The Child Birth Certificate Texas form, officially known as the Mother’s Worksheet for Child’s Birth Certificate, is designed for hospital use to collect necessary information for creating a child's birth certificate. This vital document serves as an official record of a child's age, citizenship, and parentage, playing a crucial role throughout the person's life while ensuring privacy and data protection. To ensure accuracy and avoid potential issues with corrections later on, parents are advised to fill out the form carefully and accurately.
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The Child Birth Certificate Texas form, officially titled "Mother’s Worksheet for Child’s Birth Certificate," serves an essential purpose for new parents in the state of Texas. This detailed worksheet gathers vital information required to officially record a new life, ensuring the child’s rightful recognition by the law, which encompasses their age, citizenship, and relationship to their parents. Recognizing the sensitivity of the data it captures, the State of Texas commits to protecting the confidentiality of both the parents and the child by preventing unauthorized access to this information. Accuracy while completing this form cannot be overstressed, as any mistakes made can be both challenging and costly to amend later on. The document not only facilitates the assignment of key identifiers like the social security number but also supports applications for a variety of services and rights, from healthcare to education. Furthermore, it touches on aspects of parental demographics, health, and marital status, offering a comprehensive view that goes beyond mere identification to include potentially valuable data for public health and policy planning. By capturing all this data, the worksheet underscores the importance of each child’s unique identity and lays the groundwork for safeguarding their rights and wellbeing from the very start. It’s a first, crucial step in a lifetime of opportunities and responsibilities, providing peace of mind to parents that their child’s legal and social footprints are duly recorded.
Mother’s Worksheet for Child’s Birth Certificate
FOR HOSPITAL USE ONLY:
MOTHER MR# _____________________________
NEWBORN MR# ________________________________
MEDICAID # _______________________________
DELIVERING DR ________________________________
RM # ____________
The information you provide on this worksheet is used to create your child’s birth certificate. The birth certificate is a legal document used to prove your child’s age, citizenship and parentage. Your child will use the birth certificate throughout his/her life. The State of Texas safeguards against the unauthorized release of identifying information from birth certificates to protect the confidentiality of parents and their child.
Please PRINT your responses carefully and accurately as errors are difficult and expensive to correct.
CHILD’S PLACE OF BIRTH
Name of Hospital or Location
Address
State
County
City
Zip Code
CHILD’S INFORMATION
Time of Birth
Date of Birth
Plurality (please circle one)
Am / Pm
Single / Twin / Triplets / Quadruplets / Quintuplets
Birth Order (please circle one)
Number of Infants Born Alive at this Birth? (please circle one)
First / Second / Third / Fourth / Fifth
One / Two / Three / Four / Five
MOTHER’S CURRENT LEGAL NAME
First Name
Middle Name
Last Name
Suffix
CHILD’S LEGAL NAME
VS-109.1 REV 2/2005
MOTHER’S RESIDENCE ADDRESS
Residence Address
Apartment Number
State/Foreign Country
City/Town/Location
Zip Code / Extension
Inside City Limits?
□ Yes
□ No
MOTHER’S MAILING ADDRESS
(If same as residence address, LEAVE THIS SECTION BLANK)
Mailing Address
MOTHER’S INFORMATION
Place of Birth (State/Foreign Country/Territory)
Social Security
Apply for Baby’s Social Security?
Did Mother Give up Rights to the Child?
Date Rights Given Up?
□ Yes □ No
Occupation
Type of Business
Mother’s Education
□8th grade or less
□9th – 12th grade, no diploma
□High School graduate or GED completed
□Some College credit, but no degree
□Associate degree (e.g., AA, AS)
□Bachelor’s degree (e.g., BA, AB, BS)
□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)
□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
Is Mother of Hispanic Origin?
□No, not Spanish / Hispanic / Latina
□Yes, Mexican, Mexican American, Chicana
□Yes, Puerto Rican
□Yes, Cuban
□Yes, other Spanish / Hispanic / Latina
Specify______________
What is Mother’s Race?
□ White
□ Vietnamese
□ Black/African American
□ Other Asian________
□ American Indian/Alaska Native
□ Native Hawaiian
(Name of the enrolled or principal tribe)
□ Guamanian or
Chamorro
□
□ Samoan
Asian Indian
□ Chinese
□ Other Pacific Islander
□ Filipino
Specify
□ Japanese
□ Other
□ Korean
□ Unknown
MOTHER’S HEALTH INFORMATION
Did you receive WIC for this Birth?
