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Free CDC U.S. Standard Certificate of Live Birth Template

The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the vital statistics of a newborn in the United States. This form serves as a crucial legal record, providing essential information about the child's identity, parentage, and birth details. Understanding its components and significance can help parents navigate the important process of registering their child's birth.

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Free CDC U.S. Standard Certificate of Live Birth Template

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The CDC U.S. Standard Certificate of Live Birth form is an essential document that plays a crucial role in the lives of families and individuals across the country. This form captures vital information about a newborn, including the baby's name, date of birth, time of birth, and place of birth. It also requires details about the parents, such as their names, addresses, and dates of birth. In addition to identifying the child and parents, the form collects data on the mother's prenatal care and any complications during pregnancy or delivery. This information not only serves as a legal record of the birth but also contributes to public health statistics and research. Understanding the components of this form can help parents navigate the often overwhelming process of registering a new life while ensuring that all necessary information is accurately documented. The completion and submission of the certificate are vital steps in establishing the identity of the child and securing important rights and benefits in the future.

Key takeaways

When filling out and using the CDC U.S. Standard Certificate of Live Birth form, it's important to keep several key points in mind to ensure accuracy and compliance.

Ensure all information is accurate. Double-check names, dates, and other details to avoid any discrepancies.
Complete the form in a timely manner. Submitting the certificate promptly helps in obtaining necessary documents like a Social Security number for the newborn.
Use clear and legible handwriting or type the information. This ensures that all details are easily readable and reduces the risk of errors.
Consult with hospital staff if you have questions. They are familiar with the process and can provide guidance on completing the form correctly.

Dos and Don'ts

When filling out the CDC U.S. Standard Certificate of Live Birth form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are some key dos and don'ts:

Do use black ink when filling out the form.
Do print clearly and legibly to avoid any confusion.
Do provide all required information, including the full names of both parents.
Do double-check all entries for accuracy before submitting.

Don't leave any required fields blank; if something doesn’t apply, indicate it clearly.
Don't use abbreviations or nicknames for names.
Don't alter the form in any way, such as crossing out or erasing information.
Don't forget to sign and date the form where required.

Documents used along the form

The CDC U.S. Standard Certificate of Live Birth form is a crucial document for registering a newborn's birth. Alongside this certificate, several other forms and documents may be required for various purposes, such as applying for a Social Security number, obtaining a passport, or enrolling in school. Below is a list of common forms and documents often used in conjunction with the birth certificate.

Social Security Card Application (Form SS-5): This form is used to apply for a Social Security number for the newborn. It is essential for tax purposes and accessing government services.
Application for a U.S. Passport (Form DS-11): New parents may need this form to apply for a passport for their child. A passport is necessary for international travel.
Health Insurance Enrollment Form: This document is used to add the newborn to a health insurance plan. Timely enrollment is important to ensure coverage for medical expenses.
Birth Registration Form: Some states require an additional form to officially register the birth with the state’s vital records office, separate from the CDC certificate.
School Enrollment Form: When enrolling a child in school, this form may be needed. It often requires proof of age, which the birth certificate provides.
Immunization Records: These documents track vaccinations received by the child. Schools and daycare centers often require this information for enrollment.
Child Custody Agreement: In cases of divorce or separation, this document outlines custody arrangements. It may be needed alongside the birth certificate in legal proceedings.
Medical Consent Form: This form allows parents or guardians to authorize medical treatment for their child. It may be required by healthcare providers.
Motor Vehicle Bill of Sale: For those engaging in vehicle transfers, utilize the comprehensive Motor Vehicle Bill of Sale documentation to ensure all legal requirements are met.
Adoption Papers: If the child is adopted, these documents are necessary to establish legal parentage and may be required for various legal processes.

These documents serve various purposes and are often interconnected with the birth certificate. Ensuring that you have all necessary forms can help streamline processes related to your child's identity, health, and education.

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Things to Know About This Form

What is the CDC U.S. Standard Certificate of Live Birth form?

The CDC U.S. Standard Certificate of Live Birth form is an official document used to record the birth of a child in the United States. It captures essential details such as the child's name, date of birth, place of birth, and parental information. This certificate serves as a vital record and is often required for various legal and administrative purposes.

Why is the Certificate of Live Birth important?

