UTAH CERTIFICATE OF LIVE BIRTH

Local File No. State File No.

1. CHILD'S NAME (First, Middle, Last, Suffix) 2. TIME OF BIRTH 3. SEX 4. DATE OF BIRTH (MM/DD/CCYY)
CHILD (24 Hr. Clock)

5. FACILITY NAME (If not institution, give street and number) 6. CITY, TOWN. OR LOCATION OF BIRTH 7. COUNTY OF BIRTH

8a. MOTHER'S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 8b. DATE OF BIRTH (MM/DD/CCYY)
MOTHER

8c. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) 8d. BIRTHPLACE(State, Territory or Foreign Country)

9a. RESIDENCE OF MOTHER-STATE 9b. COUNTY 9c. CITY TOWN OR LOCATION

9d. STREET AND NUMBER 9e. APT.NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS?

Yes No
10a. FATHER'S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 10b. DATE OF BIRTH (MM/DD/CCYY) 10c. BIRTHPLACE(State, Territory or
FATHER Foreign Country)

11. CERTIFIER'S NAME: 12. DATE CERTIFIED (MM/DD/CCYY) 13. DATE FILED BY REGISTRAR
CERTIFIER (MM/DD/CCYY)
TITLE Designated Representative Hospital Administrator Other

INFORMATION FOR ADMINISTRATIVE USE

14. MOTHER'S MAILING ADDRESS SAME as Residence
MOTHER Or Street & Number, PO Box APT.NO.

City, Town or Location State ZIP CODE -

15. MOTHER MARRIED? (At anytime within 300 days prior to this delivery?) Yes No 16. SOCIAL SECURITY NUMBER 17. FACILITY ID (NPI)
REQUESTED FOR CHILD?
IF NO, HAS PATERNITY ACKNOWLEDGMENT BEEN SIGNED IN THE HOSPITAL? Yes No Yes No
18. MOTHER'S SOCIAL SECURITY NUMBER 19. FATHER'S SOCIAL SECURITY NUMBER

INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY

20. MOTHER'S EDUCATION(Check the box that best describes the highest degree or 21. MOTHER OF HISPANIC ORIGIN (Check the box that best describes whether
level of school completed at the time of delivery) the mother is Spanish/Hispanic/Latina. Check the "No" box if mother is not Spanish/
Hispanic/Latina)
8th grade or less

9th-12th grade, no diploma No, not Spanish/Hispanic/Latina

High school graduate or GED completed

Yes, Mexican, Mexican American, Chicana
Some college credit but no degree
Yes, Puerto Rican
Associate degree (e.g., AA, AS)
Yes, Cuban
Bachelor's degree (e.g., BA, AB, BS)

Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Yes, other Spanish/Hispanic/Latina

Doctorate (e.g., PhD, EdD) or professional degree (e.g., MD, DDS, (Specify)
DVM, LLB, JD)
22. MOTHER'S RACE (Check one or more races to indicate what the mother considers herself to be)

White Vietnamese

Black or African American Other Asian

(Specify)
American Indian or Alaskan Native (Name of the enrolled or principal tribe)
Mother's Medical Record No.

Native Hawaiian
(Specify)
Guamanian or Chamorro
Asian Indian
Samoan
Chinese
Mother's Name

Tongan
Filipino
Other Pacific Islander
Japanese (Specify)

Korean Other (Specify)

 23. FATHER'S EDUCATION (Check the box that best describes the highest degree or 24. FATHER OF HISPANIC ORIGIN (Check the box that best describes whether the
FATHER level of school completed at the time of delivery) father is Spanish/Hispanic/Latino. Check the "No" box if father is not Spanish/
8th grade or less Hispanic/Latino)

9th-12th grade, no diploma

No, not Spanish/Hispanic/Latino
High school graduate or GED completed
Yes, Mexican, Mexican American, Chicano
Some college credit but no degree
Yes, Puerto Rican
Associate degree (e.g., AA, AS)
Bachelor's degree (e.g., BA, AB, BS) Yes, Cuban
Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA) Yes, other Spanish/Hispanic/Latino
Doctorate (e.g., PhD, EdD) or professional degree (e.g., MD, DDS, (Specify)
DVDVM, LLB, JD)
25. FATHER'S RACE (Check one or more races to indicate what the father considers himself to be)
White Vietnamese

Black or African American Other Asian (Specify)

American Indian or Alaskan Native (Name of the enrolled or principal tribe) Native Hawaiian