Height
Weight Before Pregnancy
Weight At Delivery
How many cigarettes did you smoke before and during pregnancy?
Three Months Before Cigs/Day: ____
Packs/Day: ___
First Three Months
Cigs/Day: ____
Second Three Months Cigs/Day: ____
Third Trimester
MOTHER’S MARITAL STATUS (Please read carefully)
If you are married, your husband may be listed as the father on the birth certificate, or the information may be left blank.
If you are not married, the father’s name may be listed on the birth certificate only if both parents complete an Acknowledgment of Paternity.
If you are or have been married to someone other than the biological father of this child, or have been married to someone other than the biological father within 300 days before this child’s birth, the Acknowledgment of Paternity must also include a Denial of Paternity from your husband or former husband to allow the biological father’s information to be listed on the birth certificate.
□ Yes, Currently Married
□ Yes, Never Married
□ Yes, Divorced
□ Yes, Widowed
□Yes, Married – (no paternity information on birth certificate)
Have you been married to someone other than the biological father in the 300 days before the child’s birth? □ Yes □ No
Do you want to complete an Acknowledgement of Paternity? □ Yes
MOTHER’S NAME PRIOR TO HER FIRST MARRIAGE
FATHER’S INFORMATION (Biological father)
Legal First Name
Father’s Education
Is Father of Hispanic Origin?
□No, not Spanish / Hispanic / Latino
□Yes, Mexican, Mexican American, Chicano
□Yes, other Spanish / Hispanic / Latino
What is Father’s Race?
□ Other Asian
□ Asian Indian
Has Paternity – Genetic Testing Been Done?
State/Foreign Country/Territory
PRESUMED FATHER’S INFORMATION (Complete ONLY if applicable)
Zip Code Extension
MOTHER’S MEDICAID INFORMATION (Complete ONLY if applicable)
Mother’s Medicaid Name
Mother’s Medicaid Number
IMMTRAC REGISTRY
Do you consent for your baby’s immunization information to be included in the statewide Immunization Registry and to share the immunization information with registered providers? □ Yes □ No
Congratulations on the birth of your new Little Texan!
Texas Vital Statistics would like to take this opportunity to answer some most commonly asked questions about birth certificates in Texas. . .
“How do I get a copy of my baby’s birth certificate?”
You can request and purchase a certified copy of your child’s birth certificate from the local registrar’s office located in the city or county where the birth occurred, or from the Texas Vital Statistic office located in Austin, Texas.
A CERTIFIED BIRTH CERTIFICATE is a permanent legal document filed in the State of Texas that establishes your child’s identity and is used to apply for medical or government services, passports, school admission, etc.
“When will I receive my baby’s social security card?”
If you answered “Yes” to the question, “Apply for baby’s social security number?”, the birth information will be forwarded to the Social Security Administration as soon as the Texas Vital Statistic office receives the data from the hospital. The Social Security Administration then requires 2-3 weeks to process the information. A social security card will be mailed to the mother’s mailing address as provided in this worksheet. The entire process usually takes 4-6 weeks to complete.
“When will I receive my baby’s Medicaid number?”
If you provided an answer for the questions “Mother’s Medicaid Name?” and “Mother’s Medicaid Number?”, the birth information will be forwarded to the Medicaid office as soon as the Texas Vital Statistic office receives the data from the hospital. Medicaid then requires 2-3 weeks to process the information. An Infant Medicaid card will be mailed to the mother’s mailing address as provided in this worksheet. The entire process usually takes 4-6 weeks to complete.
Medical Data Worksheet for Child’s Birth Certificate
This form to be completed by hospital staff. This data will be used to populate the medical data portion of the birth certificate for the newborn. The medical data is required to be reported within five days of the birth. [HSC §192.003]
PATIENT REFERRENCE:
MOTHER MR# _________________________________________
NEWBORN MR# ___________________________________________
MOTHER’S NAME ______________________________________
NEWBORN NAME _________________________________________
MEDICAID# ___________________________________________
DOB ____________________________________________________
DELIVERING DR _______________________________________
DATE AOP SENT__________________________________________
MOTHER TRANSFERRED _______________________________
SOURCE OF PAYMENT FOR DELIVERY ______________________
□ Born at Facility
□ Born En Route
□ Foundling
□ Home Birth
Prenatal Care □ Yes □ No □ Unknown
Date of First Visit ____/____/______
Date of Last Visit ____/____/______
Total Number of Prenatal Visits for this Pregnancy: ________
Date Last Normal Menses Began ___/___/_____
Pregnancy History
Live births now living (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____
Live births now dead (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____
Date of last live birth: ____/______
MM YYYY
Number of other pregnancy outcomes (Include fetal losses of any gestational age. If this was a multiple delivery, include all fetal losses delivered before this infant in the pregnancy.
