is
What is your Medical Insurance Policy number?
your Medical Insurance Policy number?your Medical Insurance Policy number?
your Medical Insurance Policy number?
Optional
OptionalOptional
Optional
30
3030
30.
..
.
MOTHER:
MOTHER: MOTHER:
MOTHER: Did you receive WIC (Women, Infants & Children)
Did you receive WIC (Women, Infants & Children)Did you receive WIC (Women, Infants & Children)
Did you receive WIC (Women, Infants & Children)
food for yourself because you
food for yourself because you food for yourself because you
food for yourself because you
were pregnant with this child?
were pregnant with this child?were pregnant with this child?
were pregnant with this child?
!
0;6
31
3131
31.
. .
. MOTHER:
MOTHER: MOTHER:
MOTHER: What is your height?
What is your height?What is your height?
What is your height?
3
33
32
22
2.
. .
. MOTHER:
MOTHER: MOTHER:
MOTHER: What was your pre
What was your preWhat was your pre
What was your pre-
--
-pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you pregnancy weight, that is, your weight immediately before you
pregnancy weight, that is, your weight immediately before you
became pregnan
became pregnanbecame pregnan
became pregnant with this child?
t with this child?t with this child?
t with this child?
"
3
33
33
33
3. Mother’s weight at delivery
. Mother’s weight at delivery. Mother’s weight at delivery
. Mother’s weight at delivery
"
3
33
34
44
4.
..
.
CIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGNCIGARETTE SMOKING BEFORE AND DURING PREGN
CIGARETTE SMOKING BEFORE AND DURING PREGNA
AA
ANCY
NCYNCY
NCY:
: :
: How many cigarettes OR
How many cigarettes OR How many cigarettes OR
How many cigarettes OR
packs of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of thepacks of cigarettes did you smoke on an average day during each of the
packs of cigarettes did you smoke on an average day during each of the
following time periods?
following time periods?following time periods?
following time periods?
If
IfIf
If
you NEVER smoked, enter zero for each time period.
you NEVER smoked, enter zero for each time period.you NEVER smoked, enter zero for each time period.
you NEVER smoked, enter zero for each time period.
# of cigarettes
# of cigarettes# of cigarettes
# of cigarettes
# of packs
# of packs# of packs
# of packs
+" 1
1
( 1
* 1
<=("0351/51+)5150)
!%
,>
&!
2%
% "@
.A>
<>(Mother's name prior to her first
Mother's name prior to her first Mother's name prior to her first
Mother's name prior to her first marriage, (Maiden Name)
marriage, (Maiden Name)marriage, (Maiden Name)
marriage, (Maiden Name)
+ ),*
<?(%53@)),.13!%01/3$5%53153%!%0"/+$
Yes
BC7F
No
BC73
<A(/.1
' !"
If Yes Date Affidavit was signed: ____ ____/____ ____/____ ____ ____ ____
1/27/2017 PAGE 5
VERSION 29 INDIANA'S BIRTH WORKSHEET
!"
If
IfIf
If
No
No No
No please go to question
please go to question please go to question
please go to question 53
5353
53
3
33
39
99
9.
..
.
FATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAMEFATHER'S CURRENT LEGAL NAME
FATHER'S CURRENT LEGAL NAME
% * (<= #
40
4040
40.
..
.
FATHER: What is
FATHER: What is FATHER: What is
FATHER: What is the father's
the father'sthe father's
the father's
date of birth? (Example: 03
date of birth? (Example: 03date of birth? (Example: 03
date of birth? (Example: 03-
--
-04
0404
04-
--
-1977)
1977)1977)
1977)
$$%%&&'''' 1234
4
44
41
11
1. FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born?. FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born?
Please specify one of
Please specify one of Please specify one of
Please specify one of
the following:
the following:the following:
the following:
(22
1.( .(E ) /(%
1
1534/60()(6*67,6(
/8",6
/8"6
09%8
4
44
42
22
2. What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity. What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank. acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
______ ______ ______
______ ______ ____________ ______ ______
______ ______ ______---
------
---______
______ ______
______ ______
____________
______---
------
---______ ______ ______ ______
______ ______ ______ ____________ ______ ______ ______
______ ______ ______ ______
4
44
43
33
3. What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of . What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
box that indicates the pr
box that indicates the prbox that indicates the pr
box that indicates the previous grade or highest degree received).
evious grade or highest degree received).evious grade or highest degree received).
evious grade or highest degree received).
