Facility Worksheet For The Live Birth Certificate Template (Page 6 of 6) in pdf

atresia, tricuspid atresia, truncus arteriosus, total/partial anomalous pulmonary venous return with or without

obstruction.)

_____ Congenital diaphragmatic hernia - (Defect in the formation of the diaphragm allowing herniation of

abdominal organs into the thoracic cavity.)

_____ Omphalocele - (A defect in the anterior abdominal wall, accompanied by herniation of some abdominal

organs through a widened umbilical ring into the umbilical stalk. The defect is covered by a membrane

(different from gastroschisis, see below), although this sac may rupture. Also called exomphalos. Do not

include umbilical hernia (completely covered by skin) in this category.)

_____ Gastroschisis - (An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in

herniation of the abdominal contents directly into the amniotic cavity. Differentiated from omphalocele by

the location of the defect and absence of a protective membrane.)

_____ Limb reduction defect (excluding congenital amputation and dwarfing syndromes) - (Complete or partial

absence of a portion of an extremity associated with failure to develop.)

_____ Cleft Lip with or without Cleft Palate - (Incomplete closure of the lip. May be unilateral, bilateral or

median.)

_____ Cleft Palate alone - (Incomplete fusion of the palatal shelves. May be limited to the soft palate or may

extend into the hard palate. Cleft palate in the presence of cleft lip should be included in the “Cleft Lip with

or without Cleft Palate” category above.)

_____ Down Syndrome - (Trisomy 21) (Circle One)

Karyotype confirmed

Karyotype pending

_____ Suspected chromosomal disorder - (Includes any constellation of congenital malformations resulting from or

compatible with known syndromes caused by detectable defects in chromosome structure.)

(Circle One)

Karyotype confirmed

Karyotype pending

_____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 third degree - on the penile shaft.)

_____None of the above

Was infant transferred within 24 hours of delivery? (Circle “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.) (Circle One) Yes

If Yes, name and location of the facility infant transferred to:____________________________________________

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

Is infant being breast fed at discharge? (Circle One) Yes

Yes

Don’t know

Is infant going to be adopted? (Circle One)

If the Acknowledgement of Paternity form has been signed, provide the date signed (if the date signed by the

mother and father are different, provide the latest date signed): Month __ __ Day__ __Year__ __ __ __

Mother’s Medical Record Number: ____________________________________________________

Page 6 of 6

Facility Worksheet For The Live Birth Certificate Template Page 6

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