The Child Birth Certificate Texas form is a document used to collect essential information required for registering a newborn's birth in Texas. This form serves as the basis for creating a legal birth certificate, which establishes the child's identity, age, citizenship, and parentage. It is crucial for parents to complete this form accurately, as the birth certificate will be used throughout the child's life for various legal and administrative purposes.
When welcoming a new child into the world, completing the Child Birth Certificate Texas form is an essential step for parents. This form gathers crucial information that will be used to create the official birth certificate, a vital document for establishing your child's identity and citizenship. The form requires details about the mother, including her legal name, address, and health information, as well as information about the father and the newborn. Parents must provide specifics like the child's place of birth, time and date of birth, and plurality. It is important to fill out the form carefully, as any errors can lead to complications and costly corrections. Texas law ensures the confidentiality of the information shared, protecting the privacy of families. Additionally, the form includes sections for applying for a Social Security number for the baby and Medicaid, if applicable. Completing this form accurately and promptly will help ensure that your child has the necessary documentation for future needs.
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
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