3 F56
)& ("
/// /(# @/ / (#
%@%/ %( % % %(, %/#
&& &#%& &&( &E% ** =&#
BB(8@,,,,(6(*,
..,.(.,66;.);;.1.
(
0,%,4
0,/,4
Unemployed Unknown
4
44
45
55
5. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
($$*
1/27/2017 PAGE 6
VERSION 29 INDIANA'S BIRTH WORKSHEET
' %< %</ 2
'
' 2"
' ($$*( (! & 2"#
#
4
44
46
66
6.
. .
. What is the
What is the What is the
What is the father’s race? Please check one or more races to indicate what he considers
father’s race? Please check one or more races to indicate what he considers father’s race? Please check one or more races to indicate what he considers
father’s race? Please check one or more races to indicate what he considers
himself to be.
himself to be.himself to be.
himself to be.
, A//
//A!"#
/ 2
= G E
1/#
!> )2 (
1#
1#
FATHER
FATHERFATHER
FATHER
Additional Information To Be Filled In
Additional Information To Be Filled In Additional Information To Be Filled In
Additional Information To Be Filled In If
IfIf
If
A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
FOR THIS BIRTH
FOR THIS BIRTH FOR THIS BIRTH
FOR THIS BIRTH
If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question 5
55
53
33
3
47. What is Your Phone Number? Information
47. What is Your Phone Number? Information47. What is Your Phone Number? Information
47. What is Your Phone Number? Information
is required _____
is required _____is required _____
is required _________
________
_____________________________
__________________________________________________
_________________________
4
44
48
88
8.
..
.
What is Your
What is Your What is Your
What is Your C
CC
Current
urrenturrent
urrent
A
AA
Address
ddressddress
ddress
Number, Street, City, State and Zip
Number, Street, City, State and ZipNumber, Street, City, State and Zip
Number, Street, City, State and Zip
Information is required
Information is requiredInformation is required
Information is required
_________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
4
44
49
99
9.
..
.
What is
What is What is
What is the name of your
the name of yourthe name of your
the name of your
Employer (Company name)
Employer (Company name)Employer (Company name)
Employer (Company name)?
??
?
Information is optional
Information is optionalInformation is optional
Information is optional
_________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
50
5050
50.
. .
. What is your Employer's address?
What is your Employer's address?What is your Employer's address?
What is your Employer's address?
Information is optional
Information is optional Information is optional
Information is optional
_________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
51
5151
51.
..
.
What is the name of your Medical Insurance Company?
What is the name of your Medical Insurance Company?What is the name of your Medical Insurance Company?
What is the name of your Medical Insurance Company?
Information is optional
Information is optionalInformation is optional
Information is optional
__
____
_________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________
5
55
52
22
2.
..
.
FATHER
FATHERFATHER
FATHER
What is your Medical Insurance Policy Number
What is your Medical Insurance Policy NumberWhat is your Medical Insurance Policy Number
What is your Medical Insurance Policy Number
Information is optional
Information is optionalInformation is optional
Information is optional
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________
___________________
=<($/$%533"3/C33151+"13
!3) % 09%8
=B($">
<$
>
#
%%&&''''
==($
!@#
%%&&''''
5
55
56
66
6.
. .
. Source of
Source of Source of
Source of pre
prepre
pre-
--
-natal care?
natal care?natal care?
natal care?
1/27/2017 PAGE 7
VERSION 29 INDIANA'S BIRTH WORKSHEET
MD
MDMD
MD
DO
DODO
DO
Clinic
ClinicClinic
Clinic
Other, Specify: ___________________________
Other, Specify: ___________________________Other, Specify: ___________________________
Other, Specify: ___________________________
=?(5,2!
HIJ#4
=A($4%%&&''''
=D(,,6&!
5">A#4"I
>'(,,6&!
5">A#4
"I
>&($ $%%''''
>:(5,,
$>! !
"##
"I4
><($,&>>
!"#4
$%%''''
>B(;2A#4
$E2,7,
&#
)&#
E3,..(
2#!""! #
&#
) #!""!
