October 2022
Information to Help Register
Out-of-Hospital Births
Center for Health Statistics and Informatics – Vital Records
Upon request, this document will be made available in alternate formats. To obtain a
copy in an alternate format, please call or write:
California Department of Public Health
Vital Records - M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410
Telephone: (916) 445-2684
California Relay: 711/1-800-735-2929
Website address: https://www.cdph.ca.gov
Information to Help Register Out-of-Hospital Births
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Table of Contents
Information for Physicians and Professionally Licensed Midwives or Certified Nurse-
Midwives ......................................................................................................................... 3
Information for Parents .................................................................................................... 5
Preparing for the Registration Appointment .................................................................... 7
Frequently Asked Questions ......................................................................................... 11
Resources and Links ..................................................................................................... 14
Worksheet Packet ......................................................................................................... 15
What You Need to Know about Your Child’s Birth Certificate
Importance of Collecting Complete and Accurate Birth Certificate Information
Certificate of Live Birth Worksheet
Medical Data Supplemental Worksheet, VS 10A
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Information for Physicians and Professionally Licensed Midwives or Certified
Nurse-Midwives
Dear Physician or Professionally Licensed Midwife or Certified Nurse-Midwife:
The California Department of Public Health-Vital Records (CDPH-VR) understands you
recently attended the birth of a child outside of a hospital or state-licensed alternative
birth center. Health and Safety Code Sections (HSC) 102400 and 102415 require that
you register the birth of this child with the local registrar within twenty-one (21) days of
the birth.
1. Please review this pamphlet and complete the enclosed worksheet documents.
Share the worksheet with the parent(s) of the child so they can help gather the
required information.
2. Contact the local registrar for information on their registration process. Many
registrars require appointments. A list of the local registrars and their contact
information is available at the following link:
Directory of County Vital Records Offices
(https://www.cdph.ca.gov/Programs/CHSI/Pages/County-Registrars-and-
Recorders.aspx)
3. Bring the worksheet documents to the local registrar’s office so they can prepare
the birth certificate and generate the birth certification page. You will sign the
birth certification page as the attendant. You will be required to present valid
government-issued photo identification and your current professional license
number to the local registrar for verification. If you are not currently licensed as a
physician, certified nurse-midwife, or licensed midwife, you cannot register the
birth. Births attended by unlicensed individuals must be registered by the
parents.
4. Please advise the parents that they need to visit the local registrar if they will sign
the birth certificate as an informant. Parents will be required to present valid
government-issued photo identification to the local registrar for verification.
Although CDPH-VR suggests that the parents sign the certificate at the time of
the appointment, the local registrar can make a separate appointment for the
parents.
5. Please advise the child’s parents that if they are not married to each other or in a
State-Registered Domestic Partnership with each other, the non-birthing parent
shall not be listed on the birth certificate unless the parents sign a Voluntary
Declaration of Parentage before the birth certificate is registered. Local registrar
staff are authorized witnesses for the Voluntary Declaration of Parentage. The
birth certificate may be amended to add another parent’s name at a later date
only if parentage for the child has been established by a judgment of a court or
by the filing of a voluntary declaration of parentage (HSC 102425). For
information on the Parentage Opportunity Program, call (916) 464-1982, email
(https://childsupport.ca.gov/establishing-legal-parentage/).
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The birth will not be registered until all signatures are in place. By law, the birth
certificate must be registered within twenty-one (21) days of the birth (HSC 102400).
Thank you for your help in registering the birth of this child.
Information to Help Register Out-of-Hospital Births
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Information for Parents
Dear Parents:
Congratulations on the birth of your new baby!
California Department of Public Health-Vital Records (CDPH-VR) wants you to have
information on registering your baby’s birth so you can obtain their birth certificate.
CDPH-VR is providing this information because you did not give birth in a hospital or
licensed birth center, where staff would have prepared the birth record and submitted it
to the local registrar.
1. Determine who is responsible for registering your child’s birth:
a. If a physician or professionally licensed midwife or certified nurse-midwife
attended the birth of your child, they are responsible for registering the
birth with the local registrar within twenty-one (21) days of birth. Please
review this pamphlet and work with your birth attendant to complete the
enclosed worksheet documents. Parents need to visit the local registrar if
they will sign the birth certificate as an informant. Parents will be required
to present valid government-issued photo identification to the local
registrar for verification.
b. If your child’s birth was not attended by a physician or professionally
licensed midwife or certified nurse-midwife, you are responsible for
registering the birth with the local registrar within twenty-one (21) days of
birth. Births attended by unlicensed individuals must be registered by the
parents. Please review this pamphlet, complete the enclosed worksheet
documents to ensure your child’s birth certificate is completed correctly,
and contact the local registrar for information on their registration process.
Many registrars require appointments. A list of the local registrars and
their contact information is available at the following link:
Directory of County Vital Records Offices
(https://www.cdph.ca.gov/Programs/CHSI/Pages/County-Registrars-and-
Recorders.aspx)
2. If a child’s parents are not married to each other or in a State-Registered
Domestic Partnership with each other, the non-birthing parent shall not be listed
on the birth certificate unless the parents sign a Voluntary Declaration of
Parentage before the birth certificate is registered. Local registrar staff are
authorized witnesses for the Voluntary Declaration of Parentage. The birth
certificate may be amended to add another parent’s name at a later date only if
parentage for the child has been established by a judgment of a court or by the
filing of a voluntary declaration of parentage (HSC 102425). For information on
the Parentage Opportunity Program, call (916) 464-1982, email
Information to Help Register Out-of-Hospital Births
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(https://childsupport.ca.gov/establishing-legal-parentage/).
