Blank Child Birth Certificate Texas PDF Form Get Child Birth Certificate Texas Here

Blank Child Birth Certificate Texas PDF Form

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.

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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.

Child Birth Certificate Texas Preview

Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 1
This birth certificate worksheet is a tool to help your facility collect the necessary information for
reporting births in TxEVER, the Texas Electronic Vital Events Registrar. Medical personnel should
complete this worksheet. The information you report in TxEVER is used to create a child’s birth certificate.
Ensure the information you report is correct so that an accurate birth certificate is created. The birth
Newborn
Newborn Information
Record Type:
□ Born at this facility
□ Born en-route to facility
□ Foundling/ Safe Haven
□ Home birth-Intended
□ Home birth-Intent unknown
□ Home birth-Unintended
□ Surrogacy-1 Parent
□ Surrogacy-2 Parent
Plurality:
Single
Twins
Triplets
Quadruplets
Quintuplets
Sextuplets
Septuplets
Eight
Nine
Ten
Unknown
Birth Order:
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Conjoined
Is Child Unnamed?
□ Yes
□ No
First Name:
Middle Name:
Last Name:
Suffix:
Date of Birth:
____ /
_____ / ________
Time of Birth:
_ _: _ _
□ A
M □ PM
Sex:
□ Female
□ Male
□ Unknown/ Not yet
Determined
Infant's Medical
Record Number:
SSN Information
Parents Authorize Release of Information to Social Security Administration to Issue this Child a SSN:
□ Yes
□ No
□ Unknown
Mother's Information
Title Preference:
□ Mother
□ Father
□ Parent
Legal First Name:
Legal Middle Name:
Legal Last Name:
Legal Suffix:
Medical Record Number:
certificate is a legal document that the child will use throughout their life to prove their identity,
birthplace, and parentage. The State of Texas safeguards against the unauthorized release of identifying
information from birth certificates to protect the confidentiality of parents and their child.
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 2
Name:
□
Facility Name:
□
Other
Facility Name
Other (Specify):
Type:
□ Clinic/Doctor's Office
□ Home Birth Intended
□
Home Birth Intent Unknown
□ Home Birth Unintended
□
Hospital
□ Licensed Birthing Center
□
Other
□
Unknown
Type Other Specify:
Address:
Apt:
State:
County:
Local:
City/Town:
Zip:
Zip Ext:
First Name:
Middle Name:
Last Name:
Suffix:
Date of Birth: / /
Age at Child’s Birth:
Birthplace: (Click Checkbox to Filter Foreign
Countries Only)
SSN:
Marital Status:
Never Married
Married
Married, Husband Info Refused
Divorced
Widowed
Not Stated/Unknown
Married Within 300 Days?
Yes
No
Yes, but refusing presumed father information
Unknown
AOP Involved?
□ Yes □ No □ Yes – Common Law
Date Acknowledgement of Paternity Signed:
Did Mother Relinquish Rights to Child?
□ Yes □ No □ Unknown
Mother’s Relinquish Date: / /
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 3
□ 8
th
Grade or Less
□
9
th
-12
th
Grade No Diploma
□ H
igh School Graduate or GED Completed
□ S
ome College Credit, No Degree
□ Associate Degree (E.G., AA, AS)
□ Bachelor’s Degree (BA, AB, BS)
□
Master’s Degree (E.G., MA, MS, MENG, MED, MSW, MBA)
□
Doctorate or Professional Degree (E.G., PhD, EDD, MD, DDS, DVM, LLV, JD)
Occupation:
Kind of Business or Industry:
Address:
Apt:
State/Country:
County:
City/Town:
City (Other):
Zip:
Zip Ext:
□ Yes □ No □ Unknown
Address:
Apt:
State/Country:
County:
City/Town:
City (Other):
Zip:
Zip Ext:
□ Yes, Mexican, Mexican American, Chicana
□ Y
es, Puerto Rican
□
Yes, Cuban
□ Yes, Other Hispanic (Specify: _____________________)
