Homepage Blank CDC U.S. Standard Certificate of Live Birth Form
Outline

The CDC U.S. Standard Certificate of Live Birth form plays a crucial role in documenting the vital event of birth in the United States. This form captures essential information about the newborn, including the child’s name, date of birth, and place of birth. It also records details about the parents, such as their names, addresses, and dates of birth, which helps establish the legal identity of the child. The form includes sections for medical information, such as the attending physician’s name and any complications during delivery, providing a comprehensive overview of the birth event. Additionally, it serves as an important tool for public health data collection, contributing to statistics that inform health policies and programs. The standardization of this form across states ensures consistency in how births are recorded, making it easier for researchers and policymakers to access and analyze data. Understanding the significance of this form is vital for parents, healthcare providers, and public health officials alike.

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

U.S. STANDARD CERTIFICATE OF LIVE BIRTH
LOCAL FILE NO. BIRTH NUMBER:
CHILD
1. CHILD’S NAME (First, Middle, Last, Suffix)
2. TIME OF BIRTH
(24 hr)
3. SEX
4. DATE OF BIRTH (Mo/Day/Yr)
5. FACILITY NAME
(If not institution, give street and number) 6. CITY, TOWN, OR LOCATION OF BIRTH
7. COUNTY OF BIRTH
MOTHER
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
FATHER
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: _______________________________________________
TITLE: MD DO HOSPITAL ADMIN. CNM/CM OTHER MIDWIFE
OTHER (Specify)_____________________________
12. DATE CERTIFIED
______/ ______ / __________
MM DD YYYY
13. DATE FILED BY REGISTRAR
______/ ______ / __________
MM DD YYYY
INFORMATION FOR ADMINISTRATIVE USE
MOTHER
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
IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? Yes No
16. SOCIAL SECURITY NUMBER REQUESTED
FOR CHILD? Yes No
17. FACILITY ID. (NPI)
18. MOTHER’S SOCIAL SECURITY NUMBER: 19. FATHER’S SOCIAL SECURITY NUMBER:
INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY
MOTHER
20. MOTHER’S EDUCATION (Check the
box that best describes the highest
degree or level of school completed at
the time of delivery)
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED
completed
Some college credit but no degree
Associate degree (e.g., AA, AS)
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)
21. MOTHER OF HISPANIC ORIGIN? (Check
the box that best describes whether the
mother is Spanish/Hispanic/Latina. Check the
“No” box if mother is not Spanish/Hispanic/Latina)
No, not Spanish/Hispanic/Latina
Yes, Mexican, Mexican American, Chicana
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latina
(Specify)_____________________________
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)___________________________________
FATHER
Mother’s Name
________________
Mother’s Medical Record
No.
_________________________
23. FATHER’S EDUCATION (Check the
box that best describes the highest
degree or level of school completed at
the time of delivery)
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED
completed
Some college credit but no degree
Associate degree (e.g., AA, AS)
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)
24. FATHER OF HISPANIC ORIGIN? (Check
the box that best describes whether the
father is Spanish/Hispanic/Latino. Check the
“No” box if father is not Spanish/Hispanic/Latino)
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
(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)
Hospital
Freestanding birthing center
Home Birth: Planned to deliver at home? 9 Yes 9 No
Clinic/Doctor’s office
Other (Specify)_______________________
27. ATTENDANT’S NAME, TITLE, AND NPI
NAME: _______________________ NPI:_______
TITLE: MD DO CNM/CM OTHER MIDWIFE
OTHER (Specify)___________________
28. MOTHER TRANSFERRED FOR MATERNAL
MEDICAL OR FETAL INDICATIONS FOR
DELIVERY?
Yes No
IF YES, ENTER NAME OF FACILITY MOTHER
TRANSFERRED FROM:
_______________________________________
REV. 11/2003
MOTHER
29a. DATE OF FIRST PRENATAL CARE VISIT
______ /________/ __________
No Prenatal Care
M M D D YYYY
29b. DATE OF LAST PRENATAL CARE VISIT
______ /________/ __________
M M D D YYYY
30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY
_________________________ (If none, enter A0".)
31. MOTHER’S HEIGHT
_______ (feet/inches)
32. MOTHER’S PREPREGNANCY WEIGHT
_________ (pounds)
33. MOTHER’S WEIGHT AT DELIVERY
_________ (pounds)
34. DID MOTHER GET WIC FOOD FOR HERSELF
DURING THIS PREGNANCY?
Yes No
35. NUMBER OF PREVIOUS
LIVE BIRTHS (Do not include
this child)
36. NUMBER OF OTHER
PREGNANCY OUTCOMES
(spontaneous or induced
losses or ectopic pregnancies)
35a. Now Living
Number _____
None
35b. Now Dead
Number _____
None
36a. Other Outcomes
Number _____
None
37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY
For each time period, enter either the number of cigarettes or the
number of packs of cigarettes smoked. IF NONE, ENTER A0".
