Fillable VR203-web VR203 Mothers Eng rev1 14_8x11

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VR203-web VR203 Mothers Eng rev1 14_8x11

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Dear New Mother/Parent (woman giving birth),
The New York City Department of Health and Mental Hygiene issues your
child’s birth certificate. A birth certificate is the permanent legal record of
your child’s birth and is used as proof of your child’s age, citizenship and
parentage. The information you provide is required by law. Unless you
complete this form correctly, we cannot create an accurate birth
certificate for your child.
Information about education, race, smoking, height and your weight
before pregnancy are collected for public health purposes. Additional
questions labeled “QI” (Quality Improvement) are requested by the New
York State Department of Health. New York City and State laws protect
against the unlawful release of birth certificate information to ensure the
confidentiality of you and your child.
• It is extremely important that you provide complete and accurate
information to ALL questions. Please print all information clearly.
• The worksheet MUST be completed in English. If you are not able to
complete it in English by yourself please call the hospital Birth
Registrar at __________________________.
• The completed worksheet MUST be completed and returned to the
Birth Registrar within 24 hours of the birth of your child.
• If you have any questions, please call the hospital Birth Registrar.
MOTHER/PARENT WORKSHEET - DATA COLLECTED FOR REGISTRATION OF NEWBORN BIRTH CERTIFICATE
For Facility Birth Registration Tracking Purposes
Mother/Parent’s MRN: Mother/Parent’s Name:
Child’s MRN:
Child’s DOB:
Number delivered this pregnancy If more than one, birth order of this child
VR-203 (Rev. 01/14)
New York City Department of Health and Mental Hygiene
Bureau of Vital Statistics
Mother/Parent’s First Name Mother/Parent’s Middle Name Mother/Parent’s Legal Last Name
My maiden name is my current legal name
Mother/Parent’s First Name Mother/Parent’s Middle Name Mother/Parent’s Maiden Last Name
1. What will be your
baby’s LEGAL NAME?
3. What is your CURRENT
LEGAL name?
4. What is your MAIDEN name?
Name prior to first marriage
2. Do you want a Social Security number and card for your child?
As long as you have provided the legal
first and last
name of your newborn child above, you may request a Social Security number (SSN) for your child. The Health
Department will send the request to the Social Security Administration at the time the certificate is filed. If you do not request this
now
, you will need to contact
Social Security directly to obtain an SSN for your child. The hospital, birth facility and Health Department will not be responsible for making the request on your behalf.
CHILD
MOTHER/PARENT (WOMAN GIVING BIRTH)
Child’s FIRST Name Child’s MIDDLE Name(s) Child’s LAST Name Suffix
(Jr., III, etc.)
Yes No
If yes, the card will be mailed to Mother/Parent’s
Mailing Address by the Social Security Administration.
8. What is your SOCIAL SECURITY NUMBER?
Providing parents’ Social Security numbers is required by Federal Law, 42 USC 405(c)
(§205 (c) of the Social Security Act). The numbers will be made available to the NYS
Office of Temporary and Disability Assistance to assist with child support enforcement
activities and to the Internal Revenue Service through the Social Security
Administration for the purpose of determining Earned Income Tax Credit compliance.
City State
(If not in U.S., please indicate foreign country)
Foreign Country
Never lived in U.S.
(go to next question)
Years lived in U.S.
___ ___
OR
If less than one year:
Months lived in U.S.
___ ___
9. Where were YOU BORN?
11. Where do you USUALLY LIVE?
Where is your household physically located?
If not in U.S., please indicate foreign address, city and country.
10. If you were born outside of the United States,
how long have you lived in the U.S.?
MOTHER/PARENT’S BIRTHPLACE
MOTHER/PARENT’S ADDRESS
Mother/Parent’s SSN I don’t have a SSN
____ ____ ____ – ____ ____ – ____ ____ ____ ____
Mother/Parent’s Signature
Your signature below indicates that the information regarding the Social Security number on this form is correct.
Father/Parent’s SSN will be requested in the Father/Parent’s
information section, if applicable.
Date
__ __ / __ __ / __ __ __ __
Month Day Year
Street Address
(Do NOT enter a PO Box or In Care of (c/o))
Apt. Number
City State ZIP Code Country
12. What is your MAILING address?
This is where the birth certificate will be MAILED.
The
first
copy of the birth certificate is
FREE.
