Indiana Certificate Of Live Birth Worksheet Template

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Mother’s Name_______________________________________
Mother’s Medical Record #_____________________________
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE OF LIVE BIRTH WORKSHEET
CERTIFICATE 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 - - - - PICK ONE:
PICK ONE:
TYPE OF BIRTH
TYPE OF BIRTH
PICK ONE:
PICK ONE:
Born at Facility
Born En-Route to Facility
Born at Non Participating Facility
Born En-Route to Non Participating Facility
Home Birth
Foundling
1 1 1 1 . Facility name:*
Facility name:* ____________________________________________________________________
Facility name:*
Facility name:*
(If not institution, give street and number)
2 2 2 2 . City, Town or Location of birth:
City, Town or Location of birth:
City, Town or Location of birth: ______________________________________________________
City, Town or Location of birth:
3 3 3 3 . County of birth:
County of birth:
County of birth: ____________________________________________________________________
County of birth:
4 4 4 4 . P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
. P l a c e o f b i r t h :
Hospital
Freestanding birthing center ( freestanding birthing center is one that has no direct
physical connection to a hospital)
Home birth
Planned to deliver at home?
Yes
No
Clinic/Doctor’s Office
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 5 5 5 . Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
. Time of birth: ___________
AM
AM
AM
AM
PM
PM
PM
PM
NOON
NOON
NOON
NOON
MIDNIGHT
MIDNIGHT
MIDNIGHT
MIDNIGHT
6 6 6 6 . Date of birth:
Date of birth:
Date of birth: ___ ___/___ ___/___ ___ ___ ___
Date of birth:
M M D D Y Y Y Y
7 7 7 7 . Plurality
. Plurality
. Plurality
. Plurality
(Specify SINGLE, TWIN, TRIPLET, QUADRUPLET, QUINTUPLET, SEXTUPLET, SEPTUPLET, or
OCTUPLET for 8 or more. (Include all live births and fetal losses resulting from this pregnancy.):______________
8 8 8 8 . If not single birth
. If not single birth
. If not single birth
. If not single birth
(Order delivered in the pregnancy, specify 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, etc.) (Include all live
births and fetal losses resulting from this pregnancy): ________________________
9. 9. 9. 9. If not single birth, specify number of infants in this delivery born alive:
If not single birth, specify number of infants in this delivery born alive:_________
If not single birth, specify number of infants in this delivery born alive:
If not single birth, specify number of infants in this delivery born alive:
10. Sex (Male, Female, or Not yet determined): __________________________________
5/25/2012
PAGE 1
VERSION 27 INDIANA'S BIRTH WORKSHEET

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