Parent's Worksheet to Register Birth Information

The information gathered on this worksheet will be used to register information

for your child's birth certificate and to apply for your child's Social Security Card.

Use of Birth Registration Information from this worksheet:

The information you enter here is REQUIRED to register your child's birth information and create your child's Birth Certificate.
The Birth Certificate is a legal document used to prove your child's identity, age, citizenship and parentage throughout their life.
Complete, Accurate and Readable information on this worksheet is very important. It must be registered within 10 days of birth.
In addition to legal information, data gathered here will be used by health researchers to study and improve the health of
mothers and newborn infants. This information will not appear on the birth certificate.
State laws protect against the unauthorized release of identifying information from this birth registration worksheet to
ensure the confidentiality of the parents and their child.

How do I apply to get a certified copy of a Birth Certificate?

Provide email addresses on this worksheet to receive an electronic notification when the information has been registered.
After Registration, order the certificate online at vitalrecords.utah.gov and pay the fee on the Utah.Gov website.
The footprint card or registration form you receive from the hospital or midwife is not an official birth certificate.
THIS WORKSHEET IS NOT AN APPLICATION FOR A BIRTH CERTIFICATE
What if there is a mistake on the birth certificate or I want to add or change something later?
Please make sure your information is registered correctly the first time by filling out this worksheet clearly and completely.
Use upper and lower case English standard characters only . Non-standard English characters are not accepted by the Social
Security Administration. Non-standard characters on a birth certificate require special processes, ask birth clerk for more info.
If you need to change something after the information is registered, you must file an amendment with the Office of Vital Records.
All changes made to the birth certificate after registration will show as amendments to the original record.

How do I get my child's Social Security Card?

To order a Social Security Card for your child, be sure to check "Yes" to item #11 and sign the worksheet.
The card will be mailed in 2-3 weeks to the address listed as the 'Mail To' address in #31.
The 'in-care-of name' and the names of ALL who live there MUST be listed visibly on or in the mailbox for the SSA card to be delivered.
The Post Office cannot forward the card. A Social Security Card cannot be mailed out of the country.

If you do not receive the card, apply for a replacement from the Social Security Administration at SSA.gov or 1-866-851-5275.

Birth Clerk Message

Parents: Please tear this sheet off for your records.

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 Mother's Name: ______________________________________________ Room Number: _____________
PLEASE PRINT CLEARLY. DO NOT TAKE THIS WORKSHEET HOME.
THIS WORKSHEET MUST BE LEFT FOR THE BIRTH CLERK AT TIME OF DISCHARGE.
Please fill in Circles completely ⃝

1. Child's legal name, as parents wish it to appear on the birth certificate.

Child First Name(s) _________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________

Last Name(s) ______________________________________________________________Suffix (Jr. Sr. etc): ____________

2. Child Sex: ⃝ Male ⃝ Female ⃝ Undetermined (SSA Card cannot be processed without a sex for the child.)

3. Date of birth mm/dd/yyyy: ______________________ 4. Time of birth (24 hr clock): ______________________

5. Child birth Weight: __________LBS ___________OZ. 6. Child birth Length (Inches): _____________________
Length will not be listed on the Birth Certificate
7. Where was the baby born?
⃝ Hospital - Facility Name: __________________________________________________________________________
⃝ Baby was born while traveling to hospital
⃝ Freestanding birth center - Facility Name: ___________________________________________________________
⃝ Baby was born while traveling to birth center
⃝ Clinic / Doctor's Office
⃝ Home - intended ⃝ Home - not intended ⃝ Home - unknown if intended
⃝ Other
⃝ Unknown

8. Intended place of delivery. When labor started, where did Mother plan to give birth?
This information is NOT provided to insurance companies or other state agencies. There are NO legal or insurance consequences to parents
based on where they intended to give birth.
⃝ Home - Midwife Name: _____________________________________________________________⃝ No midwife
⃝ Freestanding birth center - Midwife Name: _________________________________________ ⃝ No midwife
Facility Name: ____________________________________________________________________________
⃝ Hospital
⃝ Labor never started. Mother had a C-section without labor.