This certificate is crucial for several reasons:

It serves as proof of identity and citizenship.
It is necessary for obtaining a Social Security number.
It may be required for enrollment in school and other programs.
It can be used to establish inheritance rights and other legal matters.

Who is responsible for completing the form?

The responsibility for completing the Certificate of Live Birth typically falls on the attending physician, midwife, or hospital staff. However, parents should also ensure that all information is accurate and complete before submission.

What information is required on the form?

The form requires various pieces of information, including:

Child's full name.
Date and time of birth.
Place of birth (hospital or location).
Parents' names, including maiden names.
Parents' birthplaces and dates of birth.
Information about the parents' marital status.

How do I obtain a copy of the Certificate of Live Birth?

To obtain a copy, you typically need to contact the vital records office in the state where the birth occurred. Most states offer online services, but you can also request a copy by mail or in person. Be prepared to provide identification and possibly pay a fee.

Can I amend the Certificate of Live Birth after it has been filed?

Yes, amendments can be made to the Certificate of Live Birth. Common reasons for amendments include correcting spelling errors or updating information such as a name change. The process for making amendments varies by state, so it is important to check with the local vital records office for specific instructions.

Is the Certificate of Live Birth the same as a birth certificate?

Yes, the Certificate of Live Birth is often referred to as a birth certificate. However, the term "birth certificate" can also refer to the official document issued by the state after the Certificate of Live Birth has been filed and processed. The birth certificate is the final version that is commonly used for identification purposes.

How long does it take to receive the Certificate of Live Birth?

The timeframe for receiving the Certificate of Live Birth can vary by state and the method of request. In many cases, if requested through a hospital, the certificate can be issued shortly after the birth. For requests made through the vital records office, it may take several weeks, especially if requested by mail.

Are there any fees associated with obtaining the Certificate of Live Birth?

Yes, most states charge a fee for obtaining a copy of the Certificate of Live Birth. The amount can vary depending on the state and the number of copies requested. It's advisable to check with the local vital records office for specific fee information.

What should I do if I believe there is an error on the Certificate of Live Birth?

If you notice an error on the Certificate of Live Birth, contact the vital records office in your state as soon as possible. They can guide you through the process of correcting the information. Be prepared to provide documentation that supports your request for an amendment.

Preview - CDC U.S. Standard Certificate of Live Birth Form

U.S. STANDARD CERTIFICATE OF LIVE BIRTH

LOCAL FILE NO.							BIRTH NUMBER:
C H I L D	1. CHILD’S NAME (First, Middle, Last, Suffix)			2. TIME OF BIRTH	3. SEX			4. DATE OF BIRTH (Mo/Day/Yr)
C H I L D				(24 hr)
	5. FACILITY NAME (If not institution, give street and number)	6. CITY, TOWN, OR LOCATION OF BIRTH				7. COUNTY OF BIRTH
			8b. DATE OF BIRTH (Mo/Day/Yr)
M O T H E R	8a. MOTHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)		8b. DATE OF BIRTH (Mo/Day/Yr)

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

F A T H E R

10a. FATHER’S CURRENT LEGAL NAME (First, Middle, Last, Suffix)

10b. DATE OF BIRTH (Mo/Day/Yr)

10c. BIRTHPLACE (State, Territory, or Foreign Country)

CERTIFIER

11. CERTIFIER’S NAME: _______________________________________________

12. DATE CERTIFIED

13. DATE FILED BY REGISTRAR

TITLE: □ MD □ DO □ HOSPITAL ADMIN. □ CNM/CM □ OTHER MIDWIFE

______/ ______ / __________

□ OTHER (Specify)_____________________________

YYYY

MM DD

YYYY

INFORMATION FOR ADMINISTRATIVE

USE

M O T H E R

14. MOTHER’S MAILING ADDRESS:

9 Same as residence, or: State:

City, Town, or Location:

Street & Number:

Apartment No.:

Zip Code:

15. MOTHER MARRIED? (At birth, conception, or any time between)

□ Yes

□ No

16. SOCIAL SECURITY NUMBER REQUESTED

17. FACILITY ID. (NPI)

IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? □ Yes

□ No

FOR CHILD?

