Blank CDC U.S. Standard Certificate of Live Birth Form

The CDC U.S. Standard Certificate of Live Birth form serves as the official document that records the birth of a child in the United States. This form captures essential information about the newborn, including details about the parents, the place of birth, and the time of delivery. Understanding its components and significance is crucial for parents, healthcare providers, and public health officials alike.

Access Document

Blank CDC U.S. Standard Certificate of Live Birth Form

Structure

Misconceptions

Here are some common misconceptions about the CDC U.S. Standard Certificate of Live Birth form:

Only hospitals can issue a birth certificate.
This is not true. While most birth certificates are issued by hospitals, they must be filed with the state vital records office. Parents can also obtain a birth certificate directly from the state after the birth is registered.
Birth certificates are only needed for legal purposes.
Many people believe that birth certificates are only necessary for legal matters. In reality, they are often required for various everyday activities, such as enrolling in school, applying for a passport, or obtaining a driver's license.
All states use the same birth certificate format.
This is a misconception. While the CDC provides a standard form, each state may have its own variations and requirements for the birth certificate. It's important to check the specific format used in your state.
Birth certificates are only issued for live births.
This is misleading. Birth certificates are typically issued for live births, but some states also provide documentation for stillbirths or fetal deaths, which can be important for legal and medical reasons.
Once issued, a birth certificate cannot be changed.
This is not accurate. While a birth certificate is an official document, it can be amended in certain circumstances, such as correcting errors or updating information like a name change.
Birth certificates are not important after childhood.
Many people think that birth certificates lose their significance once a person reaches adulthood. However, they remain important for various reasons throughout life, including legal identification and proof of citizenship.

Detailed Steps for Filling Out CDC U.S. Standard Certificate of Live Birth

Completing the CDC U.S. Standard Certificate of Live Birth form is an important step in officially documenting a birth. After filling out the form, it will need to be submitted to the appropriate state or local vital records office for processing. Ensure that all information is accurate and complete to avoid delays.

Begin with the child's information. Fill in the full name, date of birth, time of birth, and place of birth.
Next, provide the parent's information. Include the full names, addresses, and dates of birth for both parents.
Indicate the parent's marital status at the time of the child's birth.
Fill out the attendant's information. This includes the name and title of the person who delivered the baby.
Provide any additional medical information requested, such as the mother's prenatal care details.
Sign and date the form in the designated areas. Ensure that the signature matches the name provided.
Review the entire form for accuracy. Check that all sections are completed and that the information is legible.
Submit the completed form to the appropriate vital records office. Be aware of any fees that may apply.

Document Preview

U.S. STANDARD CERTIFICATE OF LIVE BIRTH

LOCAL FILE NO.							BIRTH NUMBER:
C H I L D	1. CHILD’S NAME (First, Middle, Last, Suffix)			2. TIME OF BIRTH	3. SEX			4. DATE OF BIRTH (Mo/Day/Yr)
C H I L D				(24 hr)
	5. FACILITY NAME (If not institution, give street and number)	6. CITY, TOWN, OR LOCATION OF BIRTH				7. COUNTY OF BIRTH
			8b. DATE OF BIRTH (Mo/Day/Yr)
M O T H E R	8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)		8b. DATE OF BIRTH (Mo/Day/Yr)

8c. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix)

8d. BIRTHPLACE (State, Territory, or Foreign Country)

9a. RESIDENCE OF MOTHER-STATE

9b. COUNTY

9c. CITY, TOWN, OR LOCATION

9d. STREET AND NUMBER

9e. APT.

NO.

9f. ZIP CODE

9g. INSIDE CITY

LIMITS?

□ Yes □ No

F A T H E R

10a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)

10b. DATE OF BIRTH (Mo/Day/Yr)

10c. BIRTHPLACE (State, Territory, or Foreign Country)

CERTIFIER

11. CERTIFIER’S NAME: _______________________________________________

12. DATE CERTIFIED

13. DATE FILED BY REGISTRAR

TITLE: □ MD □ DO □ HOSPITAL ADMIN. □ CNM/CM □ OTHER MIDWIFE

______/ ______ / __________

□ OTHER (Specify)_____________________________

YYYY

MM DD

YYYY

INFORMATION FOR ADMINISTRATIVE

USE

M O T H E R

14. MOTHER’S MAILING ADDRESS:

9 Same as residence, or: State:

City, Town, or Location:

Street & Number:

Apartment No.:

Zip Code:

15. MOTHER MARRIED? (At birth, conception, or any time between)

□ Yes

□ No

16. SOCIAL SECURITY NUMBER REQUESTED

17. FACILITY ID. (NPI)

IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? □ Yes

□ No

FOR CHILD?