#&#%#>K
K> > #
>>KK%
#
!"L#!"7;>A
1! $>"#
6I
>A
#
L/C
2 # /+#
E )+?+#
Fertility enhancing drugs, artificial insemination, intrauterine insemination ( Any
2 #
Assisted reproductive technology – Any assisted reproduction technology (ART) technical procedures(e.g.
in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), ZIFT) used to initate the pregnancy.
%!!!!!"< "
">#
' >
Antiretrovirals administered during pregnancy or at delivery
Group B Strep
1/27/2017 PAGE 8
VERSION 29 INDIANA'S BIRTH WORKSHEET
>=(/#,
>>#2A#4
)!
(!
2!#
E E!!#
2/ 2E!2!#
6
66
66
66
6. Was a Standard Licensed Diagnostic test for HIV performed for
. Was a Standard Licensed Diagnostic test for HIV performed for . Was a Standard Licensed Diagnostic test for HIV performed for
. Was a Standard Licensed Diagnostic test for HIV performed for the Mother?
the Mother?the Mother?
the Mother?
YES
YESYES
YES
If Yes give the date the specimen was taken: ______________(MMDDYYYY)
If Yes give the date the specimen was taken: ______________(MMDDYYYY)If Yes give the date the specimen was taken: ______________(MMDDYYYY)
If Yes give the date the specimen was taken: ______________(MMDDYYYY)
If Yes when was the test performed?
If Yes when was the test performed? If Yes when was the test performed?
If Yes when was the test performed?
During pregnancy
During pregnancyDuring pregnancy
During pregnancy
Time of Delivery
Time of DeliveryTime of Delivery
Time of Delivery
NO
NONO
NO
If No give reason (check one below)
If No give reason (check one below)If No give reason (check one below)
If No give reason (check one below)
Mother's Refusal
Mother's RefusalMother's Refusal
Mother's Refusal
HIV Status Know
HIV Status KnowHIV Status Know
HIV Status Known
nn
n
Insurance would not pay
Insurance would not payInsurance would not pay
Insurance would not pay
Other (specify): _______________________________________________________
Other (specify): _______________________________________________________Other (specify): _______________________________________________________
Other (specify): _______________________________________________________
Unknown (Reason why there was no test is unknown)
Unknown (Reason why there was no test is unknown)Unknown (Reason why there was no test is unknown)
Unknown (Reason why there was no test is unknown)
Unknown
Unknown Unknown
Unknown
(Unknown whether or not the test was performed.)
(Unknown whether or not the test was performed.)(Unknown whether or not the test was performed.)
(Unknown whether or not the test was performed.)
>?(%,%!!$!
"$!#2A
#4
2!2"!<!!%&@
(A "!#
+L/>"<#
<!L/!!<"<#
(
>A(8,;, F!F
/!.04
>D(8))
!3)/!6;4$$!!!!
/!66 F$, F5$
%/;6
@, F)),96
%4
0;666,;6
0;60;666
70
7070
70. Onset of Labor
. Onset of Labor . Onset of Labor
. Onset of Labor 2A#4
1/27/2017 PAGE 9
VERSION 29 INDIANA'S BIRTH WORKSHEET
%"MN56( "A
">#56"""#
"O7#*"7#
"MN6I#*">6I
71
7171
71. Characteristics of labor and delivery
. Characteristics of labor and delivery . Characteristics of labor and delivery
. Characteristics of labor and delivery 2A#4
""P!"
"#
/"("!C>
!#
!<!< " ">
!!"!!<#
(#!"!"
< !!<
!#
/"!"""!!
#!">"!
2"M7325II8#2
""!.>Q!
$" A/"!7325II8#
%$!"">
"P!>>#
">>>A4!
!!.!>Q <
! "
<>Q
1!!!!!! !
!#
"/"
!>">"#
/"
7
77
72
22
2. Method of delivery
. Method of delivery . Method of delivery
. Method of delivery +">!>#
2/ 2 
/,!>"R1">
!!#
'
,!>!<"RE!>
!!#
'
2"2A#4
2!< 1/# 1##
" " A" "#
1/"!#
&!2A#4
E$(&!!"">>
!#
E$&!!""#
E$E&!!"!!
#
2< ""
>#
>"R*">> >!
!#
'
1/27/2017 PAGE 10
VERSION 29 INDIANA'S BIRTH WORKSHEET
?<((<">"!#
2A#4
%>"A">"!#
+7<A !
"8"!><#
+>#
.(!>"
!#
/!/$!!#
.>!/"A!