□ Yes

□ No

18. MOTHER’S SOCIAL SECURITY NUMBER:

19. FATHER’S SOCIAL SECURITY NUMBER:

INFORMATION FOR MEDICAL AND HEALTH PURPOSES ONLY

M O T H E R

F A T H E R

Mother’s Name ________________

Mother’s Medical Record No. _________________________

20. MOTHER’S EDUCATION (Check the		21. MOTHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		mother is Spanish/Hispanic/Latina. Check the
	the time of delivery)		“No” box if mother is not Spanish/Hispanic/Latina)
□	8th grade or less	□	No, not Spanish/Hispanic/Latina
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicana
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latina
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□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)

23. FATHER’S EDUCATION (Check the		24. FATHER OF HISPANIC ORIGIN? (Check
	box that best describes the highest		the box that best describes whether the
	degree or level of school completed at		father is Spanish/Hispanic/Latino. Check the
	the time of delivery)		“No” box if father is not Spanish/Hispanic/Latino)
□	8th grade or less	□	No, not Spanish/Hispanic/Latino
□	8th grade or less	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□ Yes, Mexican, Mexican American, Chicano
□	9th - 12th grade, no diploma	□	Yes, Puerto Rican
□	High school graduate or GED	□	Yes, Puerto Rican
□	High school graduate or GED	□
	completed	□	Yes, Cuban
□	Some college credit but no degree	□	Yes, other Spanish/Hispanic/Latino
□ Associate degree (e.g., AA, AS)			(Specify)_____________________________
			(Specify)_____________________________

□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)

22.MOTHER’S RACE (Check one or more races to indicate what the mother considers herself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

25.FATHER’S RACE (Check one or more races to indicate what the father considers himself to be)

□White

□Black or African American

□American Indian or Alaska Native

(Name of the enrolled or principal tribe)________________

□Asian Indian

□Chinese

□Filipino

□Japanese

□Korean

□Vietnamese

□Other Asian (Specify)______________________________

□Native Hawaiian

□Guamanian or Chamorro

□Samoan

□Other Pacific Islander (Specify)______________________

□Other (Specify)___________________________________

26. PLACE WHERE BIRTH OCCURRED (Check one)	27. ATTENDANT’S NAME, TITLE, AND NPI	28. MOTHER TRANSFERRED FOR MATERNAL
□ Hospital	NAME: _______________________ NPI:_______	MEDICAL OR FETAL INDICATIONS FOR
□ Freestanding birthing center	NAME: _______________________ NPI:_______	DELIVERY? □ Yes □ No
□ Freestanding birthing center		IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	IF YES, ENTER NAME OF FACILITY MOTHER
□ Home Birth: Planned to deliver at home? 9 Yes 9 No	TITLE: □ MD □ DO □ CNM/CM □ OTHER MIDWIFE	TRANSFERRED FROM:
□ Clinic/Doctor’s office	□ OTHER (Specify)___________________	_______________________________________
□ Other (Specify)_______________________	□ OTHER (Specify)___________________
□ Other (Specify)_______________________

REV. 11/2003

MOTHER

29a. DATE OF FIRST PRENATAL CARE VISIT

29b. DATE OF LAST PRENATAL CARE VISIT

30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

______ /________/ __________ □ No Prenatal Care

______ /________/ __________

M M

D D

YYYY

M M

D D

YYYY

_________________________ (If none, enter A0".)

31. MOTHER’S HEIGHT

32. MOTHER’S

PREPREGNANCY WEIGHT

33. MOTHER’S WEIGHT

AT DELIVERY

34. DID MOTHER GET WIC FOOD FOR HERSELF

_______ (feet/inches)

_________ (pounds)

DURING THIS PREGNANCY? □ Yes □ No

35. NUMBER OF PREVIOUS

36. NUMBER OF OTHER

37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

38. PRINCIPAL SOURCE OF

LIVE BIRTHS (Do not include

PREGNANCY OUTCOMES

For each time period, enter either the number of cigarettes or the

PAYMENT FOR THIS

this child)

(spontaneous or induced

number of packs of cigarettes smoked. IF NONE, ENTER A0".

DELIVERY

losses or ectopic pregnancies)

Average number of cigarettes or packs of cigarettes smoked per day.

□ Private Insurance

35a.