□ Unknown
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 4
Father
Father’s Legal Name
Title Preference: □ Mother □ Father □ Parent
First Name:
Middle Name:
Last Name:
Suffix:
Father’s Maiden Name
Same as Father’s Legal Name?
First Name:
Middle Name:
Last Name:
Suffix:
Father’s Information
Date of Birth:
__/__/____
Age:
Birthplace: (Click Checkbox to Filter Foreign Countries Only)
SSN:
_______-_____-_______
□ 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: _____________________)
□
Unknown
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 5
Father’s Miscellaneous Information
Education Level:
□ 8
th
Grade or Less
□
9
th
-12
th
Grade No Diploma
□ High School Graduate or GED Completed
□
Some College Credit, No Degree
□
Associate Degree (E.G., AA, AS)
□ Bachelor’s Degree (BA, AB, BS)
□
Master’s Degree (E.G., MA, MS, MENG, MED, MSW, MBA)
□
Doctorate or Professional Degree (E.G., PhD, EDD, MD, DDS, DVM, LLV, JD)
□ Unknown/Not stated
Occupation:
Kind of Business or Industry:
Father’s Mailing Address Information
Withheld by Request on AOP
Same as Mother’s Mailing?
Address:
Apt:
State/Country:
County:
City/Town:
City (Other):
Zip:
Zip Ext:
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 6
Father Demographics
Father’s Ethnicity
Father’s Race
□ No, Not Spanish/Hispanic/Latino
□ Yes, Mexican, Mexican American, Chicano
□ Yes, Puerto Rican
□
Yes, Other Hispanic (Specify)
□
Unknown
□
Refused
□ 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)
□
Unknown
□
Refused
This tab displays when AOP = yes on Mother’s Tab and marital status = yes
Presumed Father
Presumed Father's Legal Name
First Name:
Middle Name:
Last Name:
Suffix:
Presumed Father's Information
Date of Birth: _____/_____/_______ SSN: ______ - ____ - _________
Presumed Father's Mailing Address Information
Withheld by Request on AOP
Same as Mother’s Mailing?
Address:
Apt:
State/Country:
County:
City/Town:
City (Other):
Zip:
Zip Ext:
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 7
This tab displays when record type = surrogacy 1 parent/surrogacy 2 parent
Intended Mother
Intended Mother’s Current Legal Name
Title Preference: □ Mother □ Father □ Parent
First Name:
Middle Name:
Last Name:
Suffix:
Intended Mother's Name Prior to First Marriage
Same as Intended Mother's Legal Name? □ Yes □ No
First Name:
Middle Name:
Last Name:
Suffix:
Mother's Information
Date of Birth: ___/___/_____
Age:
Birthplace: (Click Checkbox to Filter Foreign Countries Only)
SSN:
Marital Status:
□ Never Married
□ Married
□
Married, Husband Info Refused
□
Divorced
□
Widowed
□ Not Stated/Unknown
Intended Mother's Medicaid Information
Intended Mothers Medicaid Chip Name:
Intended Mothers Medicaid Chip Number:
Intended Mother’s Residence Address Information
Address:
Apt:
State/Country:
County:
City/Town:
Zip:
Zip Ext:
Inside City Limits:
Intended Mother’s Mailing Address Information
□ Same as Residence?
Address:
Apt:
State/Country:
County:
City/Town:
City (Other):
Zip:
Zip Ext:
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 8
Intended Father
Intended Father's Legal Name
Title Preference: □ Mother □ Father □ Parent
First Name:
Middle Name:
Last Name:
Suffix:
Father's Maiden Name
Same as Intended Father's Legal Name? □ Yes □ No
First Name:
Middle Name:
Last Name:
Suffix:
Intended Father's Information
Date of Birth:
____ / _____ / ________
Age:
Birthplace (Click Checkbox to
Filter Foreign Countries Only):
SSN:
Mother Medical - 1
General
Mother Transferred for Delivery?
□ YES
□
NO
If YES, from What Location:
□ OTHER
(Option to Search All Locations Available in TxEVER)
Mother Transfer Facility - Other:
Principal Source of Payment:
