Indiana Certificate Of Live Birth Worksheet Template Page 3
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5
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7
8
9
10
11
1220
20. Wi
. Will infant be placed for Adoption?
ll infant be placed for Adoption?
20
20
. Wi
. Wi
ll infant be placed for Adoption?
ll infant be placed for Adoption?
Yes
No
2 2 2 2 1 1 1 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 best describes your education. If you are currently enrolled, check
delivery? (Check the box that best describes your education. If you are currently enrolled, check
delivery? (Check the box that best describes your education. If you are currently enrolled, check
delivery? (Check the box that best describes your education. If you are currently enrolled, check
the box t
the box t
the box t
the box that indicates the previous grade or highest degree received).
hat indicates the previous grade or highest degree received).
hat indicates the previous grade or highest degree received).
hat indicates the previous grade or highest degree received).
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)
22. MOTHER: What is your usual occupation or industry in which you work? Please fill in below. For
example your occupation is Teacher, CPA, Waitress, Clerk, etc., and the industry in which you work is
Department Store, Law Firm, Hospital, Factory, etc.
Usual Occupation: _____________________________________________________________________
Usual Industry: ________________________________________________________________________
Unemployed
Unknown
2 2 2 2 3 3 3 3 . . . . MOTHER:
MOTHER:
MOTHER:
MOTHER: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No”
box. If
box. If
box. If
box. If Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check
Spanish/Hispanic/Latina, check the appropriate box
Spanish/Hispanic/Latina, check
the appropriate box
the appropriate box. . . .
the appropriate box
No, not Spanish/Hispanic/Latina
Yes, Mexican, Mexican American, Chicana
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latina (e.g. Spaniard, Salvadoran, Dominican, Columbian)
(specify)____________________________________
2 2 2 2 4 4 4 4 . . . . MOTHER:
MOTHER: W W W W hat is your race? (Please check
hat is your race? (Please check all that apply
all that apply). ). ). ).
MOTHER:
MOTHER:
hat is your race? (Please check
hat is your race? (Please check
all that apply
all that apply
White
Black or Af rican American
American Indian or Alaska Native (name of enrolled or principal tribe(s))
____________________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (specify)______________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (specify)______________________________
Other (specify) ___________________________________________
MOTHER:
MOTHER:
MOTHER:
MOTHER: Additional Information To Be Filled In
Additional Information To Be Filled In
Additional Information To Be Filled In If If If If A PATERNITY AFFIDAVIT IS TO BE FILED
Additional Information To Be Filled In
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 30
If Not Filing Paternity Affidavit skip to question
30
30
30. . . .
2 2 2 2 5. 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 2 2 2 6 6 6 6 . What is
. What is
. What is the name of your
. What is
the name of your
the name of your Employer
the name of your
Employer
Employer
Employer (Company name)
(Company name)
(Company name)
(Company name)? ? ? ? Optional
Optional
Optional
Optional
_________________________________________________________________________________________
2 2 2 2 7. 7. 7. 7. What is
What is your
your Employer's address
Employer's address? ? ? ? Optional
Optional
What is
What is
your
your
Employer's address
Employer's address
Optional
Optional
_________________________________________________________________________________________________
2 2 2 2 8. 8. 8. 8. What is
What is
What is
What is the name of your
the name of your
the name of your Medical Insurance Company
the name of your
Medical Insurance Company
Medical Insurance Company
Medical Insurance Company? ? ? ? Optional
Optional
Optional
Optional
_________________________________________________________________________________________________
2 2 2 2 9. 9. 9. 9. What is
What is
What is
What is your Medical Insurance Policy n
your Medical Insurance Policy n
your Medical Insurance Policy number?
your Medical Insurance Policy n
umber?
umber?
umber? Optional
Optional
Optional
Optional
__________________________________________________________________________________________
5/25/2012
PAGE 3
VERSION 27 INDIANA'S BIRTH WORKSHEET
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