□ Yes

□ No

18. MOTHER’S SOCIAL SECURITY NUMBER:

19. FATHER’S SOCIAL SECURITY NUMBER:

INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY

M O T H E R

F A T H E R

Mother’s Name ________________

Mother’s Medical Record No. _________________________

20. MOTHER’S EDUCATION (Check the		21. MOTHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		mother is Spanish/Hispanic/Latina. Check the
	the time of delivery)		“No” box if mother is not Spanish/Hispanic/Latina)
□	8th grade or less	□	No, not Spanish/Hispanic/Latina
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latina
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

23. FATHER’S EDUCATION (Check the		24. FATHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		father is Spanish/Hispanic/Latino. Check the
	the time of delivery)		“No” box if father is not Spanish/Hispanic/Latino)
□	8th grade or less	□	No, not Spanish/Hispanic/Latino
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latino
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□Bachelor’s degree (e.g., BA, AB, BS)

□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

22.MOTHER’S RACE (Check one or more races to indicate what the mother considers herself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

25.FATHER’S RACE (Check one or more races to indicate what the father considers himself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

26. PLACE WHERE BIRTH OCCURRED (Check one)	27. ATTENDANT’S NAME, TITLE, AND NPI	28. MOTHER TRANSFERRED FOR MATERNAL
□ Hospital	NAME: _______________________ NPI:_______	MEDICAL OR FETAL INDICATIONS FOR
□ Freestanding birthing center	NAME: _______________________ NPI:_______	DELIVERY? □ Yes □ No
□ Freestanding birthing center		IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	TRANSFERRED FROM:
□ Clinic/Doctor’s office	□ OTHER (Specify)___________________	_______________________________________
□ Other (Specify)_______________________	□ OTHER (Specify)___________________
□ Other (Specify)_______________________

REV. 11/2003

MOTHER

29a. DATE OF FIRST PRENATAL CARE VISIT

29b. DATE OF LAST PRENATAL CARE VISIT

30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

______ /________/ __________ □ No Prenatal Care

______ /________/ __________

M M

D D

YYYY

M M

D D

YYYY

_________________________ (If none, enter A0".)

31. MOTHER’S HEIGHT

32. MOTHER’S

PREPREGNANCY WEIGHT

33. MOTHER’S WEIGHT

AT DELIVERY

34. DID MOTHER GET WIC FOOD FOR HERSELF

_______ (feet/inches)

_________ (pounds)

DURING THIS PREGNANCY? □ Yes □ No

35. NUMBER OF PREVIOUS

36. NUMBER OF OTHER

37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

38. PRINCIPAL SOURCE OF

LIVE BIRTHS (Do not include

PREGNANCY OUTCOMES

For each time period, enter either the number of cigarettes or the

PAYMENT FOR THIS

this child)

(spontaneous or induced

number of packs of cigarettes smoked. IF NONE, ENTER A0".

DELIVERY

losses or ectopic pregnancies)

Average number of cigarettes or packs of cigarettes smoked per day.

□ Private Insurance

35a.

Now Living

35b. Now Dead

36a. Other Outcomes

Number _____

# of cigarettes

# of packs

□ Medicaid

Three Months Before Pregnancy

_________

________

□ Self-pay

First Three Months of Pregnancy

_________

________

□ Other

□ None

Second Three Months of Pregnancy _________

________

(Specify) _______________

Third Trimester of Pregnancy

_________

________

35c. DATE OF LAST LIVE BIRTH

36b. DATE OF LAST OTHER

39. DATE LAST NORMAL MENSES BEGAN

40. MOTHER’S MEDICAL RECORD NUMBER

_______/________

PREGNANCY OUTCOME

______ /________/ __________

Y Y Y Y

_______/________

M M

D D

YYYY

Y Y Y Y

MEDICAL

41. RISK FACTORS IN THIS PREGNANCY

43. OBSTETRIC PROCEDURES (Check all that apply)

46. METHOD OF DELIVERY

(Check all that apply)

AND

Diabetes

□ Cervical cerclage

A. Was delivery with forceps attempted but

HEALTH

□

Prepregnancy

(Diagnosis prior to this pregnancy)

□ Tocolysis

unsuccessful?

□

Gestational

(Diagnosis in this pregnancy)

External cephalic version:

□ Yes

□ No

INFORMATION

B. Was delivery with vacuum extraction attempted

Hypertension

□ Successful

□

Prepregnancy

(Chronic)

□ Failed

but unsuccessful?

□

Gestational

(PIH, preeclampsia)

□ None of the above

□ Yes

□ No

□

Eclampsia

C. Fetal presentation at birth

□ Previous preterm birth

□

Cephalic

44. ONSET OF LABOR (Check all that apply)

□

Breech

□ Other previous poor pregnancy outcome (Includes

□ Premature Rupture of the Membranes (prolonged, ∃12 hrs.)

