State File Number

The State File Number will automatically be assigned when the record is saved for the first time. This field cannot be changed. If the wrong birth year has been entered in the record must be deleted and started over.

Child's Medical Record Number

Enter the newborn's medical record number. This is a required field so that the system has at least one way to access the record with hospital, birthing center or midwife specific information.

Child's Alternate Medical Record Number

Enter the newborn's alternate medical record number. This is not a required field, but may be used to enter a hospital system unit number rather than a medical record number specific to the facility of delivery.

Child's First Name

Enter the child's first name(s). Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them. If the parent(s) have not selected a name or a name is not available, leave this field blank. Do not enter 'unnamed baby', 'baby girl', 'baby boy', 'twin A' etc. Note: A Voluntary Declaration of Paternity may be created and signed by birth parents without the child's name being assigned.

Child's Middle Name

Enter the child's middle name(s). Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them. If the parent(s) have not selected a name or a middle name is not given, leave this field blank.

Child's Last Name

Enter the child's last name(s). Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them. The child's last name does not need to be the same as either parent(s) last names. If the parent(s) have not selected a name, leave this field blank.

Suffix

Enter a suffix if given. This is a smart type field. Use the arrow keys on your keyboard to select from or view the provided table. This table cannot be overridden. If the suffix you are trying to enter is not in the table, please use an affidavit to list the suffix. M.D., Esq., etc are not suffixes, but are instead titles and as such, should not be listed in this item.

Child's Sex

Mark the sex of the child as identified by the birth attendant. The choices are Male, Female or Not Yet Determined. If the sex is undetermined a Social Security card cannot be requested until the sex is amended in the child medical record and then on the birth certificate. This item aids in identification of the child. It is also used for measuring sex differentials in health-related characteristics and for making population estimates and projections.

Child's Date of Birth (Month, Day, Year)

This item records the date of birth of the individual named on the certificate. It is used to establish age for such purposes as school entrance, obtaining a driver's license, and social security benefits.

Enter the date of birth for the child.

Time of Birth

This item documents the exact time of birth for various legal uses such as the order of birth in plural deliveries. When the birth occurs around midnight, the exact hour and minute may affect the date of birth. For births occurring at the end of the year, the hour and minute affect not only the day, but the year of birth, a factor in establishing dependency for income tax purposes.

Enter the exact time of birth as recorded by the 24-hour clock.
The new day begins at 00:00 (midnight). 00:01 = 1 minute after midnight, etc.
23:59 = 11:59 pm, 00:00 = 12:00 am, 00:01 = 12:01 am.

Conversion from 12-hour clock to 24-hour clock
12:00 a.m. = 00:00 (midnight)
1:00 a.m. = 01:00
2:00 a.m. = 02:00
3:00 a.m. = 03:00
4:00 a.m. = 04:00
5:00 a.m. = 05:00
6:00 a.m. = 06:00
7:00 a.m. = 07:00
8:00 a.m. = 08:00
9:00 a.m. = 09:00
10:00 a.m. = 10:00
1:00 a.m. = 11:00
12:00 p.m. (noon) = 12:00
1:00 p.m. = 13:00
2:00 p.m. = 14:00
3:00 p.m. = 15:00
4:00 p.m. = 16:00
5:00 p.m. = 17:00
6:00 p.m. = 18:00
7:00 p.m. = 19:00
8:00 p.m. = 20:00
9:00 p.m. = 21:00
10:00 p.m. = 22:00 11:00 p.m. = 23:00

Birth Facility Type

Such information permits analysis of the number and characteristics of births by type of facility, and is helpful in determining the level of utilization and characteristics of births occurring in such facilities. The facility name is used for follow-up and query programs in the state vital records office and is of historical value to the parents and child. It is also used to produce statistical data by specific facility. These items identify the place of birth; which is used to determine U.S. citizenship. Information on the place of occurrence, together with information on the place of residence, is used to evaluate the supply and distribution of obstetrical services.

Hospital

This is a pre-loaded field for all hospitals. The pre-load fields cannot be changed unless the location of birth is also being changed. To change the location of the birth, select the appropriate location. The Place of Birth, City and County fields will automatically be cleared and the appropriate information for the event must be entered. Note: If delivery occurs in a moving conveyance and the first place that the infant is removed from the conveyance is at the hospital, check "En-route". No Report of Birth form needed if birth certificate is entered in by a Uintah user. Attendant listed shall be the clinician who provides primary care to the mom at the hospital.