Average number of cigarettes or packs of cigarettes smoked per day.
# of cigarettes # of packs
Three Months Before Pregnancy _________ OR ________
First Three Months of Pregnancy _________ OR ________
Second Three Months of Pregnancy _________ OR ________
Third Trimester of Pregnancy _________ OR ________
38. PRINCIPAL SOURCE OF
PAYMENT FOR THIS
DELIVERY
Private Insurance
Medicaid
Self-pay
Other
(Specify) _______________
35c. DATE OF LAST LIVE BIRTH
_______/________
MM Y Y Y Y
36b. DATE OF LAST OTHER
PREGNANCY OUTCOME
_______/________
MM Y Y Y Y
39. DATE LAST NORMAL MENSES BEGAN
______ /________/ __________
M M D D YYYY
40. MOTHER’S MEDICAL RECORD NUMBER
MEDICAL
AND
HEALTH
INFORMATION
43. OBSTETRIC PROCEDURES (Check all that apply)
Cervical cerclage
Tocolysis
External cephalic version:
Successful
Failed
None of the above
44. ONSET OF LABOR (Check all that apply)
Premature Rupture of the Membranes (prolonged, 12 hrs.)
Precipitous Labor (<3 hrs.)
Prolonged Labor ( 20 hrs.)
None of the above
46. METHOD OF DELIVERY
A. Was delivery with forceps attempted but
unsuccessful?
Yes No
B. Was delivery with vacuum extraction attempted
but unsuccessful?
Yes No
C. Fetal presentation at birth
Cephalic
Breech
Other
D. Final route and method of delivery (Check one)
Vaginal/Spontaneous
Vaginal/Forceps
Vaginal/Vacuum
Cesarean
If cesarean, was a trial of labor attempted?
Yes
No
41. RISK FACTORS IN THIS PREGNANCY
(Check all that apply)
Diabetes
Prepregnancy (Diagnosis prior to this pregnancy)
Gestational (Diagnosis in this pregnancy)
Hypertension
Prepregnancy (Chronic)
Gestational (PIH, preeclampsia)
Eclampsia
Previous preterm birth
Other previous poor pregnancy outcome (Includes
perinatal death, small-for-gestational age/intrauterine
growth restricted birth)
Pregnancy resulted from infertility treatment-If yes,
check all that apply:
Fertility-enhancing drugs, Artificial insemination or
Intrauterine insemination
Assisted reproductive technology (e.g., in vitro
fertilization (IVF), gamete intrafallopian
transfer (GIFT))
Mother had a previous cesarean delivery
If yes, how many __________
None of the above
42. INFECTIONS PRESENT AND/OR TREATED
DURING THIS PREGNANCY (Check all that apply)
Gonorrhea
Syphilis
Chlamydia
Hepatitis B
Hepatitis C
None of the above
45. CHARACTERISTICS OF LABOR AND DELIVERY
(Check all that apply)
Induction of labor
Augmentation of labor
Non-vertex presentation
Steroids (glucocorticoids) for fetal lung maturation
received by the mother prior to delivery
Antibiotics received by the mother during labor
Clinical chorioamnionitis diagnosed during labor or
maternal temperature >38°C (100.4°F)
Moderate/heavy meconium staining of the amniotic fluid
Fetal intolerance of labor such that one or more of the
following actions was taken: in-utero resuscitative
measures, further fetal assessment, or operative delivery
Epidural or spinal anesthesia during labor
None of the above
47. MATERNAL MORBIDITY (Check all that apply)
(Complications associated with labor and
delivery)
Maternal transfusion
Third or fourth degree perineal laceration
Ruptured uterus
Unplanned hysterectomy
Admission to intensive care unit
Unplanned operating room procedure
following delivery
None of the above
NEWBORN INFORMATION
48. NEWBORN MEDICAL RECORD NUMBER
NEWBORN
49. BIRTHWEIGHT (grams preferred, specify unit)
______________________
9 grams 9 lb/oz
50. OBSTETRIC ESTIMATE OF GESTATION:
_________________ (completed weeks)
51. APGAR SCORE:
Score at 5 minutes:________________________
If 5 minute score is less than 6,
Score at 10 minutes: _______________________
52. PLURALITY - Single, Twin, Triplet, etc.
(Specify)________________________
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________
54. ABNORMAL CONDITIONS OF THE NEWBORN
(Check all that apply)
Assisted ventilation required immediately
following delivery
Assisted ventilation required for more than
six hours
NICU admission
Newborn given surfactant replacement
therapy
Antibiotics received by the newborn for
suspected neonatal sepsis
Seizure or serious neurologic dysfunction
Significant birth injury (skeletal fracture(s), peripheral
nerve injury, and/or soft tissue/solid organ hemorrhage
which requires intervention)
9 None of the above
55. CONGENITAL ANOMALIES OF THE NEWBORN
(Check all that apply)
Anencephaly
Meningomyelocele/Spina bifida
Cyanotic congenital heart disease
Congenital diaphragmatic hernia
Omphalocele
Gastroschisis
Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
Cleft Lip with or without Cleft Palate
Cleft Palate alone
Down Syndrome
Karyotype confirmed
Karyotype pending
Suspected chromosomal disorder
Karyotype confirmed
Karyotype pending
Hypospadias
None of the anomalies listed above
Mother’s Name
________________
Mother’s Medical Record
No. ____________________
56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No
IF YES, NAME OF FACILITY INFANT TRANSFERRED
TO:______________________________________________________
57. IS INFANT LIVING AT TIME OF REPORT?
Yes No Infant transferred, status unknown
58. IS THE INFANT BEING
BREASTFED AT DISCHARGE?
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
.