9. If child was NOT born at, or while traveling to, a hospital or ____________________________________________
birth center, please list the full street address of birth location here: ____________________________________________

10. Name of delivering birth

professional or other birth attendant: ________________________________________Title: _____________________

11. ⃝ YES Provide my child's information to the

Social Security Administration for purposes of issuing a
social security card to my child. Parental signature required: X _____________________________________

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MOTHER

12. On my child's birth certificate, I wish to be known as: ⃝ Mother (Female) ⃝ Father (Male) ⃝ Parent (Female) ⃝ Parent (Male)

13. I Gave Birth: ⃝Yes ⃝ No

14. Mother's Marital Status: 15. Was Mother ever married?

⃝ Married to Biological father (Skip to Question #18) ⃝ Yes ⃝ No
⃝ Not married
⃝ Married, not to biological father (Skip to Question #17) 16. Was Mother married any time within the last 300 days (about 10 months)?
⃝ Yes ⃝ No

17. If not married to the biological father, do you wish to legally acknowledge him on the birth certificate? ⃝ Yes ** ⃝ No (Skip to #18)
The Voluntary Declaration of Paternity (VDP) form is the legal form parents who are not married must sign
in order to legally acknowledge the biological father of the child and list him on the birth certificate.

If currently married, but not to the biological father: the current spouse, the biological father and the mother must sign the VDP.
If married within the last 300 days: the ex-spouse, the biological father and the mother must sign the VDP.

**This Parental Worksheet must be turned in to the birth clerk in order for the Voluntary Declaration of Paternity form to
be prepared for parents to sign.

18. Was child delivered by a gestational surrogate? ⃝ Yes ⃝ No

19. Mother's current Legal Name:

First Name(s) _______________________________________________________________________________________________________

Middle Name(s) _____________________________________________________________________________________________________

Last Name(s) ___________________________________________________________________________ Suffix (Jr. Sr. etc): ____________

20. Mother's Name prior to first marriage - name as it appears on the current birth certificate, not a name prior to an adoption or other
court order name change. Print clearly using upper and lower case characters and spacing as needed.
The name listed below will appear on the child's birth certificate.

First Name(s) _______________________________________________________________________________________________________

Middle Name(s) _____________________________________________________________________________________________________

Last Name(s) (Maiden/Surnames) ______________________________________________________________Suffix (Jr. Sr. etc): ____________

21. Date of Birth mm/dd/yyyy: _________________________________ 22. Phone Number: ______________________________________

23. Social Security Number: ____________________________________ 24. State of Birth: _______________________________

SSN is required by Federal Law, 42 USC 405(c) Section 205(c) Social Security Act Spell out name of U.S. State

25. Country of Birth, if not U.S.A.: _______________________________________________________________________________________

26. Usual or Permanent Residence

Complete number and street Address: ____________________________________________________________________________________
Indicate directional such as Apt, Unit, Space, etc. in front of the location number to assist in mail delivery accuracy. Example: 124 West Maple Unit B

City/Town or Location: ______________________________________ U.S. State: ___________________Zip: _________________________

County ___________________________________________________ Foreign Country if not in U. S.: _______________________________

27. Inside City Limits? ⃝ Yes ⃝ No ⃝ I don't know

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28. Mother's Email Address: ________________________________________________________________________ Print Clearly
You will receive an immediate email confirming the registration of chid's birth from the Office of Vital Records and Statistics which will allow for immediate ordering and
purchase of your child's birth certificate for insurance and other family records purposes.

29. Mother's mailing address same as residence? ⃝ Yes ⃝ No - Please Complete #31

30. In Care of Mail Person's Name: __________________________________________________________________________________

Failure to list this person's name in or on the mail/PO Box will result in the SSA card being returned to SSA as undeliverable.
Parents will then need to apply to SSA for a replacement card. Hospital and Vital Records cannot process a second request.