Freestanding Birth Center

This is a pre-loaded field for all freestanding birth centers. The pre-load fields cannot be changed unless the location of birth is also being changed. To change the location of the birth, select the appropriate location. The Place of Birth, City and County fields will automatically be cleared and the appropriate information for the event must be entered. Note: If delivery occurs in a moving conveyance and the first place that the infant is removed from the conveyance is at the freestanding birth center, check "En-route". No Report of Birth form needed if birth certificate is entered in by a Uintah user. Attendant listed shall be the clinician who provides primary care to the mom at the freestanding birth center.

Home Intended

This location requires the entry of the street address and city of birth in the Non-Facility Address field(s). If location of birth is remote and does not have a street name enter the word 'Rural'. Enter 'Rural' in the city field if the birth location does not have a area or city name to identify it. Enter in county as given. Examples of location include 'Ranch', 'Hogan' or 'Homestead'.

A Report of Birth form must be submitted with the electronic birth certificate if the birth certificate is being filed by a non-Uintah user.

Home Not-Intended

This location requires the entry of the street address and city of birth in the Non-Facility Address field(s). If location of birth is remote and does not have a street name enter the word 'Rural'. Enter 'Rural' in the city field if the birth location does not have a area or city name to identify it. Enter in county as given. Examples of location include 'Ranch', 'Hogan' or 'Homestead'.

A Report of Birth form must be submitted with the electronic birth certificate if the birth certificate is being filed by a non-Uintah user.

Unknown If Home Intended

This location requires the entry of the street address and city of birth in the Non-Facility Address field(s). If location of birth is remote and does not have a street name enter the word 'Rural'. Enter 'Rural' in the city field if the birth location does not have a area or city name to identify it. Enter in county as given. Examples of location include 'Ranch', 'Hogan' or 'Homestead'.

A Report of Birth form must be submitted with the electronic birth certificate if the birth certificate is being filed by a non-Uintah user.

Clinic/Doctor's Office

This location requires the entry of the street city and county of birth in the Non-Facility Address field(s).

A Report of Birth form must be submitted with the electronic birth.

Note: If delivery occurs in a moving conveyance and the birth mother and/or child are removed from the conveyance at a doctor/clinic office select that location. The birth attendant will need to sign a Report of Birth form at the time of admit or before leaving the location. The birth certificate may not be registered without a signed Report of Birth form.

Other Birth Locations

This location requires the entry of the street address and city of birth in the Non-Facility Address field(s). A Report of Birth form must be submitted with the electronic birth.

Note: If the delivery occurs in a moving conveyance and the birth mother and/or child are removed from the conveyance at a non-facility, i.e., a convenience store, etc., select “Other”. The birth attendant will need to sign a Report of Birth form at the time of admit or before leaving the location. The birth certificate may not be registered without a signed Report of Birth form.

Facility Name

This is a pre-loaded field.

City of Birth

This is a pre-loaded field, per facility.  For non-facility births, select a city and county of birth from the tables provided.

County of Birth

This is a pre-loaded field, per facility. For non-facility births, select a city and county of birth from the tables provided.

Note: The fields following city and county are read only and used for coding purposes.

Certifier Name

Certifier name and title automatically entered based on user log on.

Note: The fields following city and county are read only and used for coding purposes.

Certifier's Title

Certifier's title automatically entered based on user log on.

Note: The fields following city and county are read only and used for coding purposes.

Attendant's Name

Enter the attendant name from the provided table. Selecting the attendant from the table also fills in the attendant title, address, city, state, and zip.

Press the insert to add an attendant that is not provided from the table. All attendant related fields must be manually entered.

Note: If delivery has occurred 'en-route' to the birthing facility, the attending physician shall be listed as the birth attendant.

Note: It is the duty of the birth certificate clerk to maintain the attendant table for their facility by adding, deleting or modifying accordingly.

Attendant's Title

The attendant title is provided by the attendant table. If the title is missing, you may select from the table provided.