Information to Help Register Out-of-Hospital Births
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Preparing for the Registration Appointment
Each local registrar has their own process and policies for registering out-of-hospital
births. The information and evidence requirements below are suggestions provided to
local registrars, parents, and attendants to out-of-hospital births. Please contact the
local registrar in the jurisdiction of birth for information on their registration process. A
list of local registrars and their contact information are available at the following link:
Directory of County Vital Records Offices
(https://www.cdph.ca.gov/Programs/CHSI/Pages/County-Registrars-and-
Recorders.aspx)
Complete the worksheet accurately with the facts of birth before the appointment with
the local registrar. The information on the worksheet will be used to prepare the baby’s
birth certificate. HSC 102425 requires that all items be completed or accounted for,
including the public health data portion of the worksheet.
If the birth was attended by a physician or professionally licensed midwife or certified
nurse-midwife, they must complete form VS 10A, which provides supplemental medical
information.
Evidence of Live Birth in California
If a physician or professionally licensed midwife or certified nurse-midwife attended the
birth, they must register the birth, and the parents only need to provide proof to
substantiate the identity of the parent(s). If the birth was not attended by a physician or
professionally licensed midwife or certified nurse-midwife, the parents need to provide
proof to substantiate all five facts.
Please bring to your appointment evidence to substantiate these five facts:
1. Identity of the parent(s)
2. Pregnancy of the person giving birth
3. Baby was born alive
4. Birth occurred in California
5. Identity of the witness (if applicable)
Fact 1: Identity of the Parents
A valid picture identification card issued to the parents by a government agency can be
provided to prove identity. Following are some recommended documents that can be
used (only the original or a certified copy is acceptable):
• A driver’s license or identification card issued by a United States (U.S.)
Department of Motor Vehicles Office.
• U.S. passport.
• U.S. military identification card.
• Permanent Resident Card (Green Card).
• Other valid picture identification card issued by a foreign government. (If the
parents gave birth in California but are not here legally, they may be able to
obtain identification verification from their consulate.)
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Fact 2: Pregnancy of the Person Giving Birth
To substantiate the pregnancy of the person giving birth, the parents may provide a
pregnancy test verification form or a letter that meets all of the following conditions:
• From a physician, professionally licensed midwife or certified nurse-midwife, or
clinic.
• Written on the doctor, midwife, or clinic official letterhead (not on a prescription
pad).
• Signed (not stamped) by the doctor, midwife, or clinic representative or nurse.
• Contains the current issued professional license number of the physician or
midwife who signed the letter.
The pregnancy test verification form or letter must include all of the following
information:
• The name of person giving birth.
• The date when the person giving birth was first seen by the doctor or midwife
(this date may be after the date of birth).
• The results of the person giving birth’s prenatal or postpartum exams or
pregnancy tests.
• The date of the person giving birth’s last menstrual period.
• The date the baby was born, or was expected to be born (due date).
Fact 3: Baby was Born Alive
The parent must provide proof that the child was born alive if there was no physician or
professionally licensed midwife or certified nurse-midwife that attended the birth.
Suggested methods of proving live birth include, but are not limited to:
1. Bringing the baby to the interview.
2. Affidavit from a physician, nurse, nurse practitioner, or physician assistant who
has provided care to the baby after the birth (license number and signature must
be on the hospital or clinic letterhead).
3. A FaceTime video in real time with the child who is at home in the presence of
the local registrar staff.
4. A verified video chat (with a valid date – within one year of the date of birth)
where the baby is present.
5. A statement from a clergy who baptized the child.
If the evidence provided is suspected to be fraudulent, the local registrar staff can
decide on a case by case basis if more information is necessary to make the birth
certificate complete before acceptance for registration.
Fact 4: Birth Occurred in California
The local registrar needs information showing that the person giving birth was in
California on the date that the birth occurred. Documentation to confirm the person
giving birth’s presence in California on the date the birth occurred may include any of
the following:
• If the birth occurred at the person giving birth’s residence, provide an electric
power, natural gas, or water bill for the period when the birth occurred. The copy
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of the bill (or statement from the company) must include the name of the utility
company, the address of the residence where the birth occurred, and the name
of either parent who is listed on the birth certificate.
• An affidavit from someone who was with the person giving birth at the time of the
baby’s birth. The affidavit must contain the address of the person with the
person giving birth, and the location of the birth.
• A current rent receipt or other similar document that shows the name of either
parent and current address.
• A statement from a state or local government agency that requires proof of
residency in California that the person giving birth was receiving services on the
date of the baby’s birth (e.g., WIC or Medi-Cal)
Fact 5: Identity of the Witness (if applicable)
It is not mandatory for the witness to accompany the parents to the appointment if there
was no physician or certified nurse-midwife/licensed midwife that attended the birth.
However, if the parents are using a witness to prove any of the other facts, then the
witness needs to accompany the parents to the appointment to prove their identity. A
witness may include any of the following:
• Spouse or other family member
• Friend
• Paramedic or fire department staff
If a paramedic or fire department staff was present at the birth, you can obtain a copy of
the official report stating the treatment or service they provided (there may be a fee for
the report). The staff does not have to be present at the appointment, nor do you have
to bring a copy of their identification.
If the paramedic arrived after the baby’s birth, bring a copy of the 911 call or an official
report of the contents of the 911 call, along with a copy of the paramedic’s report.
• If the paramedic cut the umbilical cord, or was present when the umbilical cord
was cut, the report should so state.
• If the paramedic delivered the placenta, the report should so state.
Valid ID for Witness: A valid picture identification card issued to the witness by a
government agency must be provided to prove identity. Following are some
recommended documents that can be used (only the original or a certified copy is
acceptable):
• A driver’s license or identification card issued by a United States (U.S.)
Department of Motor Vehicles Office.
• U.S. passport.
• U.S. military identification card.
• Permanent Resident Card (Green Card).