Asian Indian (Specify) Guamanian or Chamorro

Chinese Samoan

Filipino Tongan

Japanese Other Pacific Islander

Korean Other (Specify)

26. PLACE WHERE BIRTH OCCURRED (Check one) 27. ATTENDANT'S NAME, TITLE AND NPI
BIRTH

Hospital NAME: NPI:

Freestanding Birthing Center TITLE: MD Licensed Direct Entry Midwife

DO Other Midwife
Home Birth: Planned to deliver at home? Yes No
ND Other (Specify)
Clinic/Doctor's Office
CNM/CM

Other (Specify)

28. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY?
MOTHER
Facility:
Yes No If YES, enter name of facility and state Mother transferred from
State:
29a. DATE OF FIRST PRENATAL CARE VISIT (MM/DD/CCYY) 29b. DATE OF LAST PRENATAL CARE VISIT (MM/DD/CCYY)

No Prenatal Care during this pregnancy

30a. TOTAL NUMBER OF PRENATAL VISITS FOR 30b. TRANSFER OF PRENATAL CARE DURING THIS PREGNANCY 31. MOTHER HEIGHT
THIS PREGNANCY (if NONE, enter '0")
Yes No Unknown
(feet/inches)
32. MOTHER'S WEIGHT PRIOR TO 33 MOTHER'S WEIGHT AT DELIVERY 34. DID MOTHER GET WIC FOOD FOR HERSELF DURING THIS
PREGNANCY PREGNANCY?
(pounds) (pounds) Yes No Unknown
35a. NUMBER OF PREVIOUS LIVE BIRTHS NOW LIVING 35b. NUMBER OF PREVIOUS LIVE BIRTHS NOW DEAD 35c. DATE OF LAST LIVE BIRTH (MM/CCYY)
(Do not include this child) (Do not include this child)

36a. NUMBER OF OTHER PREGNANCY OUTCOMES 36b. DATE OF LAST OTHER 36c. NUMBER OF STILLBORN 36d. NUMBER OF PREVIOUS
(spontaneous or induced losses or ectopic pregnancies) PREGNANCY OUTCOME (MM/CCYY) BIRTHS - gestation of 20 weeks MULTIPLE PREGNANCIES
None or more

37. CIGARETTE SMOKING BEFORE/ DURING PREGNANCY # of cigarettes # of packs

Or
Mother's Medical Record No.

Average number of packs of cigarettes smoked per day 3 months before pregnancy
For each time period, enter the number of cigarettes or the number of packs smoked. first 3 months of pregnancy Or
second 3 months of pregnancy Or
IF NONE ENTER '0'
third trimester of pregnancy Or
38a. MOTHER ENROLLED IN MEDICAID AT TIME OF BIRTH 38b. PRINCIPAL SOURCE OF PAYMENT FOR THIS DELIVERY
Yes No Medicaid CHAMPUS/TRICARE
Mother's Name

If YES, Utah Medicaid number

39. DATE LAST NORMAL MENSES BEGAN (MM/DD/CCYY) Private Insurance Other Government (Fed/State/Local)

Self Pay CHIP

40. MOTHER'S MEDICAL RECORD NUMBER
Indian Health Insurance Other (Specify)
 41. INFERTILITY INFORMATION
Did you take any fertility drugs or receive any medical procedures to help you get pregnant with this pregnancy? Yes No
If Yes, how long had you been trying to become pregnant before taking any fertility drugs?
0-5 Months 6-11 Months 1-2 Years 3-4 Years 5-6 Years > 6 Years

Did you use any of the following fertility treatments? (Check all that apply)
Fertility-enhancing drugs Other medical treatment (specify)
Artificial insemination or intrauterine insemination None of the above
Assisted reproductive technology
42. RISK FACTORS (Check all that apply)
Antiphospholipid syndrome Gestational carrier delivery Pre-existing diabetes, non-insulin dependent
Anxiety (meds used) Gestational diabetes(diagnosed in this pregnancy) Pregnancy induced hypertension
Asthma, mild treated with over-the-counter meds Heart disease, mild Previous infant over 4,000 grams
Asthma, severe, treated with prescription meds Heart disease, severe Previous C-Sections #______
Bipolar disorder (meds used) HELLP syndrome Previous preterm infant
Chronic hypertension Hyperthyroid Previous infant with other poor outcome
Chronic renal disease Hypothyroid
Mother's Medical Record No.