Attendant Other (Specify)

If the attendant title selected was 'Other', the description of the attendant must be specified, such as, EMT, husband, neighbor, etc.

Note: If the birth occurred outside the birthing facility, 'Other' birth attendants must sign a Report of Birth form.

Attendant Address

The attendant address is provided by the attendant table. Press the insert key to enter an address not provided in the table.

Attendant City

The attendant city is provided by the attendant table. Press the insert key to enter a city not provided in the table. City must be a recognized city in Utah.

Attendant State

The attendant state is provided by the attendant table.

Attendant Zip

The attendant zip code is provided by the attendant table.

Attendant Zip 2

The attendant zip code 2 field is provided by the attendant table, if provided.

Parent 1 and Parent 2 Birth Certificate Label

Mark the appropriate box with the information provided by the parent(s) on the parental worksheet. This label will print on any certified copy of the child's birth certificate. Mother, Father or Parent can be chosen for the birth certificate label.

Parent Gave Birth

Mark the appropriate box with the information provided by the parent(s) on the parental worksheet.

Parent Sex

Mark the appropriate box as given by the parent(s) on the parental worksheet.

General Marital Information

If parent 1 is married at the time of the birth, conception or any time in between, her spouse's name should be entered.

In general, if the child was:
Born to a birth parent who is married at the time of the child's birth, enter the name of their spouse unless the birth parent indicates that the spouse is not the biological parent of the baby. This rule applies to same-sex female couples who are married or same-sex male couples who are married and have a court order identifying them as the intended parents.

If birth parent is not married to the biological parent, and birth parent wishes to have the biological parent's name to be listed on the birth certificate a 'Voluntary Declaration of Paternity by Parents' form must be signed. The paternity form MUST be provided to the State Vital Record's Office. The signed Voluntary Declaration of Paternity form will be compared to the electronic image of the birth certificate to ensure that it has been completed accurately.

Note: Handwritten paternities will not be accepted. Alterations made in boxes 1 – 13 will void the form.

The surname of the biological parent and the surname of the child are usually the same. When they are different, it should be carefully reviewed with the parents to ensure that there is no mistake. However, it is acceptable to register a birth certificate with the child's surname different from the surname of the biological parent or birth parent. The child may remain unnamed at the time of registration if the parent(s) have not decided on the name.

This is a required field.

Note: Refer problems not covered in these instructions to the Utah Department of Health Office of Vital Records and Statistics.

Paternity Papers Included?

If a paternity is going to be signed so the biological father can be listed on the birth certificate check 'Yes, Paternity'.

If the biological parent is not going to be listed, check 'No Paternity'.

If the birth mother is married, but not to the biological parent, the still-legal husband must sign the paternity if the biological parent is going to be listed on the birth certificate.

If the birth mother was married within the 300 days prior to the birth, but not to the biological parent and biological parent is going to be listed on the birth certificate, the now-divorced husband must sign the paternity form formally making a written rebuttal to his paternity of the child.

Note: Completed paternity papers must be faxed – 801-536-0499 same day that the record is 'Marked' for registration. Records received without the appropriate paternity form shall have biological father information removed and registered as is.

No Parent 2 Info

If parent 2 is married to Parent 1, but is not going to be listed on the birth certificate this box must be checked. This will turn off all parent 2 related fields. A note of explanation must be entered in Legal Notes.

Parent First Name

Enter parent first name. Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them.

Parent Middle Name

Enter the parent middle name(s) if given. Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them.

Parent Last Name

Enter the parent legal last name(s). Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them.

Note: If parent 1 last name(s) and the baby's last name(s) are not exactly the same, a reminder message will be displayed.

Parent First Name Prior to First Marriage

The parent surname is important because it remains constant throughout their life, in contrast to other names, which may change because of marriage or divorce.

Enter parent first name prior to first marriage. If the parent was adopted prior to their marriage they should list that name as their prior name and not the name given at birth. If parent last name prior to first marriage is 'Unknown' enter an asterisk in the field.

Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them.

Parent Middle Name Prior to First Marriage

Enter parent middle name prior to first marriage. If the parent was adopted prior to their marriage they should list that name as their prior name and not the name given at birth. If parent last name prior to first marriage is 'Unknown' enter an asterisk in the field.

Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them. Do not enter maiden last name.

Parent Last Name Prior to First Marriage

Enter parent last name prior to first marriage. If the parent was adopted prior to their marriage they should list that name as their prior name and not the name given at birth. If parent last name prior to first marriage is 'Unknown' enter an asterisk in the field.

Electronic characters allowed include a-z, dash and apostrophe. All other characters will require an amendment to reflect them.

Parent Date of Birth (Month, Day, Year)

This item is used to calculate the age of the birth mother. Age is one of the most important factors in the study of childbearing. Studies have shown a relationship between the health of the child and age of the birth mother. For example: Teenage women and women over 40 have a higher percentage of low birth weight and premature infants than women of other ages. This item is also useful for genealogical research.

Enter parent's date of birth as reported. An asterisk may be entered in any portion of the parent 1 birth date fields if unknown. If a partial date is given, the program will not be able to calculate parent 1's age. If partial date is given, the program will not be able to print a paternity.

Parent 1 Phone Number

Enter parent 1 home phone number, if given. This is not a required field. This phone number will be provided to Utah Department of Health Healthy Utah programs and Local Health Departments for outreach services to the parents and newborn.

Parent Social Security Number

Furnishing parent Social Security Number is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.

Enter parent Social Security number if provided. Enter the nine digits. The program will automatically enter dashes (XXX-XX-XXXX). The field must include nine digits. Leave this field blank if a valid social security number is not provided. Leave this field blank if parent does not have a social security number.

Parent Birth State

This item provides information on recent immigrant groups, such as Asian and Pacific Islanders, and is used for tracing family histories. It is also used with the U.S. Bureau of the Census data to compare the childbearing of women who were born in the U.S. with that of foreign born women.

If parent was born in the United States, enter the state of birth. If parent born in a U.S. Territory enter the territory in the STATE field (Guam, Puerto, Virgin Island, American Samoa, Northern Mariana Islands). The country will automatically fill to United States. Use the arrow keys to scroll through the selection of states and territories. Enter an asterisk to indicate 'Unknown'. Note: If 'Unknown' is entered, a paternity cannot be printed. Do not enter parent city of birth in this item.

Parent Birth Country

If parent was born in the United States then this field will autofill based on the state entered. If parent was not born in the United States, enter the name of the foreign country. Use the arrow keys to scroll through the selection of countries. Enter an asterisk for 'Unknown'. If 'Unknown' is entered, a paternity cannot be printed.

Parent Street Address Line 1

Enter parent usual street address. This is the physical location of the street location at which Parent resides. If parent street address is an unnamed street, enter 'unnamed street'. If parent 1 usual address is rural, example: Taylor Ranch, Ruby Inn, etc., enter as such. Enter an asterisk if 'Unknown'. Do not enter a PO Box in this field.

Parent Street Address Line 2

This field may be used to enter in Apartment, Unit and other directional information if needed which does not fit in the address line 1 field. Do not enter a PO Box in this field.

Parent Residence City

Accurate birth rates for cities and counties are important for planning and estimating population growth. Most population studies are based on the parent 1's residence. Statistics on births are tabulated by place of residence of parent 1. This makes it possible to compute birth rates based on the population residing in the area. These data are used in planning for and evaluating community services and facilities, including maternal and child health programs, schools, etc. Private businesses and industries also use these data for estimating demands for services.

Enter parent city of usual residence from the table provided or press the insert key to override the table and enter a non-Utah city in this field. Use the State FIPS code help tool found in Uintah/Reports to identify missing or un-legible city entries.

Parent Residence County

Enter parent county of residence from the table provided or press the insert key to override the table and enter a non-Utah county in this field. All Utah counties are in the provided table. If parent county of residence is out of state override the table and key the parent county of residence as given. Use the State FIPS code help tool found in Uintah/Reports to identify missing or un-legible county entries. Enter an asterisk if unable to identify the county or if a county in not applicable for a foreign address.

Parent Residence State

Enter parent state of residence from the table provided. All U.S. states and territories are in the provided table. Enter an asterisk if unknown. Entering a U.S. state or territory will allow the parent country of residence to auto-fill.