• Other valid picture identification card issued by a foreign government. (If the
witness is not in California legally, they may be able to get identification
verification from their consulate.)
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Verification
The local registrar may verify the accuracy of all information provided to register an out-
of-hospital birth.
Local Registrar’s Duty to Register
There is no legal authority for the local registrar to refuse to register the birth certificate.
However, the local registrar is allowed to request additional information until they are
satisfied the record is suitable for registration. HSC 102305 states, “The local registrar
of births and deaths shall carefully examine each certificate before acceptance for
registration and, if any are not completed in a manner consistent with the policies
established by the State Registrar, he or she shall require further information to be
furnished as may be necessary to make the record consistent with those policies before
acceptance for registration.”
Information to Help Register Out-of-Hospital Births
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Frequently Asked Questions
Who is required to register out-of-hospital births?
When a baby is born outside a hospital, the physician or certified nurse-
midwife/licensed midwife who attended the birth is responsible for registering the birth
with the local registrar in the county where the birth occurred (HSC 102415). If the out-
of-hospital birth was not attended by a physician or professionally licensed midwife or
certified nurse-midwife, either one of the parents is responsible for registering the birth.
When must out-of-hospital births be registered?
By law, births must be registered with the local registrar within twenty-one (21) days of
the birth and accepted up to one year from date of event (HSC 102400 California Code
of Regulations 17 CCR § 908). There is no fee to register the birth with the local
registrar within the first year.
Any birth registered on or after the child’s first birthday must be processed by CDPH-VR
as a Delayed Registration of Birth. If the requirements cannot be met for a Delayed
Registration of Birth, another option is to apply to the local Superior Court for a Court
Order Delayed Registration of Birth. More information on these processes is available
at the following link:
Correcting or Amending Vital Records
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Correcting-or-Amending-Vital-
Records.aspx)
Why do births need to be registered?
All births need to be registered to comply with state law. The birth must be registered
before a certified copy of the birth certificate can be obtained. During a child’s life, they
will need a certified copy of their birth certificate to:
• Obtain a Social Security Number
• Apply for a Driver’s License
• Enroll in School
• Travel or Obtain a Passport
• Register to Participate in Sports
• Apply for Various Benefits (Social Security, Military)
Birth certificates are also valuable to establish:
• Proof of Parentage
• Inheritance Rights
• Identity
• Citizenship
How can I make sure the birth certificate is completed correctly?
Ensure that the worksheet documents are completed fully with accurate information, as
this information is used to create the birth certificate. The local registrar will print a
working copy of the birth certificate for you to review. Please review the entire working
copy of the baby’s birth certificate for accuracy before signing the Birth Certification
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Page. If there are any errors, inform the local registrar immediately. Once the record
has been registered, any corrections, such as misspellings or omissions, must be made
through CDPH-VR, the amendment may be a second page of the birth certificate, and a
fee may be charged. The processing time for amendments can be located on the
CDPH-VR website (https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records-
Processing-Times.aspx).
Am I required to complete all information on the worksheet?
All information is required by law, except for the following fields, which apply to both
parents. Although not required, this information is very important for understanding
pregnancy outcomes and developing needed programs.
• Race and Ethnicity
• Education
• Usual Occupation
• Usual Kind of Business or Industry
• Social Security Numbers
• Email addresses and mobile telephone numbers
There are three fields on the worksheet marked, “Hospital or Attendant Use Only”:
• Complications and Procedures of Pregnancy and Concurrent Illnesses
• Complications and Procedures of Labor and Delivery
• Abnormal Conditions and Clinical Procedures Related to the Newborn
These three fields are required for births attended by a physician or professionally
licensed midwife or certified nurse-midwife. This information is not required if the
parents are registering the birth.
The information regarding Women, Infants & Children (WIC), average number of
cigarettes/packs per day, birth parent prepregnancy and delivery weight, birth parent
height, and APGAR score marked under “Medical and Health Data: Birth Parent and
Newborn” will not be transcribed onto the actual birth certificate.
Who collects the information on the birth certificate?
The birth certificate information is collected by the local health department who prepares
the birth record and transmits it to the California Department of Public Health - Vital
Records. State registered birth certificate information is then sent to the National
Center for Health Statistics, Centers for Disease Control and Prevention.
How is the information on the birth certificate used?
The information collected is used to record what happened during pregnancy, labor and
delivery, and any issues the newborn experienced. The information will be used to
understand and help prevent birth defects, preterm births, maternal deaths, and other
labor, delivery and birth outcomes. Information collected also assists local and state
public health leaders in making decisions that address programs needed in the
community such as diabetes care, teen pregnancy, WIC, etc.
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How can I obtain a certified copy of the birth certificate?
You will not automatically receive a copy of your baby’s birth certificate. Once the birth
is registered, you can purchase a certified copy of the birth certificate from the local
registrar or County Recorder in the county where your child was born, or from CDPH-
VR. The fees and processing times may vary between these offices.
How can I obtain a Social Security number for my child?
The Social Security Administration guidance limits the Enumeration at Birth program to
hospital births. You can request a Social Security number for your child by contacting
the nearest Social Security office. There is never a charge for a Social Security number
and card from the Social Security Administration. For more information about Social
Security, contact your nearest Social Security Office or call (800) 772-1213 (toll-free).
You can also visit Social Security’s website (https://www.socialsecurity.gov/).
Information to Help Register Out-of-Hospital Births
14
Resources and Links
Directory of County Vital Records Offices including local registrars
(https://www.cdph.ca.gov/Programs/CHSI/Pages/County-Registrars-and-
Recorders.aspx)
Parentage Opportunity Program
(https://childsupport.ca.gov/establishing-legal-parentage/)
Social Security Administration (SSA)
(https://www.socialsecurity.gov/)
California Department of Public Health Home Page
(https://www.cdph.ca.gov/)
Obtaining Certified Copies of Birth Records
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records-Obtaining-Certified-
Copies-of-Birth-Records.aspx)
Amendments
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Correcting-or-Amending-Vital-
Records.aspx)
Processing Times (https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records-
Processing-Times.asp)
What You Need to Know about Your Child’s Birth Certificate
Your child’s birth certificate lasts forever. Please be certain the information on
the certificate is accurate and complete before you sign it.