If none enter “0”.): _____
Date of last other pregnancy outcome: ____/______
Infections Present and/or Treated During Pregnancy
□ Gonorrhea
□ Hepatitis B
□ Syphilis
□ Hepatitis C
□ Chlamydia
□ None of the above
Source of Prenatal Care
(check all that apply)
□ None
□ Midwife
□ Hospital Clinic
□Other, Specify __________________
□ Public Health Clinic
□ Private Physician
Risk Factors in this Pregnancy (check all that apply)
Diabetes
□Prepregnancy (diagnosis prior to this pregnancy)
□Gestational (diagnosis in this pregnancy)
Hypertension
□Prepregnancy (chronic)
□Gestational (PIH, preeclampsia)
□Eclampsia
□Previous preterm birth
□Other previous poor pregnancy outcome (includes perinatal death, small-for- gestational age/intrauterine growth restricted birth)
□Pregnancy resulted from infertility treatment
□Fertility-enhancing drugs, artificial insemination or intrauterine insemination
□Assisted reproductive technology
□Mother had a previous cesarean delivery
If yes, how many?_____
□Antiretrovirals administered during pregnancy or at delivery
□None of the above
HIV Test
HIV test done Prenatally
HIV test done at Delivery
Obstetric Procedures (check all that apply)
□Cervical cerclage
□Tocolysis
External cephalic version
□Successful □ Failed
Characteristics of Labor & Delivery
□Induction of labor
□Augmentation of labor
□Non-vertex presentation
□Steroids (glucocorticoids) for fetal lung maturation received by mother prior to delivery
□Antibiotics received by mother during labor
□Chorioamnionitis or maternal temperature > = 38 degrees C or
100.4degrees F
□Moderate/heavy meconium staining of the amniotic fluid
□Fetal intolerance of labor was such that one or more of the following actions was taken: in-utero resuscitative measures, further assessments, or operative delivery
□Epidural or spinal anesthesia during labor
Maternal Morbidity – Complications associated with Labor & Delivery
□Maternal transfusion
□Third or forth degree perineal laceration
□Ruptured uterus
□Unplanned hysterectomy
□Admission to intensive care unit
□Unplanned operating room procedure following delivery
Onset of Labor (check all that apply)
□Premature Rupture of the Membranes [prolonged > =12 hours]
□Precipitous Labor [< 3 hours]
□Prolonged Labor [> = 20 hours]
Method of Delivery
Was delivery with forceps attempted but unsuccessful?
Was delivery with vacuum extraction attempted but unsuccessful?
Fetal presentation at birth
□ Other, _________________________
□ Cephalic
□ Breech
Final route and method of delivery
□ Vagina/Spontaneous
□ Vagina/Forceps □ Vagina/Vacuum
If cesarean, was a trial of labor attempted?
□ Cesarean
Child’s Health Information
Birth Weight
________ Grams, or ________LB. ________OZ.
Obstetric Estimate of Gestation (completed weeks): _________
Child’s Sex: □ Male □ Female □ Not yet determined
Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______
Abnormal Conditions of the Newborn (check all that apply)
□Assisted ventilation required immediately following delivery
□Assisted ventilation required for more than six hours
□NICU admission
□Newborn given surfactant replacement therapy
□Antibiotics received by the newborn for suspected neonatal sepsis
□Seizure or serious neurologic dysfunction
□Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)
Congenital Anomalies of the Newborn (check all that apply)
Was Infant Transferred within 24 hours of Delivery?
□No □ Yes, Specify Facility _________________
Is Infant Living at Time of Report?
□Yes □ No
Is Infant Being Breastfed at Discharge?
□Anencephaly
□Meningomyelocele/Spina bifida
□Cyanotic congenital heart disease
□Congenital diaphragmatic hernia
□Omphalocele
□Gastroschisis
□Cleft palate alone
□Down syndrome
□Karyotype confirmed
□Karyotype pending
□Suspected chromosomal disorder
Hepatitis B Immunization given?