Now Living

35b. Now Dead

36a. Other Outcomes

Number _____

# of cigarettes

# of packs

□ Medicaid

Three Months Before Pregnancy

_________

________

□ Self-pay

First Three Months of Pregnancy

_________

________

□ Other

□ None

Second Three Months of Pregnancy _________

________

(Specify) _______________

Third Trimester of Pregnancy

_________

________

35c. DATE OF LAST LIVE BIRTH

36b. DATE OF LAST OTHER

39. DATE LAST NORMAL MENSES BEGAN

40. MOTHER’S MEDICAL RECORD NUMBER

_______/________

PREGNANCY OUTCOME

______ /________/ __________

Y Y Y Y

_______/________

M M

D D

YYYY

Y Y Y Y

MEDICAL

41. RISK FACTORS IN THIS PREGNANCY

43. OBSTETRIC PROCEDURES (Check all that apply)

46. METHOD OF DELIVERY

(Check all that apply)

AND

Diabetes

□ Cervical cerclage

A. Was delivery with forceps attempted but

HEALTH

□

Prepregnancy

(Diagnosis prior to this pregnancy)

□ Tocolysis

unsuccessful?

□

Gestational

(Diagnosis in this pregnancy)

External cephalic version:

□ Yes

□ No

INFORMATION

B. Was delivery with vacuum extraction attempted

Hypertension

□ Successful

□

Prepregnancy

(Chronic)

□ Failed

but unsuccessful?

□

Gestational

(PIH, preeclampsia)

□ None of the above

□ Yes

□ No

□

Eclampsia

C. Fetal presentation at birth

□ Previous preterm birth

□

Cephalic

44. ONSET OF LABOR (Check all that apply)

□

Breech

□ Other previous poor pregnancy outcome (Includes

□ Premature Rupture of the Membranes (prolonged, ∃12 hrs.)

□

Other

perinatal death, small-for-gestational age/intrauterine

D. Final route and method of delivery (Check one)

growth restricted birth)

□ Precipitous Labor (<3 hrs.)

□ Vaginal/Spontaneous

□ Pregnancy resulted from infertility treatment-If yes,

□ Prolonged Labor (∃ 20 hrs.)

□ Vaginal/Forceps

check all that apply:

□ Vaginal/Vacuum

□ Fertility-enhancing drugs, Artificial insemination or

□ None of the above

□ Cesarean

Intrauterine insemination

If cesarean, was a trial of labor attempted?

□ Assisted reproductive technology (e.g., in vitro

□ Yes

45. CHARACTERISTICS OF LABOR AND DELIVERY

fertilization (IVF), gamete intrafallopian

□ No

(Check all that

apply)

transfer

(GIFT))

□

Induction of labor

47. MATERNAL MORBIDITY (Check all that apply)

□ Mother had a previous cesarean delivery

(Complications associated with labor and

□

Augmentation of labor

If yes, how many __________

delivery)

□

Non-vertex presentation

□

Maternal transfusion

□ None of the above

□ Steroids (glucocorticoids) for fetal lung maturation

□ Third or fourth degree perineal laceration

42. INFECTIONS PRESENT AND/OR TREATED

received by the mother prior to delivery

□

Ruptured uterus

DURING THIS

PREGNANCY (Check all that apply)

□ Antibiotics received by the mother during labor

□

Unplanned hysterectomy

□ Clinical chorioamnionitis diagnosed during labor or

□ Admission to intensive care unit

□

Gonorrhea

maternal temperature >38°C (100.4°F)

□ Unplanned operating room procedure

□

Syphilis

□ Moderate/heavy meconium staining of the amniotic fluid

following delivery

□

Chlamydia

□ Fetal intolerance of labor such that one or more of the

□ None of the above

□

Hepatitis B

following actions was taken: in-utero resuscitative

□

Hepatitis C

measures, further fetal assessment, or operative delivery

□ Epidural or spinal anesthesia during labor

□ None of the above

NEWBORN

Mother’s Name ________________

Mother’s Medical Record No. ____________________

NEWBORN INFORMATION

48. NEWBORN MEDICAL RECORD NUMBER	54. ABNORMAL CONDITIONS OF THE NEWBORN				55. CONGENITAL ANOMALIES OF THE NEWBORN
			(Check all that apply)		□		(Check all that apply)
49. BIRTHWEIGHT (grams preferred, specify unit)	□	Assisted ventilation required immediately				Anencephaly
					□	Meningomyelocele/Spina bifida
______________________		following delivery			□	Cyanotic congenital heart disease
9 grams 9 lb/oz	□				□	Congenital diaphragmatic hernia
		Assisted ventilation required for more than
					□	Omphalocele
		six hours
50. OBSTETRIC ESTIMATE OF GESTATION:					□	Gastroschisis