>!<"#
?B(G64
21)4 %0$)#%0"3)4
?=(%>A#4
+"@" "<&"
"#
?>(1/!S!"#
(=I5I
Not Taken
Unknown
9>4
(&'I5I
Not Taken
Unknown
??16&"<">"#
2A#4
/!C>!!">"A
"">!"<<
#
/!C<!!"#"
M:! C P!2/#
2./C!!
>"#
>"!!
"T"<
#
/"!">"/"
<#!!#
(K(K!! !!!"!(
!" <
<"<>2(
#
("TA# !T $$>C
!#&>!!"
>A "<!!(C
!P"!<!>#
<! P<"!P!P
("! #
?A("6%>"
!# 2A#4
/""A/ ""/
>>#
%$("(P"
%%
>#"!>A#
Form Information
| Fact Name | Description |
|---|---|
| Purpose of Birth Certificate | The birth certificate serves as a legal document that verifies a child's age, citizenship, and parentage, playing a crucial role throughout the child's life. |
| Confidentiality Protection | State laws protect the confidentiality of parents and children by restricting unauthorized access to identifying information on birth certificates. |
| Research Use | Information collected on the birth certificate, such as parental education and health factors, is used for health research but remains confidential and does not appear on official copies. |
| Editable Format | The California Birth Certificate Editable Free form allows parents to provide accurate information easily, ensuring the birth certificate reflects the correct details. |
| Governing Laws | The issuance and management of birth certificates in California are governed by the California Health and Safety Code, specifically sections 102100-102145. |
Detailed Guide for Filling Out California Birth Certificate Editable Free
Filling out the California Birth Certificate Editable Free form requires careful attention to detail. The information provided will be used to create an official birth certificate for your child, which will serve various legal purposes throughout their life. It's essential to ensure that all responses are accurate and complete.
- Begin by selecting the type of birth. Choose from the options provided.
- Fill in the facility name where the birth occurred.
- Indicate the city, town, or location of the birth.
- Specify the county of birth.
- Provide the place of birth, including any specific details if applicable.
- Record the time of birth (AM, PM, Noon, or Midnight).
- Enter the date of birth in the required format.
- Indicate the plurality of the birth (single or multiple).
- If applicable, specify the number of infants born alive during this delivery.
- Provide your baby’s legal name as it should appear on the birth certificate.
- Enter the mother's current legal name.
- Provide the mother's residence address.
- Indicate if the residence is inside city limits.
- Fill in the mother's mailing address.
- Record the mother's date of birth.
- Specify the state, U.S. territory, or foreign country where the mother was born.
- Provide the mother's Social Security Number.
- Indicate whether you want a Social Security Number issued for your baby.
- State if the infant will be placed for adoption.
- Provide the highest level of schooling completed by the mother.
- Indicate if the mother is Spanish/Hispanic/Latina.
- Specify the mother's race by checking all that apply.
- Fill in the mother's phone number.
- Provide the name of the mother's employer (optional).
- Fill in the employer's address (optional).
- Specify the name of the medical insurance company (optional).
- Provide the medical insurance policy number (optional).
- Indicate if the mother received WIC benefits during pregnancy.
- Record the mother's height.
- Provide the mother's pre-pregnancy weight.
- Indicate the mother's weight at delivery.
- Answer questions regarding cigarette smoking before and during pregnancy.
- Provide the mother's maiden name.
- Fill in the father's current legal name.
- Record the father's date of birth.
- Specify the state, U.S. territory, or foreign country where the father was born.
- Provide the father’s Social Security Number, if applicable.
- Indicate the highest level of schooling completed by the father.
- State if the father is Spanish/Hispanic/Latino.
Obtain Answers on California Birth Certificate Editable Free
-
What is the purpose of the California Birth Certificate Editable Free form?
This form is used to collect essential information needed to create your child's birth certificate. The birth certificate serves as a legal document that verifies your child's age, citizenship, and parentage. It is important for various legal and identification purposes throughout your child's life.
-
Why is accurate information important?
Providing complete and accurate information is crucial. The details you enter will not only be used for legal documentation but also for health and medical research. This research helps improve the health of mothers and newborns. Inaccurate information could lead to complications in the future.
-
What information is required about the birth?
You will need to provide details such as the facility name, city or town of birth, county of birth, time and date of birth, and plurality. This information helps ensure that the birth certificate accurately reflects the circumstances of the birth.