Parent Residence Country

Enter parent country of residence from the table provided. If parent residence country in not known enter an asterisk in this field.

Parent Residence Zip Code

Enter parent resident zip code. If 'Utah' is entered, the zip code must start with '84'. Enter an asterisk if unknown or no zip code can be obtained or is from a foreign country. If 'Unknown' is entered, a paternity cannot be printed.

Parent Residence Zip Code 2

Enter parent residence zip code extension, if provided.

Parent Residence Inside City Limits

Enter city limits as given on the parental worksheet. If item was left blank on the worksheet, the parent should be contacted to obtain this answer. If parent cannot be contacted, the birth certificate clerk may determine if parent usual residence is inside the city limits. If unable to determine city limits enter as 'Yes' in city limits.

Parent Email Address

Parents who provide their email address will receive an instant notification when the child's birth certificate registers allowing them to quickly apply for the purchase of a certified copy of the child's birth certificate.

Enter parent email address if given. This is a double key field. Key the address once and press the enter key verify. If the second entry is exactly the same as the first entry the cursor will advance to the next field. If not, it must be keyed in again until it matches twice.

Mailing Address Same

It is important to distinguish between parent mailing address and the residence address. Because each serves a different purpose, they are not substitutes for one another. This information is sometimes used to mail to the parents for clarification of birth certificate entries or obtain missing information. It is also used for follow back studies to obtain additional details about the birth. Social Security is provided with this address when parents have requested the social security card via the birth certificate.

If there is not a separate mailing address provided, check this box. If there is a separate mailing address enter the mailing information in the appropriate fields.

Parent 1 Mailing Address

If provided, enter parent mailing address or the address as given. A PO Box or drawer is acceptable.

General Delivery is not an acceptable response if requesting a social security card for the newborn. In these cases the parent must give a specific address for delivery of a social security card. A family or friend address may be used for mailing the card if the parent does not have a mailing address, but the name of the in-care of person must be listed in the 'In-care' of field. Social Security card cannot be mailed to foreign countries.

Parent 1 Mailing City

Enter the mailing city from the provided city table or press the insert key to override the provided table.

Parent 1 Mailing State

Enter the mailing state from the provided state table or press the insert key to override the provided table.

Parent 1 Mailing Country

Enter the mailing country from the provided country table or press the insert key to override the provided table.

Parent Mailing Zip Code

Enter parent mailing zip. If zip code is not known or is for a foreign country enter an asterisk.

Parent Mailing Zip Code 2

Enter parent mailing zip code extension if provided.

Child Relinquished for Adoption

Mark this box if child is being relinquished for adoption. This box should not be marked if the child is being removed by DCFS on a temporary basis.

Name of Adoption Agency/Attorney

Enter the name of the adoption agency or attorney representing the adoption. 'Private Adoption' may be entered if the name of agency or attorney is not known.

Request for SSN for Newborn

This item must be checked if the parents are requesting a Social Security Card for their newborn. Vital Records will provide the needed information to the Social Security Administration, who will mail a social security card for the infant to the parent(s). Do not assume that the parent(s) would want a Social Security card. If no answer was provided, contact parent(s) for a response. If unable to contact the parent(s), leave field blank.

Birth Parent Enrolled In Medicaid

Mark this box if the birth parent is currently enrolled as a Utah Medicaid client. If the Primary Source of Payment is marked 'Medicaid' then this field must also be marked.

Birth Parent Received WIC during pregnancy

Enter response as provided by parent. Contact the parent(s) if no answer was provided. Mark the 'Unknown' box if unable to contact the parent(s).

Birth Parent Primary Source of Payment for this Delivery

Mark the type of payment for this delivery. If the patient is NOT enrolled in Medicaid at the time of delivery, but is attempting to apply for Medicaid post-delivery and has no other source of payment mark payment type as 'Unknown'.

Note: Do not list 'Medicaid Pending' in Legal Notes or 'Other' source of payment.

Hearing Loss of Relative

Mark the box if a relative of the baby had a hearing loss that existed since childhood.

Legal Notes

If there were any unusual entries to the legal section fields, please explain in this field. Explanation of unusual field entries will speed processing and avoid Vital Record calls to explain them. Examples include, all names as given, mom refused dad info at this time, etc. Notes in this field are displayed to all vital records offices and should not include medical information.