□

Other

perinatal death, small-for-gestational age/intrauterine

D. Final route and method of delivery (Check one)

growth restricted birth)

□ Precipitous Labor (<3 hrs.)

□ Vaginal/Spontaneous

□ Pregnancy resulted from infertility treatment-If yes,

□ Prolonged Labor (∃ 20 hrs.)

□ Vaginal/Forceps

check all that apply:

□ Vaginal/Vacuum

□ Fertility-enhancing drugs, Artificial insemination or

□ None of the above

□ Cesarean

Intrauterine insemination

If cesarean, was a trial of labor attempted?

□ Assisted reproductive technology (e.g., in vitro

□ Yes

45. CHARACTERISTICS OF LABOR AND DELIVERY

fertilization (IVF), gamete intrafallopian

□ No

(Check all that

apply)

transfer

(GIFT))

□

Induction of labor

47. MATERNAL MORBIDITY (Check all that apply)

□ Mother had a previous cesarean delivery

(Complications associated with labor and

□

Augmentation of labor

If yes, how many __________

delivery)

□

Non-vertex presentation

□

Maternal transfusion

□ None of the above

□ Steroids (glucocorticoids) for fetal lung maturation

□ Third or fourth degree perineal laceration

42. INFECTIONS PRESENT AND/OR TREATED

received by the mother prior to delivery

□

Ruptured uterus

DURING THIS

PREGNANCY (Check all that apply)

□ Antibiotics received by the mother during labor

□

Unplanned hysterectomy

□ Clinical chorioamnionitis diagnosed during labor or

□ Admission to intensive care unit

□

Gonorrhea

maternal temperature >38°C (100.4°F)

□ Unplanned operating room procedure

□

Syphilis

□ Moderate/heavy meconium staining of the amniotic fluid

following delivery

□

Chlamydia

□ Fetal intolerance of labor such that one or more of the

□ None of the above

□

Hepatitis B

following actions was taken: in-utero resuscitative

□

Hepatitis C

measures, further fetal assessment, or operative delivery

□ Epidural or spinal anesthesia during labor

□ None of the above

NEWBORN

Mother’s Name ________________

Mother’s Medical Record No. ____________________

NEWBORN INFORMATION

48. NEWBORN MEDICAL RECORD NUMBER	54. ABNORMAL CONDITIONS OF THE NEWBORN				55. CONGENITAL ANOMALIES OF THE NEWBORN
			(Check all that apply)		□		(Check all that apply)
49. BIRTHWEIGHT (grams preferred, specify unit)	□	Assisted ventilation required immediately				Anencephaly
					□	Meningomyelocele/Spina bifida
______________________		following delivery			□	Cyanotic congenital heart disease
9 grams 9 lb/oz	□				□	Congenital diaphragmatic hernia
		Assisted ventilation required for more than
					□	Omphalocele
		six hours
50. OBSTETRIC ESTIMATE OF GESTATION:					□	Gastroschisis

_________________ (completed weeks)	□	NICU admission			□	Limb reduction defect (excluding congenital
						amputation and dwarfing syndromes)
	□	Newborn given surfactant replacement			□ Cleft Lip with or without Cleft Palate
					□	Cleft Palate alone
		therapy
51. APGAR SCORE:
					□	Down Syndrome
Score at 5 minutes:________________________
	□	Antibiotics received by the newborn for				□	Karyotype confirmed
If 5 minute score is less than 6,
Score at 10 minutes: _______________________		suspected neonatal sepsis			□	□	Karyotype pending
	□	Seizure or serious neurologic dysfunction				Suspected chromosomal disorder
						□	Karyotype confirmed
52. PLURALITY - Single, Twin, Triplet, etc.	□ Significant birth injury (skeletal fracture(s), peripheral				□	□	Karyotype pending
						Hypospadias
(Specify)________________________		nerve	injury, and/or soft tissue/solid organ hemorrhage
					□	None of the anomalies listed above
		which	requires intervention)
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________	9 None of the above


56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No				57. IS INFANT LIVING AT TIME OF REPORT?				58. IS THE INFANT BEING
IF YES, NAME OF FACILITY INFANT TRANSFERRED				□ Yes □ No □ Infant transferred, status unknown				BREASTFED AT DISCHARGE?
TO:______________________________________________________								□ Yes □ No

Rev. 11/2003

NOTE: This recommended standard birth certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future

activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.

Common PDF Templates

House Load Calculation - The LADBS form is vital for obtaining a green light from inspectors.

Trader Joe's Online - Offers environmentally friendly practices throughout its operations.