-
What details are needed about the mother?
Information required includes the mother's current legal name, residence, mailing address, date of birth, place of birth, and Social Security number. Additionally, questions about education level, race, and Hispanic/Latino status are included to assist with health studies.
-
Is information about the father also required?
Yes, the father's current legal name, date of birth, place of birth, and Social Security number are necessary if applicable. If the parents are not married or a paternity acknowledgment has not been completed, the Social Security number may be left blank.
-
What happens if the baby is placed for adoption?
If the infant is to be placed for adoption, there is a specific question on the form that must be answered. This information is crucial for the legal processes involved in adoption.
-
What if I have questions while filling out the form?
If you have questions while completing the form, it is advisable to consult with your healthcare provider or the facility where the birth is taking place. They can provide guidance and ensure that all necessary information is correctly filled out.
-
How is the information from the form protected?
State laws protect the confidentiality of the information provided on the birth certificate. Identifying details about the parents and child are safeguarded against unauthorized release, ensuring privacy.
-
Will the information about the mother’s education and smoking habits appear on the birth certificate?
No, while this information is collected for health studies, it will not be included on the copies of the birth certificate issued to you or your child. Only essential legal information will be displayed.
-
What if I make a mistake on the form?
If you notice a mistake after submitting the form, you may need to follow specific procedures to correct it. It is best to reach out to the issuing authority for guidance on how to amend any errors.
Common mistakes
Completing the California Birth Certificate Editable Free form is a crucial step in documenting your child's birth. However, many parents make common mistakes that can lead to complications later on. Here are ten frequent errors to avoid when filling out this important document.
One of the most prevalent mistakes is leaving out vital information. Each section of the form is designed to capture specific details about your child and your family. Omitting any required fields, such as the baby’s legal name or the mother's date of birth, can delay the processing of the birth certificate. Ensure that every question is answered fully and accurately.
Another common error involves incorrect spelling. Names can be particularly tricky, and a simple typo can create confusion down the line. Double-check the spelling of both the baby's name and the parents' names. This attention to detail helps prevent potential issues with legal documents in the future.
Providing outdated or incorrect addresses is also a frequent oversight. The form asks for the current legal name and address of the parents, which is essential for identification purposes. If your address has changed recently, make sure to update it on the form to avoid complications with receiving the birth certificate.
Parents sometimes forget to indicate the type of birth. Whether the birth occurred in a hospital, at home, or in transit, this information is crucial. Selecting the appropriate option helps ensure that the birth is recorded accurately in state records.
Additionally, some individuals neglect to specify the time of birth. This detail, while it may seem minor, is significant for legal and medical reasons. Always provide the exact time of birth, including whether it was AM or PM, to maintain accuracy.
Another mistake is failing to include the Social Security Number for the baby. If you wish for your child to have a Social Security Number, be sure to indicate this on the form. This step is essential for future benefits and identification.
Many parents also overlook the educational background question. While it may feel irrelevant, this information contributes to health studies and helps researchers understand trends in maternal health. Be sure to provide accurate details about the highest level of education completed.
It’s not uncommon for parents to misunderstand the questions regarding race and ethnicity. Take your time to read these sections carefully and select all that apply. This information is essential for health statistics and community resources.
Finally, some parents fail to sign and date the form correctly. The signature is a critical part of the document, verifying that the information provided is accurate and complete. Always ensure that the form is signed by the appropriate parent or guardian before submission.
By being aware of these common mistakes, parents can navigate the process of filling out the California Birth Certificate Editable Free form more smoothly. Taking the time to review the information and ensure accuracy will save time and prevent potential legal issues in the future.
Documents used along the form
When applying for a California birth certificate, you may encounter several other important forms and documents that are often used in conjunction with it. Each of these documents serves a specific purpose and can help streamline various processes related to your child's identity and legal status. Below is a brief overview of some commonly associated forms.
- Social Security Card Application: This form is used to request a Social Security number for your child. It is essential for tax purposes and may be required for various benefits and services throughout their life.
- Paternity Affidavit: This document establishes the legal father of a child when the parents are not married. It can be crucial for determining custody, child support, and inheritance rights.
- Health Insurance Enrollment Form: This form allows you to enroll your newborn in a health insurance plan. Having health coverage is vital for ensuring your child receives necessary medical care from the start.