31. Complete Mailing Address: ______________________________________________________________________________________

City/Town or Location: _______________________________ U.S. State: ______________________ Zip: _________________________

To order a Social Security Card for your child, be sure to check "Yes" to item #11 and sign the worksheet.
The Social Security card will be mailed in 2-3 weeks.
The 'in-care-of name' and the names of ALL who live there MUST be listed visibly on or in the mailbox for the SSA card to be delivered.
The Post Office cannot forward the card. A Social Security Card cannot be mailed out of the country.

32. Mother Signature: _____________________________________________________________________________________________

By signing here, I certify that the personal information provided on this worksheet is correct to the best of my knowledge and belief.

FATHER

33. Travel out of Utah in the last 12 months? ⃝ Yes ⃝ No

34. If Yes, list U.S. States and Foreign Countries: ________________________________________________________________________

35. Tested for Zika? ⃝ Yes ⃝ No ⃝ Unknown

36. On my child's birth certificate, I wish to be known as: ⃝ Mother (Female) ⃝ Father (Male) ⃝ Parent (Female) ⃝ Parent (Male)

37. Father's current Legal Name:

First Name(s) _____________________________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________________________

Last Name(s) __________________________________________________________________________Suffix (Jr. Sr. etc): ______________

38. Father's Name prior to first marriage - name as it appears on the current birth certificate, not a name prior to an adoption or other
court order name change. Print clearly using upper and lower case characters and spacing as needed.
The name listed below will appear on the child's birth certificate.

First Name(s) _____________________________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________________________

Last Name(s) __________________________________________________________________________Suffix (Jr. Sr. etc): ______________

39. Date of Birth mm/dd/yyyy: ___________________________40. Phone Number: _____________________________________________

41. Social Security Number: ____________________________________ 42. State of Birth: ___________________________________

SSN is required by Federal Law, 42 USC 405(c) Section 205(c) Social Security Act Spell out name of U.S. State

43. Country of Birth, if not U.S.A.: ____________________________________________________________________________________

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44. Usual or Permanent Residence
Complete number and street Address: _______________________________________________________________________________
Indicate directional such as Apt, Unit, Space, etc. in front of the location number to assist in mail delivery accuracy. Example: 124 West Maple Unit B

City/Town or Location: _______________________________ U.S. State: ______________________ Zip: ___________________

County ____________________________________________ Foreign Country if not in U. S.: _________________________________

45. Inside City Limits? ⃝ Yes ⃝ No ⃝ I don't know

46. Father's Email Address: _________________________________________________________________________Print Clearly

You will receive an immediate email confirming the registration of chid's birth from the Office of Vital Records and Statistics which will allow for immediate purchase
of your child's birth certificate for insurance and other family records purposes.

47. Father Signature: _____________________________________________________________________________________________

By signing here, I certify that the personal information provided on this worksheet is correct to the best of my knowledge and belief.

ADOPTION?

48. Is this child to be relinquished or placed for adoption? ⃝ Yes ⃝ No

49. If 'Yes', please list the name of the agency and/or attorney or 'private adoption': ______________________________________________________

CONFIDENTIAL HEALTH INFORMATION OF BIOLOGICAL MOTHER

50. Was Mother enrolled in Medicaid at time of birth? ⃝ Yes ⃝ No

51. Did Mother receive food vouchers for Women, Infants and Children (WIC) food for herself during this Pregnancy?
⃝ Yes ⃝ No ⃝ I Don't know

52. Primary Source of payment for this delivery: ⃝ Medicaid ⃝ Private Insurance ⃝ Self-Pay ⃝ Indian Health Service
⃝ CHAMPUS/TRICARE ⃝ Other Government (Fed, State, Local) ⃝ CHIP ⃝ Other ⃝ Unknown (check if Medicaid Pending)

