Mother'S Worksheet For Child'S Birth Certificate Page 2
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4MOTHER’S INFORMATION
Date of Birth
Place of Birth (State/Foreign Country/Territory)
Social Security
Apply for Baby’s Social Security?
Did Mother Give up Rights to the Child?
Date Rights Given Up?
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Yes
No
Yes
No
Occupation
Type of Business
Mother’s Education
Is Mother of Hispanic Origin?
What is Mother’s Race?
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th
8
grade or less
No, not Spanish / Hispanic / Latina
White
Vietnamese
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th
th
9
– 12
grade, no diploma
Yes, Mexican, Mexican American,
Black/African American
Other Asian________
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Chicana
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High School graduate or GED
American Indian/Alaska Native
Native Hawaiian
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Yes, Puerto Rican
completed
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Guamanian or
(Name of the enrolled or principal tribe)
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Some College credit, but no degree
Yes, Cuban
Chamorro
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Associate degree
Yes, other Spanish / Hispanic / Latina
Asian Indian
Samoan
(e.g., AA, AS)
______________
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Specify
Bachelor’s degree
Chinese
Other Pacific Islander
(e.g., BA, AB, BS)
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Master’s degree
Filipino
Specify
(e.g., MA, MS,
MEng, MEd, MSW, MBA)
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Japanese
Other
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Doctorate
or
(e.g., PhD, EdD)
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Korean
Unknown
Professional degree
(e.g., MD, DDS,
DVM, LLB, JD)
MOTHER’S HEALTH INFORMATION
Did you receive WIC for this Birth?
Height
Weight Before Pregnancy
Weight At Delivery
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Yes
No
How many cigarettes did you smoke before and during pregnancy?
Three Months Before
Cigs/Day: ____
Packs/Day: ___
First Three Months Cigs/Day: ____
Packs/Day: ___
Second Three Months Cigs/Day: ____
Packs/Day: ___
Third Trimester
Cigs/Day: ____ Packs/Day: ___
MOTHER’S MARITAL STATUS (Please read carefully)
• If you are married, your husband may be listed as the father on the birth certificate, or the information may be left blank.
• If you are not married, the father’s name may be listed on the birth certificate only if both parents complete an
Acknowledgment of Paternity.
• If you are or have been married to someone other than the biological father of this child, or have been married to
someone other than the biological father within 300 days before this child’s birth, the Acknowledgment of
Paternity must also include a Denial of Paternity from your husband or former husband to allow the biological
father’s information to be listed on the birth certificate.
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Yes, Currently Married
Yes, Never Married
Yes, Divorced
Yes, Widowed
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Yes, Married – (no paternity information on birth certificate)
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Have you been married to someone other than the biological father in the 300 days before the child’s birth?
Yes
No
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Do you want to complete an Acknowledgement of Paternity?
Yes
No
MOTHER’S NAME PRIOR TO HER FIRST MARRIAGE
First Name
Middle Name
Last Name
Suffix
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