Mother'S Worksheet For Child'S Birth Certificate Page 3
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4FATHER’S INFORMATION (Biological father)
Legal First Name
Middle Name
Last Name
Suffix
Date of Birth
Place of Birth (State/Foreign Country/Territory)
Social Security
Occupation
Type of Business
Father’s Education
Is Father of Hispanic Origin?
What is Father’s Race?
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□
□
□
th
8
grade or less
No, not Spanish / Hispanic / Latino
White
Vietnamese
□
□
□
□
th
th
9
– 12
grade, no diploma
Yes, Mexican, Mexican American,
Black/African American
Other Asian
□
Chicano
□
□
High School graduate or GED
American Indian/Alaska Native
Native Hawaiian
□
Yes, Puerto Rican
completed
(Name of the enrolled or principal tribe)
□
Guamanian or
□
□
Some College credit, but no
Yes, Cuban
Chamorro
degree
□
□
□
Yes, other Spanish / Hispanic / Latino
Asian Indian
Samoan
□
Associate degree
(e.g., AA, AS)
______________
□
□
Specify
Chinese
Other Pacific Islander
□
Bachelor’s degree
(e.g., BA, AB,
□
Filipino
Specify
BS)
□
□
□
Japanese
Other
Master’s degree
(e.g., MA, MS,
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□
MEng, MEd, MSW, MBA)
Korean
Unknown
□
Doctorate
or
(e.g., PhD, EdD)
Professional degree
(e.g., MD,
DDS, DVM, LLB, JD)
Has Paternity – Genetic Testing Been Done?
Mailing Address
Apartment Number
□
□
Yes
No
State/Foreign Country/Territory
City/Town/Location
Zip Code / Extension
PRESUMED FATHER’S INFORMATION (Complete ONLY if applicable)
Date of Birth
Social Security
First Name
Middle Name
Last Name
Suffix
Mailing Address
Apartment Number
State/Foreign Country/Territory
City/Town/Location
Zip Code Extension
MOTHER’S MEDICAID INFORMATION (Complete ONLY if applicable)
Mother’s Medicaid Name
Mother’s Medicaid Number
IMMTRAC REGISTRY
Do you consent for your baby’s immunization information to be included in the statewide Immunization Registry and to
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share the immunization information with registered providers?
Yes
No
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