Divorce Forms Michigan - It ensures that all claims regarding children, property, and debts are clearly laid out.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Live Birth form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are four things you should and shouldn't do:

Do use black ink when completing the form to ensure readability.
Do provide accurate information, including full names and dates, to avoid any discrepancies.
Don't leave any required fields blank; all sections must be completed.
Don't use correction fluid or tape; if a mistake is made, cross it out neatly and write the correct information next to it.

Key takeaways

Filling out the CDC U.S. Standard Certificate of Live Birth form is an important process that ensures accurate record-keeping for newborns. Here are some key takeaways to keep in mind:

Accuracy is Crucial: Ensure that all information provided is accurate. Mistakes can lead to complications in obtaining vital records later.
Provide Complete Information: Fill in all required fields completely. Missing information may delay the processing of the birth certificate.
Signature Requirement: The form must be signed by the attending physician or midwife. This signature validates the information provided.
Timely Submission: Submit the completed form to the appropriate state office as soon as possible. Most states require the birth certificate to be filed within a specific timeframe.
Understand Local Regulations: Different states may have varying requirements regarding the form. Familiarize yourself with your state’s specific guidelines.
Keep Copies: After submission, retain a copy of the completed form for your records. This can be useful for future reference or in case of any issues.

Similar forms

The CDC U.S. Standard Certificate of Live Birth is similar to the Certificate of Death, which is used to officially document the passing of an individual. Both documents serve as vital records that provide essential information about a person's life events. The Certificate of Death includes details such as the deceased's name, date of birth, date of death, and cause of death. Just like the birth certificate, it is typically issued by a government authority and is required for legal purposes, such as settling estates or claiming life insurance benefits.

Another document akin to the Certificate of Live Birth is the Marriage Certificate. This document serves as an official record of the union between two individuals. It contains information such as the names of the parties involved, the date of the marriage, and the location where the marriage took place. Like the birth certificate, a marriage certificate is often required for various legal processes, including name changes and spousal benefits, and it is recognized by government agencies.

The Adoption Certificate is also similar in nature, as it formalizes the legal process of adopting a child. This document provides information about the adopted child, the adoptive parents, and the date of the adoption. It plays a crucial role in establishing legal parentage and is essential for the child's identity and rights. Like the birth certificate, it is a vital record that must be kept updated to reflect the child's legal status.

The Social Security Card is another important document that shares similarities with the Certificate of Live Birth. While it serves a different purpose, both documents are critical for establishing identity and legal status in the United States. The Social Security Card contains the individual’s name and Social Security number, which is necessary for employment and accessing government services. A birth certificate is often required to obtain a Social Security Card, highlighting their interconnectedness.

The Passport is a travel document that also resembles the Certificate of Live Birth in its role as proof of identity and citizenship. A passport includes personal information such as the holder's name, date of birth, and photograph. It is essential for international travel and serves as a legal identification document. Like the birth certificate, it requires official documentation to obtain, often including a birth certificate as part of the application process.

Finally, the Driver's License is a document that, while primarily a means of identification for driving, shares similarities with the Certificate of Live Birth in terms of its role in establishing identity. A driver's license contains personal information, including the individual's name, date of birth, and address. It is commonly used for identification purposes in various situations, such as age verification and legal transactions. To obtain a driver's license, one typically must provide a birth certificate as proof of identity and age.

Documents used along the form

The CDC U.S. Standard Certificate of Live Birth is a crucial document for establishing a person's identity and citizenship. However, several other forms and documents often accompany this certificate, serving various purposes in legal, medical, and administrative contexts.

Application for Social Security Card: This form is necessary for obtaining a Social Security number, which is essential for employment and accessing government services.
Certificate of Live Birth Registration: This document confirms that the birth has been officially recorded in the state registry and may be required for certain legal processes.
Affidavit of Parentage: This form establishes legal parentage when parents are not married at the time of the child's birth, helping to clarify custody and support obligations.
Hospital Discharge Summary: This document provides a summary of the birth event, including medical details, and may be needed for health records or insurance claims.
Immunization Records: These records track vaccinations received by the child and are often required for school enrollment and public health compliance.
Birth Notification Form: Some states require hospitals to submit this form to the vital records office, ensuring timely registration of the birth.
Health Insurance Information: This document is necessary for processing medical claims related to the birth and ensuring coverage for the newborn.
Parent's Identification Documents: Valid ID, such as a driver's license or passport, is often needed to verify the identity of the parents when registering the birth.

These documents work together with the CDC U.S. Standard Certificate of Live Birth to provide a comprehensive legal and medical record for the newborn. It is important to ensure that all necessary forms are completed accurately and submitted in a timely manner to avoid complications in the future.