• The birth certificate is a legal document.
• An amendment form is required to make corrections to the birth certificate.
• The birth certificate will become a two-page document if an amendment is requested after the
original has been processed.
• Many changes on the birth certificate require the applicant to go to court for a court order,
including reversing the order of last names (surnames).
• Parents may have problems receiving benefits, traveling on an airline, or obtaining a passport
or Social Security Number (SSN) for their child if the birth certificate is not true and correct.
• It can take several weeks to apply an amendment. The processing time for amendments can
be located on the California Department of Public Health-Vital Records website
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records-Processing-Times.aspx).
Common mistakes that require amendments or court orders:
• Misspelled first, middle, or last names of child and/or parents
• Incorrect birth place or date of birth of parent(s)
• Reversed order of last names (surnames)
• Adding additional names to parent(s) or child later
• Incorrect sex of child
• Incorrect birth date
Errors on birth certificates
cannot be corrected on the original certificate.
The original birth certificate does not change, but an amendment
is attached to create a two-page document.
✓ Parents, please review the information on the birth certificate carefully before you sign it.
✓ Your signature confirms that you have reviewed the information and that the facts are correct.
Amendment forms may be obtained at the local health department or county recorder’s
office, or online (https://www.cdph.ca.gov/Programs/CHSI/Pages/Correcting-or-Amending-Vital-
Records.aspx).
California Department of Public Health – Vital Records October 2022
Importance of Collecting Complete and Accurate Birth Certificate Information
What You Need to Know about Data
Collected from Your Child’s Birth Certificate
Why is birth
certificate
information
collected?
The birth certificate information is collected based on California Health and
Safety Code (HSC) sections 102425 and 102426. This law lists all of the
information required on the California birth certificate. This law also makes all
medical information confidential.
Is birth
certificate
information
confidential?
All medical information, including parents’ race, education, occupation, SSNs,
and address, is considered confidential and is not released to the public.
Access to the confidential portion of the birth certificate is limited to the
California Department of Public Health, California Department of Health Care
Services, California Department of Finance, ScholarShare Investment Board,
local health department, persons with a valid scientific interest as determined
by the State Registrar, Committee for Protection of Human Subjects, parent who
signed the certificate or parent giving birth, the child named on the birth
certificate, and the hospital responsible for preparing and submitting the birth
record (Reference HSC 102430). This packet identifies the pages that contain
confidential data collected from the parents at the top of the pages.
What is birth
certificate
information
used for?
The information collected is used to record what happened during pregnancy,
labor and delivery, and any issues the newborn experienced. The information
will be used to understand and help prevent birth defects, preterm births,
maternal deaths, other labor and delivery outcomes, and public health
programs.
Do I have to
provide all
information?
All information is required by law with the exception of the parents’ race,
occupation, education, and SSNs. Although not required, reporting information
about your race, occupation, and education helps public health programs to
succeed. Without information, we cannot effectively develop public health
programs to treat gestational diabetes, assist with teen pregnancies, manage
services for Women, Infants & Children (WIC), and so much more.
Who collects
birth certificate
information?
Birth certificate information is collected by the birth clerk. It is then securely
sent to the local health department, then to the California Department of Public
Health - Vital Records for registration, and finally sent to the National Center for
Health Statistics within the Centers for Disease Control and Prevention. If
parents request an SSN for their newborn, then non-medical information as well
as parent SSN (if listed) and address of where SSN card should be sent are
forwarded to the Social Security Administration. Scholarshare information is
collected solely for the purposes and use of the Scholarshare program.
I still have
questions…
Please contact the California Department of Public Health - Vital Records
at (916) 445-2684.
Certificate of Live Birth Worksheet
Please complete this information to prepare your child’s birth certificate.
Name of Child:
3A. Plurality:
☐ Single ☐ Twin ☐ Triplet ☐ Quadruplet
☐ Quintuplet ☐ Sextuplet ☐ Septuplet ☐ Octuplet or More ☐ Unknown
9
9C.
D.
R
Last
elat
N
ions
ame:
hip t
_
o Child (Optional): M
______________________
10. Birth State/Foreign Country:
☐ US State. State Name: ____________________________________________
☐ US Territory. Territory Name: _______________________________________
☐ Canadian Province. Province Name: _________________________________
☐ Mexican State. State Name: ________________________________________
☐ Other Country. Country Name: ______________________________________
☐ Other Country Unknown
☐ Unknown
(
Specify the Birth State/Foreign Country from the dropdown in EBRS)
11. Birth Date: _________________________________
3B. Birth Order: ☐ 1
st
☐ 2
nd
☐ 3
rd
☐ 4
th
☐ 5
th
☐ 6
th
☐ 7
th
☐ 8
th
or more ☐ Unknown
4A. Date of Birth: _____________________ 4B. Time of
Birth: _____________
5A. Place of Birth: _______________________________________________________________________________________
5B. Street Address: _____________________________________________________________________________________
5C. City: ______________________________________ 5D. County: __________________ Zip Code: ________________
Birth name of Parent Giving Birth (fields 9A, 9B, 9C, on child’s birth certificate), unless a certified copy of a surrogate
court order is presented. If only one parent is listed on the birth certificate, they must be listed in fields 9A, 9B, 9C.