Form Information

Fact Name Description
Purpose The CDC U.S. Standard Certificate of Live Birth form is used to record the birth of a child in the United States.
Standardization This form is standardized across states to ensure consistency in birth data collection and reporting.
State-Specific Forms Each state may have its own version of the form, governed by state laws related to vital records.
Legal Importance The completed certificate serves as an official legal document for identity, citizenship, and parental rights.

Detailed Guide for Filling Out CDC U.S. Standard Certificate of Live Birth

Filling out the CDC U.S. Standard Certificate of Live Birth form is essential for officially recording the birth of a child. After completing the form, it will need to be submitted to the appropriate state office to ensure the birth is registered and a birth certificate is issued.

  1. Begin by entering the child's full name in the designated section. Include the first, middle, and last names.
  2. Fill in the child's date of birth. Use the format MM/DD/YYYY.
  3. Provide the place of birth. This includes the city, county, and state where the birth occurred.
  4. Indicate the sex of the child by checking the appropriate box for male or female.
  5. List the mother's full name, including her maiden name. Ensure all names are spelled correctly.
  6. Enter the mother's date of birth. Again, use the format MM/DD/YYYY.
  7. Provide the mother's place of birth, including city and state.
  8. List the father's full name. Include any suffixes, such as Jr. or Sr.
  9. Enter the father's date of birth using the MM/DD/YYYY format.
  10. Provide the father's place of birth, including city and state.
  11. Fill out the information regarding the parents' marital status at the time of the child's birth.
  12. Complete the section for the mother's address. Include street address, city, state, and ZIP code.
  13. Provide the father's address in the same format as the mother's.
  14. Sign and date the form at the bottom. The signature should be that of the parent or guardian completing the form.

Once all sections are filled out accurately, review the form for any errors. After confirming the information is correct, submit the form to the appropriate state vital records office for processing.

Obtain Answers on CDC U.S. Standard Certificate of Live Birth

  1. What is the 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 serves as a vital record that provides essential information about the child, the parents, and the circumstances of the birth. It is crucial for obtaining legal identification, enrolling in school, and accessing various services.