- Child's Name Change Application: If you wish to change your child's name after the birth certificate has been issued, this application is required. It outlines the legal process for making such changes.
- Application for a Passport: If you plan to travel internationally with your child, a passport application will be necessary. It ensures that your child has the proper identification for travel purposes.
Understanding these forms and their significance can help you navigate the process of securing your child's legal identity and rights. Each document plays a vital role in ensuring that your child is recognized and protected within the legal system.
Similar forms
The California Birth Certificate Editable Free form shares similarities with several important documents. Here are four documents that are comparable:
- Certificate of Live Birth: This document serves as the official record of a child's birth. Like the California Birth Certificate, it provides essential details such as the child's name, date of birth, and parentage, and is used for legal identification purposes.
- Social Security Card: A Social Security card is crucial for establishing identity and eligibility for benefits. Similar to a birth certificate, it includes personal information, such as the individual's name and Social Security number, which are important for legal and financial matters.
- Passport: A passport is an official document that certifies a person's identity and citizenship. Much like the birth certificate, it is required for international travel and serves as a proof of identity.
- Marriage Certificate: A marriage certificate is a legal document that confirms the union between two individuals. It contains important details about the parties involved, similar to how a birth certificate records vital information about a child and their parents.
Dos and Don'ts
Filling out the California Birth Certificate Editable Free form is an important task that requires careful attention. Here’s a helpful list of things to do and avoid to ensure the process goes smoothly.
- Do provide complete and accurate information for all questions. This ensures that your child’s birth certificate is correct and valid.
- Do use the legal names of both parents as they should appear on the birth certificate.
- Do specify the place of birth clearly, including the facility name and location.
- Do check the box for whether you want a Social Security Number issued for your baby.
- Do ensure that you include your current address and contact information for future correspondence.
- Don't leave any fields blank unless instructed. Missing information can delay processing.
- Don't provide inaccurate or misleading information, as this can lead to legal complications later.
- Don't forget to sign and date the form. An unsigned form may be considered invalid.
- Don't rush through the process. Take your time to review each section before submitting.
By following these guidelines, you can help ensure that your child's birth certificate is filled out correctly and efficiently.
Misconceptions
There are several misconceptions surrounding the California Birth Certificate Editable Free form. Understanding these can help ensure that parents fill out the form correctly and efficiently. Here are four common misunderstandings:
- Misconception 1: The editable form can be submitted without verification of information.
- Misconception 2: All information on the birth certificate will be publicly available.
- Misconception 3: The birth certificate can be easily edited after submission.
- Misconception 4: The birth certificate is only needed for legal purposes.
Many believe that they can simply fill out the editable form and submit it without double-checking their answers. However, it is crucial to provide accurate and complete information, as this document will be used for legal purposes throughout the child's life.
Some parents worry that personal details, such as their education or race, will be accessible to the public. In reality, while this information is collected for health research, it does not appear on the copies issued to parents or children, ensuring confidentiality.
Once the birth certificate is filed, making changes is not a simple process. Parents must be diligent when filling out the form, as corrections can require additional steps and documentation.
While it is true that the birth certificate serves as a legal document to prove age, citizenship, and parentage, it also plays a significant role in health research. The information provided can help improve maternal and infant health, making it essential for parents to take this process seriously.
Key takeaways
Filling out the California Birth Certificate Editable Free form is an important task that requires attention to detail. Here are some key takeaways to consider:
- Purpose of the Birth Certificate: This document serves as a legal proof of your child's age, citizenship, and parentage.
- Confidentiality: State laws protect the information on the birth certificate, ensuring that identifying details remain confidential.
- Accuracy is Crucial: Providing complete and accurate information is essential to avoid complications later.
- Health Research: Some information collected will be used for health studies but will not appear on the official certificate.
- Type of Birth: Indicate the facility name, city, and county of birth, as well as the specific place of birth.
- Legal Name: Ensure the baby's legal name is entered correctly as it will appear on the birth certificate.
- Mother's Information: The form requires detailed information about the mother, including her legal name, address, and education level.
- Father's Information: Similar details are required for the father, including his legal name and date of birth.
- Social Security Number: You can request a Social Security number for your baby through this form.
- Optional Information: Some sections, such as employment and insurance details, are optional but can be helpful.
Completing this form accurately will ensure that your child's birth certificate is processed smoothly and serves its purpose throughout their life.