9A. First Name: __________________________________________________________________________________________
9B. Middle Name: _______________________________________________________________________________________
9C. Last Name: _________________________________________________________________________________________
Suffix: ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI ☐ VII ☐ VIII ☐ IX ☐ X ☐
JR ☐ SR
9D. Relationship to Child (Optional): ☐ Mother ☐ Father ☐ Parent
PARENT CONTACT INFORMATION
_______________________________________________
Parent Name
_______________________________________________
Parent Signature
Phone: _________________________________________
1A. First Name:____________________________________________________________________________________________
1B. Middle Name: __________________________________________________________________________________________
1C. Last Name: ____________________________________________________________________________________________
Suffix (Optional): ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI ☐ VII ☐ VIII ☐ IX ☐ X ☐ JR ☐ SR
2. Sex: ☐ Male ☐ Female ☐ Nonbinary ☐ Unknown/Undetermined
Did the actual place of birth match the planned place of birth? ☐ Yes ☐ No ☐ Unknown
If not, where did you plan for this birth to take place?
☐ Hospital
☐ Freestanding Birth Center
☐ Home Delivery
☐ Clinic/Doctor's office
☐ Other (specify other place) ____________________________________________________________________
☐ Unknown
Would you (parent giving birth [9A-9C]) like to complete the confidential sexual orientation/gender identity questionnaire?
Yes No
Fresno
7. Birth State/Foreign Country:
☐ US State. State Name: ____________________________________________
US Territory. Territory Name:☐ _______________________________________
☐ _________________________________Canadian Province. Province Name:
________________________________________ ☐ Mexican State. State Name:
☐ _____________________________________Other Country. Country Name: _
☐ Other Country Unknown
☐ Unknown
(
Specify the Birth State/Foreign Country from the dropdown in EBRS)
6D. Relationship to Child (Optional): ☐ Mother ☐ Father ☐ Parent
Page 2
Birth Name of Parent Not Giving Birth or Intended Parent (Fields 6A, 6B, 6C, on child’s birth certificate):
6A. First Name: __________________________________________________________________________________________
6B. Middle Name: _______________________________________________________________________________________
6C. Last Name: _________________________________________________________________________________________
Suffix: ☐ I ☐ II ☐ III ☐ IV ☐ V ☐ VI ☐ VII ☐ VIII ☐ IX ☐ X ☐ JR ☐ SR
32. 6A-6C/Parent Social Security Number: __________________________________________________
☐ Withheld ☐None ☐ Unknown
33. 9A-9C/Birth Parent Social Security Number: _____________________________________________
☐ Withheld ☐ None ☐ Unknown
Are parents married or in a State Registered Partnership
(SRDP), or is there a certified surrogate court order?
☐ Yes ☐ No ☐ Unknown
If the parents are not married, do the parents want to sign a VDOP
to add the father to the birth certificate?
If the parents are not married or in an SRDP, then the biological or intended parents may sign the Voluntary Declaration of
Parentage (VDOP) form to list the biological parent not giving birth or intended parent in fields 6A, 6B, 6C at the time of birth.
Reference Health and Safety Code Section 102425(a)(4). Additional parents may be added through the amendment process
after the certificate is registered.
☐ Yes ☐ No
Scholarshare Contact Information This contact information is for Scholarshare use only. This information does not print on the birth
certificate and is not included with any data collected on the birth certificate.
Parent Giving Birth (9A-9C)
Email address: __________________________________________________________________________________________________
Mobile Phone Number (include area code): ____________________________________________________________________________
Parent Not Giving Birth/Intended Parent (6A-6C). If no parent is listed in fields 6A-6C, do not collect this information.
Email address: __________________________________________________________________________________________________
Mobile Phone Number (include area code): ____________________________________________________________________________
Yes No
8. Birth Date: __________________________________
Would you (parent not giving birth [6A-6C]) like to complete the confidential sexual orientation/gender identity questionnaire?
Page 3
Father or Parent Information Mother Information
Field 19 (Father or Parent)
Is the father or parent Hispanic, Latino, or Spanish?
☐Yes If Yes, please specify: ☐Cuban
☐No ☐Mexican
☐Unknown ☐Puerto Rican
_________________ ☐Withheld ☐Other
Field 22 (Mother)
Is the mother Hispanic, Latina, or Spanish?
☐Yes If Yes, please specify: ☐Cuban
☐No ☐Mexican
☐Unknown ☐Puerto Rican
_________________ ☐Withheld ☐Other
Fields 18 and 21
Up to three races may be entered for each parent on the birth certificate. Unless otherwise specified, the selected race(s) will print
on the certificate. If the parent(s) would like a different description to print on the certificate, enter it in the space provided.