Birth Mother's Height (Feet)

Enter the birth mother's height in feet. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible.

Birth Mother's Height (Inches)

Enter the birth mother's height in inches. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible.

Birth Mother's Weight Prior to Pregnancy

Enter the birth mother's weight before pregnancy - rounded to whole pounds. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible. Verification required if weight at delivery is greater than 400 pounds.

Birth Mother's Weight at Delivery

Enter the birth mother's weight at delivery rounded to whole pounds. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible. Verification required if weight at delivery is greater than 400 pounds.

Birth Mother's Pregnancy Weight Gain or Loss

Birth mother's weight gain or loss during the pregnancy will be calculated from the birth mother's weight prior to pregnancy and birth mother's weight at delivery. Verification required if mom weight gain or loss is more than 50 pounds.

Tobacco Use

Mark box if birth mother used tobacco 3 months prior to the pregnancy or during her pregnancy. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item. Indicate 'Unknown' if no mention of mother tobacco use from either the parental worksheet or the medical care record.

Tobacco Used 3 Months Prior to Pregnancy

Enter the average number of cigarettes smoked per day. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item. Indicate 'Unknown' if no mention of mother tobacco usage from either the parental worksheet or the medical care record.

Tobacco - Trimester 1

Enter the average number of cigarettes smoked per day. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item. Indicate 'Unknown' if no mention of mother tobacco usage from either the parental worksheet or the medical care record.

Tobacco - Trimester 2

Enter the average number of cigarettes smoked per day. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item. Indicate 'Unknown' if no mention of mother tobacco usage from either the parental worksheet or the medical care record.

Tobacco - Trimester 3

Enter the average number of cigarettes smoked per day. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item. Indicate 'Unknown' if no mention of mother tobacco usage from either the parental worksheet or the medical care record.

E-Cigarette Use

Enter the response as indicated by the parent. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible.

E-Cigarette Frequency

Enter the frequency of use as indicated by the parent. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. If unable to contact the parent use the medical record and prenatal care history to complete this item when possible.

Infant Being Breastfed at Discharge

Mark the box if the infant was being breast-fed during the period between birth and discharge from the hospital. If the question was left blank on Parental Worksheet refer to birth mother's chart for appropriate response to question.

Gestational Diabetes during this Pregnancy – As Reported by Birth Mother

Mark the response box indicated by birth mother. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided.

Gestational Diabetes Confirmed in Birth Mother Chart

Mark the box with the appropriate response after reviewing the birth mother's medical records. This information should be found on the patient's prenatal care record, History and Physical, Delivery Summary, OP Report or Maternal Progress Notes.

Where Was Gestational Diabetes Found

If 'Yes' to Gestation Diabetes Confirmed, enter the name of document where the confirmed diagnosis was found. List the first document confirming diagnosis.

Where Was Gestational Diabetes Found – Other Specify

If 'Yes' to Gestation Diabetes Confirmed, enter the name of documents where the confirmed diagnosis was found. List the second document confirming diagnosis.

Medication for Prevention of Preterm Birth Not Indicated

If 'No' to Preterm Birth Medication Injection indicated by parent, check this box. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. The patient medical record may be used if indicated by a health care provider.

Medication for Prevention of Preterm Birth Unknown

This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. The patient medical record may be used if indicated by a health care provider.

Medication for Prevention of Preterm Birth Injection

If 'Yes' to Preterm Birth Medication Injection indicated by parent, check this box. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. The patient medical record may be used if indicated by a health care provider.

Medication for Prevention of Preterm Birth Suppository

If 'Yes' to Preterm Birth Medication Suppository indicated by parent, check this box. Enter an asterisk to indicate 'Unknown'. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. The patient medical record may be used if indicated by a health care provider.

Parent Signature

Mark the appropriate parent title, 'Parent 1', 'Parent 2' or 'Other'. If left blank on Parental worksheet and parent(s) did not sign the Birth Information Sheet, mark 'Other'. If the Parental Worksheet was completed by parent 2, but parent 2 is not going to be listed on the birth certificate, but parent 1 sign anywhere on the Parental Worksheet or the BIS, please enter parent 1 instead. No social security card can be requested if no parent signature obtained.