□ PRIVATE INSURANCE (BLUE CROSS/ BLUE SHIELD, AETNA, ETC.)
□
MEDICAID/CHIP (PENDING OR NOT)
□
SELF PAY
□
OTHER
□ INDIAN HEALTH SERVICE
□
CHAMPUS/TRICARE
□
OTHER GOVERNMENT (FEDERAL, STATE, LOCAL)
Principal Source of Payment – Other (Specify):
Did Mother Get WIC Food for Herself during This Pregnancy? □ Yes □ No
Mother's Medicaid Chip Name: Mother's Medicaid Chip Number:
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 9
Cigarettes Information
Did Mother Smoke Cigarettes before or during Pregnancy? □ Yes □ No
Did Mother Report in Packs? □
Did Mother Report in Cigarettes? □
# of Cigarettes Per Day # of Packs Per Day
Three Months before Pregnancy
First Trimester
Second Trimester
Third Trimester
Mother’s Health Information
Mother's Weight at Delivery (lbs):
Mother's Pre-Pregnancy Weight (lbs):
Mother's Height (Feet/Inches):
Date Last Normal Menses Began:
HIV Testing
HIV Test Done Prenatally? □ Yes □ No □ Unknown
Check All that Apply:
□ First Trimester
□ Second Trimester
□
Third Trimester
□
None
□ Unknown
HIV Test Done at Delivery? □ Yes □ No □ Unknown
Infant Tested for HIV at Birth? □ Yes □ No □ Unknown
Birth Worksheet
for Child’s Birth Certificate
VS-109 (rev. 07/21) Page | 10
Mother Medical – 2
Pregnancy History
Number of Previous Live Births Now Living (Do Not Include This Child):
Number of Previous Live Births Now Dead:
Date of Last Live Birth: _____ / _____ / ________
Number of Other Pregnancy Outcomes:
Date of Last Other Pregnancy Outcome: _____ / _____ / ________
Prenatal
Did Mother Receive Prenatal Care? □ Yes □ No □ Unknown
Date of First Prenatal Care Visit: _____ / _____ / ________
Date of Last Prenatal Care Visit: _____ / _____ / ________
Total Number of Prenatal Care Visits; If None, Enter '0':
Source of Prenatal Care Visits
□ Hospital
□
Public Health Clinic
□ Private Physician
□
Midwife
□ Other: Specify
□
None
□
Unknown
MVR (Missing Value Reason)
□
Refused
□ Not Obtainable
□
Sought But Not Obtainable
Method of Delivery
Was Delivery with Forceps Attempted but Unsuccessful? □ Yes □ No
Was Delivery with Vacuum Extraction Attempted but Unsuccessful? □ Yes □ No
Fetal Presentation at Birth?
□ Cephalic
□
Breech
□
Other
Final Route & Method of Delivery?
□ Vaginal/Spontaneous
□ Vaginal/Forceps
□ Vaginal/Vacuum
□
Cesarean (Final Route)
□ Unknown
If Cesarean, Was a Trial of Labor Attempted? □ Yes □ No
⇓ Child Birth Certificate Texas PDF

Document Specs

Fact Name Description
Purpose of Birth Certificate The birth certificate serves as a legal document that establishes a child's age, citizenship, and parentage. It is essential for various life activities, including school enrollment and applying for government services.
Confidentiality Protection Texas law ensures the confidentiality of parents and their child by safeguarding against the unauthorized release of identifying information from birth certificates.
Accuracy Requirement It is crucial to provide accurate information on the form. Errors can be difficult and costly to correct, emphasizing the need for careful completion of the worksheet.
Legal Framework The creation and management of birth certificates in Texas are governed by the Health and Safety Code, specifically HSC §192.003, which mandates the reporting of birth data within five days of delivery.
Social Security and Medicaid Processing If applicable information is provided, the birth data is forwarded to the Social Security Administration and Medicaid office, typically taking 4-6 weeks for processing and card issuance.
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Blank Child Birth Certificate Texas PDF Form

Get Child Birth Certificate Texas Here