Facility Worksheet For The Live Birth Certificate Template

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FACILITY WORKSHEET FOR THE LIVE BIRTH CERTIFICATE
For pregnancies resulting in the births of two or more live-born infants, this worksheet should be completed for the 1st live born
infant in the delivery. For each subsequent live-born infant, complete the “Attachment for Multiple Births.” For any fetal loss in
the pregnancy reportable under State reporting requirements, complete the “Facility Worksheet for the Fetal Death Report."
Mother’s name: ______________________________________________________________________________
Mother’s medical record # ________________________
Facility name: _______________________________________________________________________________
(If not institution, give street and number)
County of birth: _____________________________________________________________________________
City, Town or Location of birth: __________________________________________Zip Code: ____________
Place of birth:
___Hospital
___Freestanding birthing center (Freestanding birthing center is defined as one which has no direct physical
connection with an operative delivery center.)
___Home birth, Planned to deliver at home (Circle one)
Yes
No
___Clinic/Doctor’s Office
___Other (specify, e.g., taxi cab, train, plane, etc.)_____________________________________________
Information for the following items should come from the mother’s prenatal care records and from other medical reports in the
mother’s chart, as well as the infant’s medical record. If the mother’s prenatal care record is not in her hospital chart, please
contact her prenatal care provider to obtain the record, or a copy of the prenatal care information. Preferred and acceptable
sources are given before each section. Please do not provide information from sources other than those listed.
Prenatal
(Sources: Prenatal care records, mother’s medical records, labor and delivery records)
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):
Month __ __ Day__ __Year__ __ __ __
___No prenatal care (The mother did not receive prenatal care at any time during the pregnancy. If no
prenatal care, skip the next question)
Date of last prenatal care visit (Enter the date of the last visit recorded in the mother’s prenatal records):
Month__ __ Day__ __ Year__ __ __ __
Total number of prenatal care visits for this pregnancy (Count only those visits recorded in the record.
If none enter “0”): ____________
Date last normal menses began: Month __ __ Day__ __Year__ __ __ __
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. If none enter “0”): ________
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. If none enter “0”): ________
Date of last live birth: Month __ __ Year__ __ __ __
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. If none enter “0”): ________
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