Birth Mother's Medical Record Number

Enter the birth mother's medical record number.

Birth Mother's Alternate Medical Record Number

Enter the birth mother's alternate medical record number.

Date of Last Menses (Month, Day, Year)

Enter the date of the birth mother's last normal menstrual period. An LMP date reported with only the month and year is acceptable. The year or day only are not acceptable responses. An asterisk must be used to indicate missing date of last normal menses fields.

Notes:
If either the month and/or year are entered as 'Unknown' all three date fields will automatically fill with asterisks. Do not enter an EDC date in this field. If birth mother had no period after having had a termination do not use the termination date as the LMP date. Enter 'Unknown'. Indicate in the medical notes field that mom has had no regular LMP date since date of last termination.

Other Births - Now Living

Enter the number of live births for that are still living. Do not include this child. If this is the first birth for this birth mother, enter a zero. Count twin A, triplet, B and C and so forth for all multiples births. Enter an asterisk if number of previous live births cannot be determined. Any number, other than zero, will require the birth month and year.

Other Births - Now Dead

Enter the number of children, born live that are no longer living. Do not include this child. Enter an asterisk if number of previous live births now dead cannot be determined. Any number, other than zero, will require the birth month and year.

Date of Last Live Birth (Month, Year)

Enter the date of last live birth as found on the prenatal care record or by birth mother if no prenatal care record can be obtained. Enter an asterisk to indicate 'Unknown' for either the month and/or year field. Enter Twin A's birth date in Twin B's record and so forth for all multiple births.

Number of Previous Terminations

Enter the number of pregnancies in which gestation did not result in a live birth, regardless of the length of gestation (include ectopic pregnancies, miscarriages, elective therapeutic terminations, non-therapeutic terminations, stillbirths/fetal deaths in this item). If none, enter a zero. Any number, other than zero, will require the termination month and year. Enter an asterisk to indicate 'Unknown' for either the month and/or year fields.

Date of Last Termination (Month, Year)

Enter the last termination date as found on the prenatal care record or by birth mother if no prenatal care record can be obtained. Enter an asterisk to indicate 'Unknown' for either the month and/or year field.

Number of Previous Stillbirths

Enter the number of pregnancies which resulted in a stillbirth/fetal demise (gestation of 20 weeks or more without signs of life when entirely outside of birth mother). If none, enter a zero. Enter an asterisk to indicate 'Unknown'.

Number of Previous Multiple Pregnancies

Enter the number of pregnancies which resulted in a multiple live birth delivery. Excludes fetal demises, early term stillbirths or other gestations born without signs of life when entirely outside of birth mother. If none, enter a zero. Enter an asterisk to indicate 'Unknown'.

No Prenatal Care

Mark this box if birth mother received no prenatal care during her pregnancy. Prenatal care includes all traditional and non-traditional care by a health care provider. Record self-care during the pregnancy as 'No Prenatal Care'.

Date of First Prenatal Care Visit

Enter the date of first prenatal care visit as indicated by prenatal care provider. If no prenatal care record or an incomplete prenatal care record found contact the provider for a current prenatal care record. A prenatal care record is considered incomplete if the gestational weeks at delivery are 35 or greater and the prenatal care record does not show through the 35th week. You must request a new copy from the provider's office. If date of first visit missing or reported partially enter and asterisk for the missing date fields.

If the gestational weeks at delivery are less than 36 weeks and a prenatal care record can be obtained then record the visits as shown. If date of first visit missing or reported partially enter an asterisk for the missing date fields.

If a complete prenatal care record is not available or cannot be obtained and the prenatal care has been self-reported by the parent it may be used if complete with both date of first visit and total number of visits are shown. Exclude a self-care during the pregnancy.

If mom transferred prenatal care and both the earlier and current care records cannot be obtained and review for a complete picture of the prenatal care history record the date and visits as 'Unknown' and note in the medical/confidential note field that there was a transfer of care.

Rule:
If the prenatal care record shows the gestational weeks through the 35th week, but not up to the week of delivery, count one visit for each week not shown and add to the total visits shown. Example, the prenatal care record ends at 36 weeks, but mom delivered at 39 - add 3 visits to the total listed on the prenatal care record.