□ Hypospadias
□ Cleft lip with or without Cleft palate
Filling out a birth certificate form is a significant first step in ensuring your newborn's legal identity and access to benefits such as healthcare and education. The State of Texas provides detailed instructions to safeguard your child's personal information while ensuring accuracy in the document that will play a crucial role in your child's life. Here is a straightforward guide to accurately completing the Child Birth Certificate Form in Texas.
Once the form is meticulously filled out, review all the information for accuracy to prevent any issues or delays. This detailed record not only validates your child's existence and identity but also serves as a foundation for their rights as a citizen. The process to receive your baby’s social security card, Medicaid number, and certified birth certificate may take several weeks, so it’s pertinent to ensure all details are correct the first time around.
A certified copy of your child's birth certificate can be requested and purchased either from the local registrar's office located in the city or county where the birth took place, or directly from the Texas Vital Statistics office in Austin, Texas. As a critical legal document, the certified birth certificate verifies your child's identity and is essential for obtaining medical or government services, passports, and school enrollment among other needs.
If "Apply for baby's social security number?" was answered with "Yes" on the worksheet, the birth details are sent to the Social Security Administration by the Texas Vital Statistics office shortly after receiving the data from the hospital. The Social Security Administration then processes this information within 2-3 weeks, and the social security card is mailed to the provided mailing address of the mother. This entire process typically takes between 4-6 weeks.
Upon providing the "Mother's Medicaid Name?" and "Mother's Medicaid Number?" on the worksheet, the birth details are forwarded to the Medicaid office soon after they are received by the Texas Vital Statistics office. The Medicaid office requires approximately 2-3 weeks to process the information. Consequently, an Infant Medicaid card will be mailed to the mother’s mailing address. The total time for this process is generally 4-6 weeks.
The mother is asked to provide comprehensive personal information, including:
For the father's part, the form requests details similar to those asked from the mother, such as:
The State of Texas protects the privacy of the parents and child by preventing the unauthorized release of identifying information from birth certificates. This ensures that the intimate details shared in the birth certificate remain confidential, safeguarding the family's personal information.
Due to the legal significance of a birth certificate, errors on the document are not only difficult but also expensive to correct. It is vital that information provided is accurate at the outset to avoid complex correction processes in the future.
The mother's educational background is collected as part of the birth certificate data to support statistical analyses aimed at understanding demographic trends and for improving health services and educational resources for families across Texas.
Yes, you can initiate the application for your baby’s Social Security number directly through the birth certificate worksheet by answering "Yes" to the relevant question. This streamlines the process, allowing the Texas Vital Statistics office to forward the necessary data to the Social Security Administration.
Filling out a birth certificate is one of the first official acts as a new parent, and it is pivotal to get things right the first time around. The Child Birth Certificate Texas form, while seemingly straightforward, can also be a source of errors if due care isn't taken. Let's walk through some common mistakes to avoid when completing this important document.
Not double-checking the spelling of names. It may sound simple, but ensuring the correct spelling of the child’s name, as well as the parents' names, is crucial. Misspelled names can lead to significant hassles in obtaining accurate identification documents in the future.
Overlooking the importance of the mother’s maiden name. The mother's maiden name should be accurately recorded, as it is often used for security questions and legal identifications throughout life.
Failing to correctly specify the place of birth. Be precise about the hospital or location's name, including the address. Mistakes here can complicate proofs of citizenship or residency in the future.
Incorrectly listing parental information. All parental information should be accurate. This includes checking the boxes that accurately describe the mother's marital status at the time of birth, which can affect the listing of the father’s name on the birth certificate.
Skipping the Social Security application. It’s easy to overlook the box asking if you want to apply for a Social Security number for your baby, but doing so can delay the process of obtaining one.
Omitting or inaccurately reporting medical and health information. This information can provide critical data for public health studies and inform future medical needs for the child.
Providing incomplete or incorrect information regarding the acknowledgment of paternity. If not married, certain steps must be followed to list the father’s name on the birth certificate, including completing an Acknowledgment of Paternity.
Mistakes in recording the child’s birth data. The time of birth, date of birth, and birth order, especially in multiples, must be accurately listed. This affects not only identification but sometimes legal rights and benefits.