Field 18 (Father or Parent)
White
☐White ____________________
____________________ ☐Caucasian
Black or African American
☐Black ____________________
____________________ ☐African American
Hispanic
☐Mexican ____________________
____________________ ☐Mexican American
____________________ ☐Other Hispanic, specify
American Indian or Alaskan Native
☐Alaska Native ____________________
____________________ ☐Eskimo
____________________ ☐Aleut
____________________ ☐Native American
____________________ ☐American Indian
Asian
☐Chinese ____________________
____________________ ☐Japanese
____________________ ☐Filipino
____________________ ☐Korean
____________________ ☐Vietnamese
____________________ ☐Asian Indian
____________________ ☐Cambodian
____________________ ☐Thai
____________________ ☐Laotian
____________________ ☐Hmong
____________________ ☐Other Asian, specify
Native Hawaiian or Other Pacific Islander
☐Native Hawaiian ____________________
____________________ ☐Guamanian
____________________ ☐Samoan
____________________ ☐Other Pacific Islander, specify
Unknown or Other
☐Unknown
____________________ ☐Other
____________________ ☐Other
☐Other ____________________
Withheld
☐Withheld
Field 21 (Mother)
White
____________________ ☐White
____________________ ☐Caucasian
Black or African American
____________________ ☐Black
____________________ ☐African American
Hispanic
____________________ ☐Mexican
____________________ ☐Mexican American
____________________ ☐Other Hispanic, specify
American Indian or Alaskan Native
____________________ ☐Alaska Native
____________________ ☐Eskimo
____________________ ☐Aleut
____________________ ☐Native American
____________________ ☐American Indian
Asian
____________________ ☐Chinese
____________________ ☐Japanese
____________________ ☐Filipino
____________________ ☐Korean
____________________ ☐Vietnamese
____________________ ☐Asian Indian
____________________ ☐Cambodian
____________________ ☐Thai
____________________ ☐Laotian
____________________ ☐Hmong
____________________ ☐Other Asian, specify
Native Hawaiian or Other Pacific Islander
____________________ ☐Native Hawaiian
____________________ ☐Guamanian
____________________ ☐Samoan
____________________ ☐Other Pacific Islander, specify
Unknown or Other
☐Unknown
____________________ ☐Other
☐ ____________________ Other
____________________ ☐Other
Withheld
☐Withheld
Page 4
20C. Father or Parent Education: (Enter Highest Level or Degree of School Completed)
☐☐ 12
th
Grade with No Diploma0-11
th
Grade. Highest Grade Completed: ____ _
High School Diploma ☐☐ General Equivalency Diploma (GED)
☐ Some College (No degree) ☐ Associate’s Degree
☐ Bachelor’s Degree ☐ Master’s Degree
☐ Doctorate Degree ☐ Professional Degree
20A. Father or Parent Usual Occupation:
______________________________________________________________________________________________________________
Work done for the longest period of time. Do not enter company name.
20B. Father or Parent Kind of Business/Industry:
______________________________________________________________________________________________________________
Do not enter company name.
23C. Mother Education: (Enter Highest Level or Degree of School Completed)
☐☐ 12
th
Grade with No Diploma0-11
th
Grade. Highest Grade Completed: _____
☐ High School Diploma ☐ General Equivalency Diploma (GED)
☐ Some College (No degree) ☐ Associate’s Degree
☐ Bachelor’s Degree ☐ Master’s Degree
Doctorate Degree ☐☐ Professional Degree
23A. Mother Usual Occupation:
______________________________________________________________________________________________________________
Work done for the longest period of time. Do not enter company name.
23B. Mother Kind of Business/Industry:
______________________________________________________________________________________________________________
Do not enter company name.
24D. Parent Giving Birth Residence Address (Required. P.O. Boxes Are Not Acceptable.)
Apt/Suite/Unit:Street Number and Name: ______________________________________________________ _____________________
State/Province:City: _________________________________________ ___________________________________________________
Country:Zip Code/Postal Code: _____________________ ______________________________________________________________
Medical and Health Data: Birth Parent and Newborn
Did the person giving birth receive Women, Infants and Children (WIC) food while pregnant?
☐ Yes
☐ No
☐ Unknown
Did the person giving birth smoke before or during the pregnancy? Enter number of cigarettes smoked per day as follows:
During the three months prior to becoming pregnant:
☐ Did not smoke
_______☐ Cigarettes. # per day
_______☐ Packs. # per day
☐ Unknown
During the first three months of pregnancy:
☐ Did not smoke
_______☐ Cigarettes. # per day
_______☐ Packs. # per day
☐ Unknown
Page 5
During the second three months of pregnancy:
☐ Did not smoke
_______☐ Cigarettes. # per day
_______☐ Packs. # per day
☐ Unknown
During the last three months of pregnancy:
☐ Did not smoke
_______☐ Cigarettes. # per day
_______☐ Packs. # per day
☐ Unknown
Height:Delivery Weight:Birth Parent: Prepregnancy Weight: ____________ __________ __________
APGAR score (10 minute):APGAR score (5 minute): _________________ ___________________
25A. Date Last Normal Menses Began: (if exact date is unknown, enter the month and year) ________________
25AA. Date of First Prenatal Care Visit: (if exact date is unknown, enter the month and year) ________________
25BA. Date of Last Prenatal Care Visit:25B. Month Prenatal Care Began: ______________ ___________________
(e.g., 1
st
, 2
nd
, 3
rd
, Unknown, etc.) (Do not enter delivery date)
25C. Number of Prenatal Visits: _______________
(Count only visits recorded in the most current record available. Do not estimate additional prenatal visits when the prenatal record is not
up to date. Do not include non-pregnancy related visits to ER; visit to confirm pregnancy; nutritionist; dietitian; health educator, etc. Normal
prenatal visits are approximately 16.)
25D. Principal Source of Payment for Prenatal Care:
☐ No Prenatal Care (00)
☐ Medi-Cal, without CPSP Support Services (02)
☐ Other Governmental Programs (Federal, State, Local) (05)
☐ Private Insurance Company (07)
☐ Self Pay (09)
☐ Medi-Cal, with CPSP Support Services (13)
☐ Other (14)
☐ Unknown (99)
(Completed Weeks)
26A. Obstetric Estimate of Gestation:26. Birthweight in Grams: ______________ _________
26B. Hearing Screening:
☐ Pass Both
☐ Refer One
☐ Refer Both
☐ Results Pending
☐ Waived
☐ Not Med Indicated
☐ Test Not Available
27B. Number of Previous Live Births Now Dead:27A. Number of Previous Live Births Now Living: _____________ ____________
(Do not count this child.)
