Indiana Certificate Of Live Birth Worksheet Template Page 6
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12FATHER
FATHER Additional Information To Be Filled In
Additional Information To Be Filled In If If If If A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
FATHER
FATHER
Additional Information To Be Filled In
Additional Information To Be Filled In
A PATERNITY AFFIDAVIT IS TO BE FILED
A PATERNITY AFFIDAVIT IS TO BE FILED
FOR THIS BIRTH
FOR THIS BIRTH
If Not Filing Paternity Affidavit skip to question 5 5 5 5 3 3 3 3
If Not Filing Paternity Affidavit skip to question
FOR THIS BIRTH
FOR THIS BIRTH
If Not Filing Paternity Affidavit skip to question
If Not Filing Paternity Affidavit skip to question
47. What is Your Phone Numbert? Information is
47. What is Your Phone Numbert? Information is
47. What is Your Phone Numbert? Information is
47. What is Your Phone Numbert? Information is required _____
required _____
required _________
required _____
____
____
_____________________________
_________________________
_________________________
_________________________
4 4 4 4 8 8 8 8 . . . . What is Your
What is Your
What is Your
What is Your C C C C urrent
urrent
urrent
urrent A A A A ddress
ddress
ddress
ddress Number, Street, City, State and Zip
Number, Street, City, State and Zip
Number, Street, City, State and Zip Information is required
Number, Street, City, State and Zip
Information is required
Information is required
Information is required
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4 4 4 4 9 9 9 9 . . . . What is
What is
What is
What is the na
the na
the name of your
the na
me of your
me of your Employer (Company name)
me of your
Employer (Company name)
Employer (Company name)
Employer (Company name)? ? ? ? Information is optional
Information is optional
Information is optional
Information is optional
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
50
50
50
50. . . . What is your Employer's address?
What is your Employer's address?
What is your Employer's address?
What is your Employer's address? Information is optional
Information is optional
Information is optional
Information is optional
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
51
51. . . . What is the name of your Medical Insurance Company?
What is the name of your Medical Insurance Company? Information is optional
Information is optional
51
51
What is the name of your Medical Insurance Company?
What is the name of your Medical Insurance Company?
Information is optional
Information is optional
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5 5 5 5 2 2 2 2 . . . . FATHER
FATHER What is your Medical Insurance Policy Number
What is your Medical Insurance Policy Number Information is optional
Information is optional
FATHER
FATHER
What is your Medical Insurance Policy Number
What is your Medical Insurance Policy Number
Information is optional
Information is optional
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
53. DID MOTHER RECEIVE PRENATAL CARE?
YES
NO
UNKNOWN
54. Date of first prenatal care visit (prenatal care begins when a Physician or other health professional first
examines and/or counsels the pregnant
___ ___ ___ ___ ___ ___
woman as part of an ongoing program of care for the pregnancy)
___ ___M M D D Y Y Y Y
55. Date of last prenatal care visit
(Enter the date of the last visit recorded in the mother’s prenatal records)
___ ___ ___ ___ ___ ___ ___ ___
M M D D Y Y Y Y
5 5 5 5 6 6 6 6 . . . . Source of
Source of
Source of
Source of pre
pre
pre- - - - natal care?
pre
natal care?
natal care?
natal care?
M D
M D
M D
M D
D O
D O
D O
D O
C l i n i c
C l i n i c
C l i n i c
C l i n i c
O t h e
O t h e
O t h e
O t h e r , S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
r , S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
r , S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
r , S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
57. Total number of prenatal care visits for this pregnancy (Count only those visits recorded in the record.
If none enter “0”):
____________
58. Date last normal menses began: ___ ___ ___ ___ ___ ___ ___ ___ M M D D Y Y Y Y
59. Number of previous live births now living (Do not include this child. For multiple deliveries, do not
include the 1st born in the set if completing this worksheet for that child): Enter number or 0 for none.
___________
60. Number of previous live births now dead (Do not include this child. For multiple deliveries, do not
include the 1st born in the set if completing this worksheet for that child):
Enter number or 0 for none.
___________
61. Date of last live birth
_____ _____/_____ _____ _____ _____ M M Y Y Y Y
62. Total number of other pregnancy outcomes (Include fetal losses of any gestational age-spontaneous
losses, induced losses, and/or ectopic pregnancies. If this was a multiple delivery, include all fetal losses delivered
before this infant in the pregnancy) .)
Enter number or 0 for none.:
___________
5/25/2012
PAGE 6
VERSION 27 INDIANA'S BIRTH WORKSHEET
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