Ignoring instructions about mother’s Medicaid information. If applicable, correctly including the mother’s Medicaid information can streamline access to benefits for the child.
Avoiding these common mistakes not only ensures the issuance of an accurate legal document but also protects against future administrative headaches. Remember, the birth certificate is more than just a formality; it's a foundational document for your child's identity and citizenship. Attention to detail today can save time and effort down the road.
When preparing for the arrival of a new child, several critical documents are needed alongside the Child Birth Certificate Texas form to ensure the child's well-being and legal identity. These documents are vital for various purposes including medical care, government services, and educational needs. Here is an overview of four important forms and documents often used in conjunction with the Child Birth Certificate Texas form:
These documents play a significant role in safeguarding the child's rights and access to services. It's essential to understand the purpose of each and ensure they are accurately completed and securely stored. As the child grows, these documents will be foundational for accessing education, healthcare, and other critical services.
One document similar to the Texas Child Birth Certificate form is the Application for a Social Security Card. Both forms require detailed personal information, including legal names, addresses, and social security numbers, if applicable. They are used to establish an individual's identity within government systems. Applying for a Social Security Card for a newborn, as prompted by the birth certificate worksheet, links the child's identity to a national identification system, just as the birth certificate confirms their legal identity and citizenship from birth.
The Application for a U.S. Passport is another document with similarities to the birth certificate form in Texas. Both require proof of citizenship, full legal names, and parental information to process. The birth certificate serves as a foundational document often required when applying for a passport, as it proves the applicant's age, identity, and citizenship, underscored by the state's authentication.
Another comparable document is the Enrollment Form for Public Schools. This type of form typically requires a child's birth certificate to verify the child's legal name, age, and residency. Both documents collect detailed personal and family information to establish the child's eligibility and identity within an institutional setting, emphasizing the importance of accurate, official records from the outset of a child's life.
The Medicaid Application also parallels the Child Birth Certificate Texas form. Both solicit detailed personal, residency, and family information, including Medicaid numbers when applicable, to establish identity and eligibility for benefits. The birth certificate information directly impacts the newborn's immediate eligibility and enrollment in state-supported healthcare, showcasing the interconnection between governmental records and services from birth.
Finally, the Acknowledgment of Paternity form shares similarities with the birth certificate worksheet, especially in the context of establishing paternity information. Both documents deal with parental identity and legal responsibilities, and accurate completion can have legal implications regarding custody, support, and inheritance. The birth certificate's section on father's information often requires acknowledgment of paternity to be completed, underlining the legal recognition of fatherhood alongside the official documentation of birth.
When you are filling out the Child Birth Certificate form for Texas, there are specific guidelines you should follow to ensure the process goes smoothly and the birth certificate can serve its intended legal purposes without any hitches. Here are 10 do's and don'ts you should consider:
Adhering to these guidelines can make the process of obtaining a birth certificate for your child in Texas smoother and help avoid common pitfalls that can delay receipt of this important document.
There are several misconceptions surrounding the process of obtaining and understanding the Child Birth Certificate in Texas. It's crucial to clarify these misunderstandings to ensure parents and guardians have the correct information.
Contrary to this belief, correcting errors on a birth certificate after it has been officially recorded can be a complicated and occasionally costly process. Parents are encouraged to review all information thoroughly before submission to prevent any future difficulties.
This is not always the case. In Texas, if the parents are married, the husband is presumed to be the father and can be listed as such on the birth certificate. However, this does not occur automatically; the information must be provided at the time of registration.
Actually, there is a question on the Texas Birth Certificate form that inquires whether parents wish to apply for a Social Security number for their newborn. If they answer "Yes," the information will be forwarded directly to the Social Security Administration, streamlining the process.
While it is true that a birth certificate is required for enrolling in school, its importance goes beyond educational needs. It's a critical legal document necessary for applying for a passport, obtaining government and medical services, and proving age, citizenship, and parentage.
Understanding the correct processes and requirements for a Child Birth Certificate in Texas is crucial for ensuring the document's accuracy and legal validity for the child's future needs.
Filling out the Child Birth Certificate form in Texas is an essential step after the birth of a child. It establishes the child’s legal identity and is used throughout the child's life for various purposes. Here are some key takeaways to consider:
Understanding and accurately completing the Child Birth Certificate Texas form is a vital step towards securing a child's rights and access to services.
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