27C. Date of Last Live Birth: ________________________
27E. After 20 Weeks:27D. Number of Miscarriages Before 20 Weeks:
(Do not count abortions) _______ _______
27F. Date of Last Miscarriage: _______________________
Page 6
28A. Method of Delivery
28AA. Final Delivery Route: ________________________________________________________________________
28AB. Number of Previous Cesarean(s): ______________________________________________________________
28AC. Fetal Presentation:__________________________________________________________________________
28AD. Forceps Attempted, But Unsuccessful:
☐ Yes
☐ No
☐ Unknown
28AE. Vacuum Attempted, But Unsuccessful:
☐ Yes
☐ No
☐ Unknown
28B. Expected Source of Payment for Delivery:
☐ Medically Unattended Birth (00)
☐ Medi-Cal (02)
☐ Other Governmental Programs (Federal, State, Local) (05)
☐ Private Insurance (07)
☐ Self Pay (09)
☐ Other (14)
☐ Indian Health Service (15)
☐ CHAMPUS/TRICARE (16)
☐ Unknown (99)
HOSPITAL OR ATTENDANT USE ONLY
29. Complications and Procedures of Pregnancy and Concurrent Illnesses:
Codes to Enter? ☐ Yes ☐ No ☐ Unknown
(If Yes, Hospital Staff or Attendant Circle the Appropriate Codes on VS 10A)
30. Complications and Procedures of Labor and Delivery:
Codes to Enter? ☐ Yes ☐ No ☐ Unknown
(If Yes, Hospital Staff or Attendant Circle the Appropriate Codes on VS 10A)
31. Abnormal Conditions and Clinical Procedures Relating to the Newborn:
Codes to Enter? ☐ Yes ☐ No ☐ Unknown
(If Yes, Hospital Staff or Attendant Circle the Appropriate Codes on VS 10A)
ATTENDANT CERTIFICATION
I hereby certify and affirm that all the information shown on this worksheet is true and correct to the best of my knowledge.
Name: _______________________________________________________ Signature: ___________________________________________
Address: __________________________________________________________________________________________________________
City: _____________________________________________________ State: __________________ Zip Code: ______________________
State License Number: ______________________ Date Signed: _________________________ Phone: ____________________________
WITNESS INFORMATION - If applicable
Name: _______________________________________________________ Signature: ___________________________________________
Relationship to Child: _____________________________ Date: _________________________ Phone: ____________________________
HOSPITAL OR ATTENDANT USE ONLY
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH
MEDICAL DATA SUPPLEMENTAL WORKSHEET
VS 10A (Rev. 10/2022)
Use the codes on this Worksheet to report the appropriate entry in items numbered 25D and 28A through 31 on the
“Certificate of Live Birth” and for items 29D and 32B through 35 on the “Certificate of Fetal Death.”
Item 25D. (Birth)
Item 29D. (Fetal Death)
PRINCIPAL SOURCE OF PAYMENT FOR PRENATAL CARE
(Enter only 1 code)
02 Medi-Cal, without CPSP Support Services
13 Medi-Cal, with CPSP Support Services
05 Other Government Programs (Federal, State,
Local)
07 Private Insurance Company
09 Self Pay
14 Other
99 Unknown
00 No Prenatal Care
Item 28A. (Birth)
Item 32A (Fetal Death)
METHOD OF DELIVERY
(Enter only 1 code/number under each section, separated by commas: A,B,C,D,E,F)
A. Final delivery route
01 Cesarean—primary
11 Cesarean—primary, with trial of labor
attempted
21 Cesarean—primary, with vacuum
31 Cesarean—primary, with vacuum & trial of
labor attempted
02 Cesarean—repeat
12 Cesarean—repeat, with trial of labor attempted
22 Cesarean—repeat, with vacuum
32 Cesarean—repeat, with vacuum & trial of labor
attempted
03 Vaginal—spontaneous
04 Vaginal—spontaneous, after previous
Cesarean
05 Vaginal—forceps
15 Vaginal—forceps, after previous Cesarean
06 Vaginal—vacuum
16 Vaginal—vacuum, after previous Cesarean
88 Not Delivered (Fetal Death Only)
B. If mother had a previous Cesarean—How many? _______
(Enter 0 – 9, or U if Unknown)
C. Fetal presentation at birth
20 Cephalic fetal presentation at delivery
30 Breech fetal presentation at delivery
40 Other fetal presentation at delivery
90 Unknown
D. Was vaginal delivery with forceps attempted, but
unsuccessful?
50 Yes 58 No 59 Unknown
E. Was vaginal delivery with vacuum attempted, but
unsuccessful?
60 Yes 68 No 69 Unknown
F. Hysterotomy/Hysterectomy (Fetal Death Only)
70 Yes 78 No
Item 28B. (Birth)
Item 32B (Fetal Death)
EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY
(Enter only 1 code)
02 Medi-Cal
05 Other Government Programs
(Federal, State, Local)
09 Self Pay
07 Private Insurance – Employer Sponsored
17 Private Insurance – Covered California
18 Private Insurance – Individual Plan
14 Other
99 Unknown
Do not enter any identification by patient name or number on this worksheet. Discard after use.
Do not retain the worksheet in the medical records or submit with the “Certificates of Live Birth or Fetal Death.”
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH—MEDICAL DATA SUPPLEMENTAL WORKSHEET (Continued)
Item 29. (Birth)
Item 33. (Fetal Death)
COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES
(Enter up to 16 codes, separated by commas, for the most important complications/procedures.)
DIABETES
09
Prepregnancy (Diagnosis prior to this pregnancy)
31
Gestational (Diagnosis in this pregnancy)
HYPERTENSION
03
Prepregnancy (Chronic)
01
Gestational (PIH, Preeclampsia)
02
Eclampsia
OTHER COMPLICATIONS/PREGNANCIES
32
Large fibroids
33
Asthma
34
Multiple pregnancy (more than 1 fetus this
pregnancy)
35
Intrauterine growth restricted birth this pregnancy
23
Previous preterm live birth (less than 37 weeks
gestation)
36
Other previous poor pregnancy outcomes (Includes
perinatal death, small-for-gestational age/
intrauterine growth restricted birth, large for
gestational age, etc.)