53. Does anyone in the family (child's mother, father, siblings, aunts, uncles, grandparents, cousins) have a hearing loss (not caused by loud noise,
illness or ear infection) they were born with or which developed in childhood? ⃝ Yes ⃝ No ⃝ I don't know

54. Mother height: _________ Feet _________ Inches 55. Mother weight prior to pregnancy: ________________ Lbs.

56. Mother weight at Delivery: ___________________________ Lbs.

57. Did Mother Smoke? ⃝ Yes ⃝ No

58. If 'yes', how many cigarettes per day did you smoke on an average day during each of the following time periods? (20 cigarettes per pack)
Three months before pregnancy # ___________________ Second three months of pregnancy # __________________
First three months of pregnancy # ___________________ Third trimester of pregnancy # _______________________

59. Were e-cigarettes or other electronic nicotine products used during pregnancy? ⃝ Yes ⃝ No

60. If 'yes' frequency of e-cigarette use: ⃝ More than once per day ⃝ Once a day ⃝ 2-6 days per week ⃝ 1 day per week or less

61. Is infant being breast-fed at discharge? ⃝ Yes ⃝ No

62. Was Mother told by her healthcare provider that she had gestational diabetes during this pregnancy? ⃝ Yes ⃝ No

63. During your most recent pregnancy, did a doctor, nurse, or other health care worker try to keep your new baby from being born too early by
giving you a series of weekly shots or daily vaginal suppositories of a medicine called Progesterone, Makena ® or 17P (17 alpha-hydroxyprogesterone)?
⃝ Yes - weekly injection ⃝ Yes - vaginal suppository ⃝ No ⃝ Unknown

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64. Date of last menses (last period) mm/dd/yy: ____________________ 65. Number of previous births now living: #_______________
Do not include this child.
66. Date of last live birth (do not include this child) mm/yyyy: _________________67. Number of previous live births now deceased: #________

68. Total number of pregnancies not resulting in live birth: #___________69. Date of last pregnancy not resulting in a live birth: ______

70. Total number of stillbirths: _____________ 71. Number of previous live multiple birth pregnancies: # ____
Losses at 20+ weeks or greater born without signs of life, do not include induced terminations - any weeks)

72. Date of first prenatal care visit mm/dd/yyyy: ____________________73. Number of prenatal visits this pregnancy: # ____________

74. Prenatal care Provider(s) / Facility: ____________________________________________________________________________

75. Did Mother transfer to a hospital during labor, but before delivery from an attempted home or birth center birth?
This information is NOT provided to insurance companies or other state agencies. There are NO legal or insurance consequences to parents based on
where they intend to give birth.
⃝ Yes, transferred from attempted birth at home Midwife Name: _________________________________________________
⃝ Midwife attended, name unknown ⃝ Unknown if midwife attended ⃝ No midwife
⃝ Yes, transferred from attempted birth at freestanding birth center - Midwife Name: ______________________________________
Facility Name: ________________________________________________________________________________________
⃝ No, Mother did not transfer to a hospital during labor from an attempted home or birth center birth.
⃝ Unknown if Mother transferred to a hospital during labor from an attempted home or birth center birth.

76. Did Mother transfer to a hospital within 24 hours after delivering at a home or birth center?
⃝ Yes, transferred after delivering at home Midwife Name: _________________________________________________
⃝ Midwife attended, name unknown ⃝ Unknown if midwife attended ⃝ No midwife
⃝ Yes, transferred after delivering at freestanding birth center - Midwife Name: ___________________________________________
Facility Name: ________________________________________________________________________________________
⃝ No, Mother did not transfer to a hospital within 24 hours after delivering at a home or birth center.
⃝ Unknown if Mother transferred to a hospital within 24 hours after delivering at a home or birth center.

