Indiana Certificate Of Live Birth Worksheet Template Page 11
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12Karyotype Pending
U n k n o w n
Hypospadias ( Incomplete closure of the male urethra resulting in the urethral meatus opening on the ventral surface of the penis.
Includes first degree- on the glans ventral to the tip, second degree- in the coronal sulcus, and thried degree- on the penile shaft)
M i c r o c e p h a l y
79. Was infant transferred within 24 hours of delivery ? (Check “yes” if the infant was transferred from this
facility to another within 24 hours of delivery. If transferred more than once, enter name of first facility to which
the infant was transferred.)
Yes
No
U n k n o w n
If yes, name of facility infant transferred to:_______________________________________
80. Is infant living at time of report? (Infant is living at the time this birth certificate is being completed.
Answer “Yes” if the infant has already been discharged to home care.)
Yes
No
Infant transferred, status unknown
81. Is infant being breastfed at discharge?
Yes
No
U n k n o w n
82. Hepatitis B Immunization given?
Yes
No
U n k n o w n
If Yes, Date given: ______ ______/______ ______/______ ______ ______ ______
8 8 8 8 3 3 3 3 . Attendant’s name,
. Attendant’s name,
. Attendant’s name, title, and N.P.I
. Attendant’s name,
title, and N.P.I
title, and N.P.I
title, and N.P.I
________________________________________________________________________________
Attendant’s name
A t t e n d a n t ’ s t i t l e :
A t t e n d a n t ’ s t i t l e :
A t t e n d a n t ’ s t i t l e :
A t t e n d a n t ’ s t i t l e :
M.D.
D.O.
CNM/CM - (Certified Nurse Midwife/Certified Midwife)
Other Midwife - (Midwife other than CNM/CM)
Other specify):__________________________________________
84. Is the Certifier the same as the Attendant
Yes
No
U n k n o w n
If NO answer Certifier question
85. Certifier’s name and title: __________________________________________________
(The individual who certifies to the fact that the birth occurred. May be, but need not be, the same as the attendant at birth.)
M.D.
D.O.
Hospital administrator or designee
CNM/CM (Certified Nurse Midwife / Certified Midwife)
Other Midwife (Midwife other than CNM/CM)
Other (Specify)_____________________
86. Date certified: __ __ __ __ __ __ __ __ M M D D Y Y Y Y
87. Principal source of payment for this delivery (At time of delivery):
Private Insurance
Medicaid (Comparable State program)
Self-pay (No third party identified)
Other (Specify, e.g., Indian Health Service, CHAMPUS/TRICARE, Other Government (federal,state, local))
_____________________________________________________
8 8 8 8 8 8 8 8 . Infant’s medical record number:
. Infant’s medical record number:
. Infant’s medical record number: ____________________________________________________
. Infant’s medical record number:
8 8 8 8 9 9 9 9 . . . . Newborn Screening Number: _________________________________________
_________________________________________
_________________________________________
_________________________________________
If Unknown check reason why
R e l i g i o u s W a i v e r
R e l i g i o u s W a i v e r
R e l i g i o u s W a i v e r
R e l i g i o u s W a i v e r
5/25/2012
PAGE 11
VERSION 27 INDIANA'S BIRTH WORKSHEET
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