  2. Who is responsible for completing the birth certificate?

    The responsibility for completing the birth certificate typically falls on the attending physician or midwife. However, parents or guardians should ensure that all information is accurate and complete. Once the birth occurs, the healthcare provider will fill out the necessary details and submit the form to the appropriate state or local vital records office.

  3. What information is required on the birth certificate?

    The birth certificate includes several important pieces of information, such as:

    • The child's full name
    • Date and time of birth
    • Place of birth (city and state)
    • Gender of the child
    • Parents' names, addresses, and dates of birth
    • Information about the attending physician or midwife

    Accurate information is vital, as it can impact the child's legal status and access to services.

  4. How can I obtain a copy of the birth certificate?

    To obtain a copy of a birth certificate, you typically need to contact the vital records office in the state where the birth occurred. Each state has its own process, which may include submitting a request form, providing identification, and paying a fee. It is advisable to check the specific requirements for your state to ensure a smooth process.

  5. Can the information on the birth certificate be changed?

    Yes, changes can be made to the birth certificate, but the process varies by state. Common reasons for changes include correcting spelling errors or updating parental information. Generally, a formal request must be submitted, along with any required documentation and fees. It is essential to follow the specific procedures outlined by the state’s vital records office.

  6. Why is the birth certificate important?

    The birth certificate is a crucial document for several reasons. It serves as proof of identity and citizenship. Additionally, it is often required for enrolling in school, applying for a passport, and accessing healthcare and social services. Having an accurate and official birth certificate is vital for a child's future opportunities and rights.

  7. What should I do if I cannot find my child's birth certificate?

    If you cannot locate your child's birth certificate, the first step is to check any personal records you may have. If it is still missing, contact the vital records office in the state where your child was born. They can guide you through the process of obtaining a replacement copy. Be prepared to provide identification and any necessary information to facilitate the request.

Common mistakes

Filling out the CDC U.S. Standard Certificate of Live Birth form can be straightforward, but many people make common mistakes that can lead to complications. One frequent error is providing incorrect or incomplete information about the parents. For instance, if the parents' names are misspelled or the wrong social security numbers are listed, it can create issues when trying to obtain a birth certificate later. Always double-check the spelling of names and ensure that all required fields are filled out completely.

Another mistake involves the date and time of birth. Parents sometimes forget to include this critical information or may write it incorrectly. The exact date and time are vital for legal records and can affect the issuance of the birth certificate. Make sure to confirm the details with the hospital or birthing center to ensure accuracy.

Additionally, many individuals overlook the section regarding the place of birth. This includes not just the name of the hospital or birthing facility but also the city and state. Incomplete or inaccurate information in this section can lead to delays in processing the birth certificate. It’s essential to verify the exact address and name of the place where the birth occurred.

Finally, some people fail to sign the form or neglect to have the necessary witnesses sign it. A signature is required to validate the information provided. Without it, the form may be deemed invalid, causing further delays. Ensure that all signatures are obtained before submitting the form to avoid any issues.

Documents used along the form

The CDC U.S. Standard Certificate of Live Birth form is a crucial document for recording the birth of a child. Alongside this form, several other documents may be necessary for various purposes, such as legal identification, citizenship, and health records. Below is a list of commonly used forms and documents that often accompany the birth certificate.

  • Social Security Card Application - This form is used to apply for a Social Security number for the newborn, which is essential for tax purposes and accessing government services.
  • Application for State ID or Driver’s License - Some states allow parents to apply for a state-issued ID for their child, which can be useful for identification purposes.
  • Health Insurance Enrollment Form - This document is necessary for adding the newborn to a health insurance plan, ensuring access to medical care from an early age.
  • Passport Application - If parents wish to travel internationally with their newborn, a passport application will be required, along with the birth certificate.
  • Child Custody Agreement - In cases of separation or divorce, a custody agreement may be needed to establish parental rights and responsibilities concerning the child.
  • Immunization Records - Keeping track of vaccinations is important for the child’s health and may be required for school enrollment or travel.
  • School Enrollment Forms - These forms are necessary when registering a child for school and often require proof of age, such as a birth certificate.
  • Affidavit of Parentage - This document may be used to establish legal parentage when the parents are not married or when there are questions about paternity.
  • Medical Records Release Form - This form allows parents to obtain or share their child’s medical records with healthcare providers or schools.