77. During most recent pregnancy, did Mother have teeth cleaned by a dentist or dental hygienist? ⃝ Yes ⃝ No ⃝ Unknown

78. Did any of the following things make it difficult for Mother to go to a dentist or dental clinic during the most recent pregnancy?
⃝ Could not find a dentist or clinic who would take pregnant patients ⃝ Did not think it safe to go to dentist during pregnancy
⃝ Could not find a dentist or clinic who would take Medicaid patients ⃝ Could not afford to go to a dentist or dental clinic

79. During the month before pregnancy, how many times per week did Mother take a multivitamin, prenatal vitamin or folic acid vitamin?
⃝ Did not take vitamins ⃝ 1 to 3 times per week ⃝ 4 to 6 times per week ⃝ Every Day ⃝ Unknown

80. If Mother did not take vitamins, what were the reasons - choose all that apply.
⃝ Wasn’t planning to get pregnant ⃝ Didn't want to take vitamins ⃝ Other - specify reasons:
⃝ Didn't think vitamins were needed ⃝ Vitamins were too expensive ___________________________________________
⃝ Unknown ⃝ Vitamins gave side effects ___________________________________________

81. Did Mother travel out of state in the last 12 months? ⃝ Yes ⃝ No If 'yes', list U.S. states and foreign countries:

___________________________________________________________________________________________________________

82. Was Mother tested for Zika virus by healthcare provider? ⃝ Yes ⃝ No ⃝ Unknown

83. Was Mother tested for Hepatitis B by a healthcare provider during this pregnancy or at the hospital? ⃝ Yes ⃝ No ⃝ Unknown

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 RACE/ETHNICITY

84. Mother of Hispanic Origin? ⃝ Yes ⃝ No ⃝ Unknown

if 'Yes', check all that apply: ⃝ Mexican, Mexican American, Chicana ⃝ Puerto Rican ⃝ Cuban
⃝ Other Spanish / Hispanic / Latina - Specify: __________________________________
(e.g. Spaniard, Salvadoran, Dominican, Colombian)

85. Race of Mother, Check all that apply: ⃝ Other Asian - Specify: ⃝ Guamanian
⃝ White ⃝ Chinese ___________________________ ⃝ Pacific Islander - Specify:
⃝ Black ⃝ Japanese ⃝ Asian Indian ________________________
⃝ American Indian or ⃝ Native Hawaiian ⃝ Korean ⃝ Tongan
Alaska Native - Specify: ⃝ Filipino ⃝ Samoan ⃝ Other - Specify:
_______________________________ ⃝ Vietnamese ________________________
⃝ Unknown
86. Mother's Education
⃝ 8th grade or less ⃝ Some college credit, but no degree ⃝ Doctorate (e.g. PhD, EdD) or Prof.
⃝ 9th-12th grade no diploma ⃝ Associate Degree (e.g. AA, AS) Degree (e.g. MD, DDs, DVM, LLB, JD)
⃝ High School Graduate or GED completed ⃝ Bachelor's Degree (e.g. BA, AB, BS) ⃝ None
⃝ Master's Degree (MA MS, MEng, Med, MSW, MBA) ⃝ Unknown

87. Father of Hispanic Origin? ⃝ Yes ⃝ No ⃝ Unknown

if 'Yes', check all that apply: ⃝ Mexican, Mexican American, Chicano ⃝ Puerto Rican ⃝ Cuban
⃝ Other Spanish / Hispanic / Latino - Specify: __________________________________
(e.g. Spaniard, Salvadoran, Dominican, Colombian)

88. Race of Father, Check all that apply: ⃝ Other Asian - Specify: ⃝ Guamanian
⃝ White ⃝ Chinese ___________________________ ⃝ Pacific Islander - Specify:
⃝ Black ⃝ Japanese ⃝ Asian Indian ________________________
⃝ American Indian or ⃝ Native Hawaiian ⃝ Korean ⃝ Tongan
Alaska Native - Specify: ⃝ Filipino ⃝ Samoan ⃝ Other - Specify:
_______________________________ ⃝ Vietnamese ________________________
⃝ Unknown
89. Father's Education
⃝ 8th grade or less ⃝ Some college credit, but no degree ⃝ Doctorate (e.g. PhD, EdD) or Prof.
⃝ 9th-12th grade no diploma ⃝ Associate Degree (e.g. AA, AS) Degree (e.g. MD, DDs, DVM, LLB, JD)
⃝ High School Graduate or GED completed ⃝ Bachelor's Degree (e.g. BA, AB, BS) ⃝ None
⃝ Master's Degree (MA MS, MEng, Med, MSW, MBA) ⃝ Unknown