_________________ (completed weeks)	□	NICU admission			□	Limb reduction defect (excluding congenital
						amputation and dwarfing syndromes)
	□	Newborn given surfactant replacement			□ Cleft Lip with or without Cleft Palate
					□	Cleft Palate alone
		therapy
51. APGAR SCORE:
					□	Down Syndrome
Score at 5 minutes:________________________
	□	Antibiotics received by the newborn for				□	Karyotype confirmed
If 5 minute score is less than 6,
Score at 10 minutes: _______________________		suspected neonatal sepsis			□	□	Karyotype pending
	□	Seizure or serious neurologic dysfunction				Suspected chromosomal disorder
						□	Karyotype confirmed
52. PLURALITY - Single, Twin, Triplet, etc.	□ Significant birth injury (skeletal fracture(s), peripheral				□	□	Karyotype pending
						Hypospadias
(Specify)________________________		nerve	injury, and/or soft tissue/solid organ hemorrhage
					□	None of the anomalies listed above
		which	requires intervention)
53. IF NOT SINGLE BIRTH - Born First, Second,
Third, etc. (Specify) ________________	9 None of the above


56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No				57. IS INFANT LIVING AT TIME OF REPORT?				58. IS THE INFANT BEING
IF YES, NAME OF FACILITY INFANT TRANSFERRED				□ Yes □ No □ Infant transferred, status unknown				BREASTFED AT DISCHARGE?
TO:______________________________________________________								□ Yes □ No

Rev. 11/2003

NOTE: This recommended standard birth certificate is the result of an extensive evaluation process. Information on the process and resulting recommendations as well as plans for future

activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.

Document Specifics

Fact Name	Details
Purpose	The CDC U.S. Standard Certificate of Live Birth form is used to record the birth of a child in the United States.
Standardization	This form is standardized across the United States to ensure uniformity in birth registration.
Information Collected	It collects essential information including the child's name, date of birth, place of birth, and parents' details.
Legal Requirement	Most states require the completion of this form for the issuance of a birth certificate, which is a legal document.
Governing Laws	Each state has specific laws governing the registration of births, often found in the state health code or vital statistics laws.
Submission Timeline	Typically, the form must be submitted to the relevant state authority within a certain timeframe after the birth, often within a week.
Access to Records	Access to the completed form is generally restricted to the parents and authorized individuals, ensuring privacy and security.

How to Fill Out CDC U.S. Standard Certificate of Live Birth

Filling out the CDC U.S. Standard Certificate of Live Birth form is an important step in documenting the birth of a child. Completing this form accurately ensures that all necessary information is recorded for legal and administrative purposes. Follow these steps carefully to ensure the form is filled out correctly.

Begin with the child's full name. Write the first, middle, and last names clearly.
Next, provide the child's date of birth. Include the month, day, and year.
Indicate the place of birth. This includes the city, county, and state where the birth took place.
Fill in the sex of the child. Mark either male or female as appropriate.
Enter the parents' full names. Include both mother's and father's names as they appear on official documents.
Provide the parents' addresses. This should be the current address for both parents.
List the parents' dates of birth. Include the month, day, and year for both parents.
Complete the information regarding the parents' places of birth. Include the city and state for each parent.
Fill in the mother's maiden name. This is her last name before marriage.
Sign and date the form. Ensure that both parents sign where required.

After completing the form, review it carefully to ensure all information is accurate. Any errors may delay processing. Once confirmed, submit the form to the appropriate office to finalize the birth registration process.

Free CDC U.S. Standard Certificate of Live Birth Template

Key takeaways

Dos and Don'ts

Documents used along the form

More PDF Documents

Things to Know About This Form

What is the CDC U.S. Standard Certificate of Live Birth form?

Why is the Certificate of Live Birth important?

Who is responsible for completing the form?

What information is required on the form?

How do I obtain a copy of the Certificate of Live Birth?

Can I amend the Certificate of Live Birth after it has been filed?

Is the Certificate of Live Birth the same as a birth certificate?

How long does it take to receive the Certificate of Live Birth?

Are there any fees associated with obtaining the Certificate of Live Birth?

What should I do if I believe there is an error on the Certificate of Live Birth?

Preview - CDC U.S. Standard Certificate of Live Birth Form

Document Specifics

How to Fill Out CDC U.S. Standard Certificate of Live Birth