Schizophrenia (meds used)

Cystitis Illicit drug use (specify drug used) Rheumatoid arthritis
Depression (meds used) Lupus Sjogrens Syndrome
Eclampsia Pre-existing diabetes, insulin dependent No risk factors
43. INFECTIONS PRESENT AND/OR TREATED DURING THIS PREGNANCY (Check all that apply)
Mother's Name

Bacterial Vaginosis Gonorrhea Hepatitis C Pyelonephritis Urinary Tract Infection (UTI)

Chlamydia Group B+ Strep HIV/AIDS Rubella Unknown
Cytomegalovirus Hepatitis A Human parvovirus Syphilis None
General Herpes (HSV) Hepatitis B Listeria Toxoplasmosis
44. OBSTETRIC PROCEDURES (Check all that apply) 44. METHOD OF DELIVERY Please check appropriate box in the Type of Delivery
Cervical cerclage Cervical ripening Fetal presentation at birth Spontaneous vaginal Vacuum vaginal: Unsuccessful
Unknown version Failed version Cephalic Forceps vaginal: Successful Cesarean
Amniocentesis Chronic villus sampling Breech Forceps vaginal: Unsuccessful Unknown
Successful version None Other
Vacuum vaginal: Successful
Unknown
Tocolysis If cesarean, was a trial of labor attempted? Yes No
45. CHARACTERISTICS OF LABOR AND DELIVERY (Check all that apply)
Abruptio placenta Elective induction Non-vertexpresentation
Antibiotics received by the mother during labor Epidural or spinal anesthesia during labor Outlet forceps delivery
Augmentation of labor (stimulation) Fetal intolerance of labor Placenta previa
Clinical chorioamnionitis diagnosed during labor or Induction of labor Steroids (glucocorticoids) for fetal lung maturation
maternal temperature >38 C (110.4 F) Mid forceps delivery True knot in cord
Cord prolapse Moderate/heavy meconium staining of amniotic fluid Unknown None

46. MATERNAL MORBIDITY (Check all that apply) 47. NEWBORN MEDICAL RECORD NUMBER 50. APGAR SCORE
(Complications associated with labor and delivery) Score at 1 minute:
Admission to intensive care Unplanned hysterectomy 48. BIRTHWEIGHT
Score at 5 minutes:
Maternal transfusion Unplanned operating room procedure grams lbs ozs
If 5 minute score is less than
Perineal laceration - 3rd or 4th degree None of the above 49. OBSTETRIC ESTIMATION OF GESTATION 6, enter score at 10 minutes:
Ruptured uterus (completed weeks)
51. PLURALITY - Single, twin, triplet, etc. 52. IF NOT SINGLE - Born first, second, third, etc. 53. If multiple birth, how many born alive?
(Specify) (Specify)
54. ABNORMAL CONDITIONS OF THE NEWBORN (Check all that apply)
NICU admission 24 hours or less Unknown None
Anemia NICU admission greater than 24 hours
Assisted ventilation required immediately following delivery (first 30 minutes)
Perinatal substance abuse
Assisted ventilation required for more than six hours
Respiratory distress syndrome (RDS)/hyaline membrane disease
Antibiotics received for suspected neonatal sepsis Seizure or serious neurologic dysfunction
Meningitis Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft
Newborn given surfactant replacement therapy tissue/solid organ hemorrhage which requires intervention)
55. CONGENITAL ANOMALIES OF THE NEWBORN (Check all that apply)
Anencephaly Down Syndrome Omphalocele
Central Nervous System (Specify) Karyotype confirmed Karyotype pending Other Musculoskeletal Anolmalies (Specify)
Chromosomal Anomaly (Specify) Gastroschisis Disease Other Urogenital Anomalies (Specify)
Child's Medical Record No.

Other Gastrointestinal (Specify) Polydactyly/Syndactyly/Adactyly

Karyotype confirmed Karyotype pending
Hydrocephalus Rectal Atresia
Cleft Lip Cleft Palate
Hypospadias Renal Agenesis
Cleft Lip and Palate
Malformation of Genitalia (Specify) Tracheo-esophageal fistula/esophageal atresia
Club Foot Other Congenital Anomalies (Specify)
Limb Reduction (Specify)
Congenital Diaphragmatic Hernia Other Limb Anomalies (Specify) Unknown
Child's Name

Cyanotic Congenital Heart (Specify) Meningomyelocele/Spina Bifida None

Other Congenital Heart Disease(Specify) Microcephalus
56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY ? Yes 57. INFANT DECEASED Yes No 58. IS INFANT BEING BREAST FED AT
If YES, name of facility transferred to: If YES, Date of Death DISCHARGE?
No Yes No
State: (MM/DD/CCYY)