MOTHER'S MEDICAL INFORMATION

Questions have been raised regarding the incidence of birth defects and other birth outcomes and fertility treatments. Your answers to the
following questions will help scientists answer these questions. Answers are important whether or not your baby had any problems and
whether or not you used any fertility treatments.

90. Did you take any fertility drugs or receive any medical procedures to help you get pregnant for this pregnancy? ⃝ Yes ⃝ No

91. How long had you be trying to get pregnant when you conceived? Please count the time from when you first started having sexual
intercourse without any contraception.
⃝ 0-5 months ⃝ 6-11 months ⃝ 1-2 years ⃝ 3-4 years ⃝ 5-6 years ⃝ >6 years

92. Did you use any of the following fertility treatments?

⃝ Fertility enhancing drugs by mouth (Clomid, Clomiphene, or others)
⃝ Fertility enhancing drugs by injection (Pergonal, Follistim, HGG or others)
⃝ Artificial Insemination or Intrauterine Insemination (AIH, AID/DI)
⃝ Assisted Reproductive Technology (IVG, GIFT, ZIFT, ICSI)
⃝ Other Medical Treatment - Specify: ______________________________________
⃝ Use of Donor Semen ⃝ Use of Donor Eggs ⃝ Surgery for endometriosis
⃝ Metformin or Glucophage ⃝ Progesterone
⃝ None of the Above
UDOH-OVRS-105 Nov 18 2019 Page 7 of 8 Parental Birth Worksheet
 Mother's Name: ______________________________________________ Room Number: _____________
SFN# of Baby A: ______________________________________________

MULTIPLE CHILD DELIVERY

TWIN B / TRIPLET B / QUADRUPLET B

93. Child's legal name, as parents wish it to appear on the birth certificate.

Child First Name(s) _________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________

Last Name(s) _________________________________________________________Suffix (Jr. Sr. etc): ____________

2. Child Sex: ⃝ Male ⃝ Female ⃝ Undetermined (SSA Card cannot be processed without a sex for the child.)

3. Date of birth mm/dd/yyyy: ______________________ 4. Time of birth (24 hr clock): ______________________

5. Child birth Weight: __________LBS ___________OZ. 6. Child birth Length (Inches): _____________________
Length will not be listed on the Birth Certificate
TRIPLET C/ QUADRUPLET C
94. Child's legal name, as parents wish it to appear on the birth certificate.

Child First Name(s) _________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________

Last Name(s) _________________________________________________________Suffix (Jr. Sr. etc): ____________

2. Child Sex: ⃝ Male ⃝ Female ⃝ Undetermined (SSA Card cannot be processed without a sex for the child.)

3. Date of birth mm/dd/yyyy: ______________________ 4. Time of birth (24 hr clock): ______________________

5. Child birth Weight: __________LBS ___________OZ. 6. Child birth Length (Inches): _____________________
Length will not be listed on the Birth Certificate
QUADRUPLET D
95. Child's legal name, as parents wish it to appear on the birth certificate.

Child First Name(s) _________________________________________________________________________________

Middle Name(s) ___________________________________________________________________________________

Last Name(s) _________________________________________________________Suffix (Jr. Sr. etc): ____________

2. Child Sex: ⃝ Male ⃝ Female ⃝ Undetermined (SSA Card cannot be processed without a sex for the child.)

3. Date of birth mm/dd/yyyy: ______________________ 4. Time of birth (24 hr clock): ______________________

5. Child birth Weight: __________LBS ___________OZ. 6. Child birth Length (Inches): _____________________
Length will not be listed on the Birth Certificate

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