Number of Prenatal Visits

Enter the number of visits as indicated on the prenatal care record or as reported by the parent.

Birth Mother Transferred From Facility to Facility

Mark this box if birth mother was transferred from one birthing facility to another birthing facility during labor or within 24 hours postpartum of delivery. Occasionally a birth mother will be transferred for urgent care that can only be provided by being transferred to another facility.

If Mom Transferred

Indicate the time of transfer as during labor or postpartum within 24 hours of delivery. If the time of transfer cannot be found 'Unknown' should be marked.

Facility Transferred From

Select the name of the facility from the provided table. If the birthing facility name cannot be found in the provided table press the insert key and type in the facility name as given. Use the up and down arrow keys to scroll through the provided table which also includes out of state hospitals. Check medical records to determine where birth mother was transferred from. An asterisk may be entered if no indication of which birthing facility mom was transferred from.

State Facility Transferred From

Enter the name of the state the birth mother was transferred from. This is a smart type field and it cannot be overridden.

Birth Mother Transferred To Hospital from Attempted Home Birth

Mark the appropriate box if birth mother was transferred from an attempted home delivery during labor or 24 hours postpartum to the delivery. Occasionally a birth mother will be transferred for urgent care that can only be provided by a hospital.

Birth Mother Transferred To Hospital from Attempted Home Birth If 'Yes'

Mark the appropriate box if birth mother was transferred from an attempted home delivery during labor or 24 hours postpartum. An asterisk may be entered if no indication of when mom was transferred. Contact the midwife for missing information. Use the Midwife Contact List in Uintah to contact the midwife.

Mom Teeth Cleaned during Pregnancy

Enter response as given. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided contact the parents for a response. Mark 'Unknown' if no response can be obtained.

Reason for Teeth Not Cleaned during Pregnancy – Check all that apply

Enter responses as given. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided.

Vitamin Usage during Pregnancy

Enter response as given. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

No Vitamin Usage during Pregnancy

Enter responses as given. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

Mom Zika Virus Test Self-Report

Enter the appropriate response as reported by mom on the parental worksheet. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

Mom Zika Virus Test from Medical Chart

Enter the appropriate response as reported by pregnancy care provider from the medical care records during this pregnancy.

Mom Hep B Test

Enter the appropriate response as reported by pregnancy care provider from the medical care records during this pregnancy.

Parent 1 and Parent 2 Hispanic Origin

Enter response as given by the parent. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

Parent 1 and Parent 2 Hispanic Type – Check all that apply

Check all Hispanic origin types given by parent. This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

Parent 1 and Parent 2 Hispanic Origin Specify

Enter specified types as given by parent. Types of Hispanic origin to list in Other Specify: Argentina, Balearic Islands, Brazil, Basque, Belizian, Bolivian, Boricua, Californio, Canary Islands, Castilian, Catalonia, Centroamericano, Chicano, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Espana, Espanol, Falkland Islands, Fernando Po, Galapagos Islands, Guatemala, Hispano, Honduras, Iberia, La Raza, Latin American, Latino, Majorca, Mallorca, Nicaragua, Panama, Paraguay, Peru, Salvadoreno, Spain, Spaniard, Uruguay, Valencian and Venezuela.

Parent 1 and Parent 2 Race – Check all that apply

This is a self-reported item and should be taken from Parental Worksheet. Contact the parent if no answer was provided. Mark 'Unknown' if no response can be obtained.

Parent 1 and Parent 2 'Other' Race Specify

Enter 'Other Specified' race as reported by parent. If parent has reported a Hispanic origin, but failed to list a race enter the Hispanic origin as reported in the 'Other Specify' race field.

Parent 1 and Parent 2 Education

Mark education as given by parent. If item is blank on the Parental Worksheet, contact parent for missing information. If unable to contact parent indicate 'Unknown'.

Medical Notes

This field is for medical information verification and to report Covid-19 moms and babies. To report Covid positive cases, start the field with this exact text: 'Covid-19 Mom' or 'Covid-19 Mom and Baby'. Verification for responses out of the 'normal' range of responses for a specific field such as 'LMP Unknown', 'Mom pregnancy weights verified', etc. may be entered here.