OBSTETRIC PROCEDURES
24
Cervical cerclage
28
Tocolysis
37
External cephalic version—Successful
38
External cephalic version—Failed
39
Consultation with specialist for high-risk obstetric
services
57
Progesterone use in second half of pregnancy
PREGNANCY RESULTED FROM INFERTILITY
TREATMENT
40
Fertility-enhancing drugs, artificial insemination or
intrauterine insemination
41
Assisted reproductive technology (e.g., in vitro
fertilization (IVF), gamete intrafallopian transfer
(GIFT)
INFECTIONS PRESENT AND/OR TREATED DURING THIS
PREGNANCY
42
Chlamydia
43
Gonorrhea
44
Group B streptococcus
18
Hepatitis B (acute infection or carrier)
45
Hepatitis C
16
Herpes simplex virus (HSV)
46
Syphilis
47
Cytomegalovirus (Fetal Death Only)
48
Listeria (Fetal Death Only)
49
Parvovirus (Fetal Death Only)
50
Toxoplasmosis (Fetal Death Only)
PRENATAL SCREENING DONE FOR INFECTIOUS
DISEASES
51
Chlamydia
52
Gonorrhea
53
Group B streptococcal infection
54
Hepatitis B
55
Human immunodeficiency virus (offered)
56
Syphilis
NONE OR OTHER COMPLICATIONS/PROCEDURES NOT
LISTED
00
None
30
Other Pregnancy Complications/Procedures not Listed
EPIDEMICS AND/OR DISASTERS
91
COVID-19 Confirmed
See reverse side for codes to Birth Items 30 and 31 and Fetal Death Items 34 and 35.
Do not enter any identification by patient name or number on this worksheet. Discard after use.
Do not retain the worksheet in the medical records or submit with the “Certificates of Live Birth or Fetal Death.”
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH—MEDICAL DATA SUPPLEMENTAL WORKSHEET (Continued)
Item 30 (Birth)
Item 34 (Fetal Death)
COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY
(Enter up to 9 codes, separated by commas, for the most important complications/procedures.)
ONSET OF LABOR
10
Premature rupture of membranes (greater than or
equal to 12 hours)
07
Precipitous labor (less than 3 hours)
08
Prolonged labor (greater than or equal to 20 hours)
CHARACTERISTICS OF LABOR AND DELIVERY
11
Induction of labor
12
Augmentation of labor
32
Non-vertex presentation
33
Steroids (glucocorticoids) for fetal lung maturation
received by the mother prior to delivery
34
Antibiotics received by the mother during labor
35
Clinical chorioamnionitis diagnosed during labor or
maternal temperature greater than or equal to 38°C
(100.4°F)
19
Moderate/heavy meconium staining of the amniotic
fluid
36
Fetal intolerance of labor such that one or more of
the following actions was taken: in-utero
resuscitative measures, further fetal assessment, or
operative delivery
37
Epidural or spinal anesthesia during labor
25
Mother transferred for delivery from another facility
for maternal medical or fetal indications
COMPLICATIONS OF PLACENTA, CORD, AND
MEMBRANES
38
Rupture of membranes prior to onset of labor
13
Abruptio placenta
39
Placental insufficiency
20
Prolapsed cord
17
Chorioamnionitis
MATERNAL MORBIDITY
24
Maternal blood transfusion
40
Third or fourth degree perineal laceration
41
Ruptured uterus
42
Unplanned hysterectomy
43
Admission to ICU
44
Unplanned operating room procedure following
delivery
NONE OR OTHER COMPLICATIONS/PROCEDURES
NOT LISTED
00
None
31
Other Labor/Delivery Complications/Procedures not
Listed
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH—MEDICAL DATA SUPPLEMENTAL WORKSHEET (Continued)
Item 31 (Birth)
Item 35 (Fetal Death)
ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE FETUS
(Enter up to 10 codes, separated by commas, for the most important conditions/procedures.)
CONGENITAL ANOMALIES (NEWBORN OR FETUS)
01
Anencephaly
02
Meningomyelocele/Spina bifida
76
Cyanotic congenital heart disease
77
Congenital diaphragmatic hernia
78
Omphalocele
79
Gastroschisis
80
Limb reduction defect (excluding congenital
amputation and dwarfing syndromes)
28
Cleft palate alone
29
Cleft lip alone
30
Cleft palate with cleft lip
57
Down’s Syndrome—Karyotype confirmed
81
Down’s Syndrome—Karyotype pending
82
Suspected chromosomal disorder—Karyotype
confirmed
83
Suspected chromosomal disorder—Karyotype
pending
35
Hypospadias
62
Additional and unspecified congenital anomalies not
listed above
ABNORMAL CONDITIONS (NEWBORN OR FETUS)
66
Significant birth injury (skeletal fracture(s), peripheral
nerve injury, and/or soft tissue/solid organ hemorrhage
which requires intervention)
ADDITIONAL ABNORMAL CONDITIONS/PROCEDURES
(NEWBORN ONLY)
71
Assisted ventilation required immediately following
delivery
85
Assisted ventilation required for more than 6 hours
73
NICU admission
86
Newborn given surfactant replacement therapy
87
Antibiotics received by the newborn for suspected
neonatal sepsis
70
Seizure or serious neurological dysfunction
74
Newborn transferred to another facility within 24 hours
of delivery
NONE OR OTHER ABNORMAL CONDITIONS/
PROCEDURES NOT LISTED
00
None (Newborn or Fetus)
75
Other Conditions/Procedures not Listed (Newborn
Only)
67
Other Conditions/Procedures not Listed (Fetal Death
Only)
EPIDEMICS AND/OR DISASTERS
91
COVID-19 Confirmed
