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Printable CDC U.S. Standard Certificate of Live Birth Form in PDF

The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the details of a newborn's birth in the United States. This certificate serves not only as a vital record but also as a crucial piece of identification for the child. Understanding its components and purpose can help parents navigate the process of obtaining this important document.

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Printable CDC U.S. Standard Certificate of Live Birth Form in PDF

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CDC U.S. Standard Certificate of Live Birth Preview

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.

Documents used along the form

The CDC U.S. Standard Certificate of Live Birth form is a critical document for registering a birth in the United States. Along with this form, several other documents may be required or useful in the process of establishing identity and citizenship for a newborn. Below are some commonly used forms and documents.

Social Security Card Application: This application is necessary to obtain a Social Security number for the newborn. A Social Security number is essential for tax purposes and access to various government services.
Hospital Birth Record: This document is issued by the hospital where the birth took place. It serves as a preliminary record of the birth and may include details such as the date, time, and location of the birth, as well as the names of the parents.
Parentage Acknowledgment Form: This form is used to establish legal parentage when the parents are not married. It is often required for legal documentation and can help secure parental rights.
Motorcycle Bill of Sale: This essential document facilitates the transfer of ownership for a motorcycle and ensures a legal record of the transaction. For more information, you can access the Motorcycle Bill of Sale form.
Application for a Passport: If parents wish to obtain a passport for their newborn, they will need to fill out this application. A passport is essential for international travel and requires proof of citizenship, which can be established through the birth certificate.

Each of these documents plays a significant role in the legal recognition and identity establishment of a newborn. It is important for parents to gather and complete these forms promptly to ensure a smooth registration process.

Similar forms

Certificate of Death: Similar to the birth certificate, this document records vital information about an individual's death, including the date, place, and cause of death.
Marriage Certificate: This document serves as legal proof of a marriage, detailing the names of the spouses, the date of marriage, and the location where the marriage took place.
Divorce Decree: A legal document that finalizes the dissolution of a marriage. It includes details about the parties involved and any agreements on asset division and custody.
Social Security Card: This card provides a unique identification number for individuals. It is often required for employment and tax purposes, similar to how a birth certificate is used for identification.
Passport: A government-issued document that certifies a person's identity and nationality. Like the birth certificate, it is essential for travel and serves as proof of identity.
Adoption Decree: This legal document finalizes the adoption process, establishing a new legal parent-child relationship. It includes details similar to those found on a birth certificate.
Power of Attorney Form: For those looking to delegate authority, explore the crucial Power of Attorney document options to ensure your legal affairs are in order.
Naturalization Certificate: This document is issued to individuals who have become U.S. citizens through the naturalization process. It contains personal information and serves as proof of citizenship.
Voter Registration Card: This card confirms a person's registration to vote. It includes personal information and is essential for participating in elections, much like a birth certificate is for obtaining certain rights.

Misconceptions

The CDC U.S. Standard Certificate of Live Birth form is an important document for recording the birth of a child in the United States. However, several misconceptions surround this form that can lead to confusion for new parents. Here are five common misunderstandings:

Misconception 1: The form is only needed for legal purposes.

While it is true that the certificate serves legal functions, such as establishing identity and citizenship, it also plays a vital role in public health data collection and statistical analysis.

Misconception 2: Any birth certificate can be used interchangeably.

Not all birth certificates are the same. The CDC U.S. Standard Certificate of Live Birth is a specific form that complies with federal standards, ensuring consistency across states.

Misconception 3: Parents can fill out the form at their convenience.

There is a timeline for submitting the birth certificate. Parents must ensure that the form is completed and submitted within a certain period after the birth to avoid complications.

Misconception 4: The information on the certificate is not important.

Every detail on the certificate is significant. Errors or omissions can lead to issues with identity verification, enrollment in schools, and accessing government services.

Misconception 5: The form is only relevant for the child’s early years.

The birth certificate remains relevant throughout a person’s life. It is often required for various legal processes, including applying for a passport, enrolling in school, or obtaining a driver's license.

Understanding CDC U.S. Standard Certificate of Live Birth

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. It serves as a vital record that captures essential information about the newborn, including the child's name, date and place of birth, and the parents' details. This form is crucial for establishing identity and citizenship.
Who is responsible for completing the birth certificate?
The responsibility for completing the birth certificate typically falls on the attending physician, midwife, or hospital staff. They collect the necessary information during the birth process. However, parents should also ensure that all details are accurate and complete, as they will need to sign the document.
What information is required on the form?
The form requires various pieces of information, including:
- The child's full name
- Date and time of birth
- Place of birth (hospital or home address)
- Parents' names and addresses
- Mother's date of birth
- Father's date of birth
- Parents' marital status
Providing accurate information is vital, as this document will be used for legal and identification purposes throughout the child's life.
How can I obtain a copy of the birth certificate?
To obtain a copy of the birth certificate, parents or legal guardians can typically request it through the vital records office in the state where the birth occurred. This process may involve filling out a request form, providing identification, and paying a fee. Some states also offer online services for convenience.
What should I do if there is an error on the birth certificate?
If an error is discovered on the birth certificate, it is important to address it promptly. Most states allow for corrections to be made, but the process can vary. Generally, you will need to submit a request for correction along with any necessary documentation that supports the change. Contact the vital records office for specific instructions.
Is the birth certificate necessary for obtaining a Social Security number?
Yes, the birth certificate is typically required when applying for a Social Security number for the newborn. The Social Security Administration uses the birth certificate to verify the child's identity and citizenship, which is essential for issuing a Social Security card.
Can a birth certificate be used as proof of citizenship?
Yes, a birth certificate is an important document that can be used as proof of citizenship in the United States. It establishes that the individual was born in the country and is a U.S. citizen. However, for certain legal purposes, additional documentation may be required.
How long does it take to receive a birth certificate after filing the form?
The time it takes to receive a birth certificate can vary by state and the method of application. Generally, it may take anywhere from a few days to several weeks. If you need the certificate urgently, some states offer expedited services for an additional fee.
Are there any fees associated with obtaining a birth certificate?
Yes, there are usually fees associated with obtaining a birth certificate. These fees can vary by state and may depend on whether you are requesting a certified copy or a regular copy. It is advisable to check with the local vital records office for the most accurate and up-to-date fee information.
What if the parents are not married at the time of the birth?
If the parents are not married when the child is born, both parents can still be listed on the birth certificate. However, the father may need to acknowledge paternity, which can involve signing a form. The specific requirements can vary by state, so it is essential to check local regulations.