Having these documents prepared and organized can facilitate various processes related to the care and legal status of a newborn. Each document serves a specific purpose, ensuring that the child's rights and needs are met from the very beginning.

Similar forms

The CDC U.S. Standard Certificate of Live Birth form serves as an important document for recording vital information about a newborn. Several other documents share similarities in purpose and function. Here’s a list of seven such documents:

  • Certificate of Death: This document records the details surrounding an individual's death, similar to how the birth certificate captures essential information about a birth.
  • Marriage Certificate: Like the birth certificate, this document officially records a significant life event, providing legal recognition of the marriage.
  • Divorce Decree: This document outlines the legal dissolution of a marriage, serving as a formal record similar to how a birth certificate records the beginning of life.
  • Adoption Certificate: This document legally establishes the relationship between an adoptive parent and child, paralleling the birth certificate's role in documenting biological relationships.
  • Social Security Card: While it serves a different purpose, the Social Security card is another official document that provides a unique identifier for individuals, much like a birth certificate does for newborns.
  • Passport: This document serves as a legal form of identification for international travel, similar to how a birth certificate serves as proof of identity and citizenship.
  • Voter Registration Card: This card officially registers an individual to vote, functioning as a vital record of civic engagement, akin to how a birth certificate marks the beginning of a person’s legal identity.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Live Birth form, accuracy and attention to detail are crucial. Here are some important dos and don'ts to consider:

  • Do ensure that all information is accurate and complete.
  • Do use black or blue ink to fill out the form.
  • Do print clearly to avoid any misinterpretation of your handwriting.
  • Do double-check all dates and names for correct spelling.
  • Do submit the form promptly after the birth to avoid delays in registration.
  • Don't leave any required fields blank; if something does not apply, indicate that appropriately.
  • Don't use correction fluid or tape to alter any information on the form.
  • Don't provide inaccurate information, as this can lead to legal issues later.
  • Don't forget to sign the form, as an unsigned document may be considered invalid.
  • Don't submit the form without reviewing it for errors or omissions.

Misconceptions

Many people have misunderstandings about the CDC U.S. Standard Certificate of Live Birth form. Here are ten common misconceptions and clarifications regarding the form:

  1. All states use the same form.

    While the CDC provides a standard template, each state may have variations in their forms to meet local requirements.

  2. Only hospitals can issue birth certificates.

    Birth certificates can be issued by authorized entities, including local health departments, not just hospitals.

  3. Birth certificates are automatically sent to parents.

    Parents typically need to request a copy of the birth certificate after the birth is registered.

  4. The form must be filled out in person.

    Many states allow parents to complete the form online or through mail, depending on their policies.

  5. Only the mother’s information is required.

    Both parents' information is usually required, including names and sometimes addresses.

  6. Birth certificates are only needed for travel.

    They are often required for various purposes, such as enrolling in school or obtaining a passport.

  7. Amendments to the birth certificate are impossible.

    Corrections or changes can be made, but the process may vary by state and require documentation.

  8. The certificate is valid for a lifetime.

    While the certificate does not expire, certain agencies may require recent copies for verification.

  9. All information on the form is public.

    Some details are protected and not available to the public, depending on state laws.

  10. Once filed, the information cannot be changed.

    Changes can be made under specific circumstances, such as legal name changes or corrections.

Key takeaways

Filling out the CDC U.S. Standard Certificate of Live Birth form is an important task that requires attention to detail. Here are key takeaways to consider:

  • Accuracy is crucial. Ensure that all information is correct and matches official documents to avoid complications later.
  • Complete all sections. Every part of the form must be filled out, including the child's name, date of birth, and parents' information.
  • Use clear handwriting. If completing the form by hand, write legibly to ensure that all details can be easily read.
  • Provide identification. Some states require identification for parents when submitting the form, so be prepared to provide this documentation.
  • Submit promptly. File the certificate with the appropriate state office as soon as possible to ensure the child’s birth is officially recorded.
  • Understand state-specific requirements. Different states may have unique regulations or additional forms, so check with local authorities.
  • Keep copies. Retain a copy of the completed form for your records, as it may be needed for future identification or legal purposes.

By following these guidelines, you can help ensure that the birth certificate is accurately completed and submitted without delay.