13. What are your TELEPHONE numbers?
In Care of
(another person or organization/agency)
Street Address
(PO Box is not permitted in a NYC mailing address)
Apt. Number
City State ZIP Code Country
If NYC, County
(borough)
New York
(Manhattan)
Bronx
Kings
(Brooklyn)
Queens
Richmond
(Staten Island)
Do you live within the city limits specified above? Yes No Outside NYC
(Specify County): _____________________________________
Same as my USUAL residence above
No mailing address
If no mailing address, certificate will NOT be mailed; you will need to pick it up at the Health Department.
If mailing address is In Care of (c/o), please indicate here:
Day
( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___ Ext. _____________
Evening
( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___
Please print all names
exactly
as you would like them to appear on the birth certificate.
To change this information in the future, you will be required to submit a correction application to the Health Department.
5-7. What is your DATE OF BIRTH, current AGE and
SEX?
If more than one child delivered, birth order of this child: _____
Date of
Mother/Parent’s
Birth
____ ____ / ____ ____ / ____ ____ ____ ____
Month Day Year
Current
Age
____ ____
Sex
Female
Male
0 7 3 0 2 0 1 4
White
Black or African American
American Indian or Alaska Native
(name of 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)
________________________
Occupation
(For example: cashier, bank teller, nurse, attorney, etc.)
Time Period Number of Cigarettes per day
OR
Number of Packs per day
3 months before your pregnancy ___ ___ _____
First 3 months of your pregnancy ___ ___ _____
Second 3 months of your pregnancy ___ ___ _____
Third 3 months of your pregnancy ___ ___ _____
Industry
(For example: restaurant, banking, health care, legal, etc.)
14. EDUCATION: What is the highest level of school that you
COMPLETED at the time of your baby’s delivery?
Check (
8
) ONE box only
15. Were you EMPLOYED during the pregnancy?
16. What is your current/most recent OCCUPATION (job)?
17. What INDUSTRY did you perform this occupation (job)?
Do not give the name of the business, but write what type of business it is.
18. What is your ANCESTRY?
Check (
8
) ONE box and specify what you most consider yourself to be.
19. What is your RACE?
Race is defined by U.S. Census. Hispanic is not a race according to the U.S.
Census. For Hispanic ancestry, please use Question 18.
Check (
8
) ALL that apply and specify where indicated.
MOTHER/PARENT’S ATTRIBUTES
8th grade or less; none
9th-12th grade, no diploma
High school graduate or GED
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)
Yes No
Hispanic
(For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)
Specify:
_____________________________________________________________________
NOT Hispanic
(For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)
Specify:
_____________________________________________________________________
20. Did you participate in WIC during this pregnancy?
(Special supplemental nutrition for Woman, Infants and Children.)
21. What is your HEIGHT?
22. What was your PRE-PREGNANCY WEIGHT?
23. Did you smoke CIGARETTES in the three months
before or during this pregnancy?
24. Did you use ALCOHOL during this pregnancy?
26. (QI) How many times per week during your current pregnancy did
you EXERCISE for 30 minutes or more, above your usual activities?
27. (QI) Did you have any problems with your GUMS at any time during pregnancy, for example, swollen or bleeding gums? Yes No
28. (QI) During your pregnancy, would you say that you were:
Check (
8
) ONE box only
29. (QI) Thinking back to just before you were pregnant, how did
you feel about becoming pregnant?
Check (
8
) ONE box only
Yes No
Yes No
No Yes If yes, what was the average number of cigarettes/day or packs/day you smoked during the following times?
Please answer below. Enter 0 if NONE during any of these periods
MOTHER/PARENT’S HEALTH
Quality Improvement (QI) questions are asked for the New York State Department of Health. They are designed to learn more
about the quality of prenatal care New Yorkers are receiving. All answers will be used for public health purposes only.
Height Pre-Pregnancy Weight
____ ____ Feet ____ ____ Inches ____ ____ ____ lbs.
____ ____ Times per week
25. (QI) Did you receive
PRENATAL CARE (medical care
for this pregnancy) before
admission for this delivery?
No
Skip to Question 26
Yes
If yes, please answer the following:
Not depressed at all A little depressed Very depressed and did not receive help
Moderately depressed Very depressed and did receive help
You wanted to be pregnant sooner You wanted to be pregnant then
You wanted to be pregnant later You didn’t want to be pregnant
then or at any time in the future
During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?
a) How smoking during pregnancy could affect your baby? Yes No
b) How drinking alcohol during your pregnancy could affect your baby? Yes No
c) How using illegal drugs could affect your baby? Yes No
d) How long to wait before having another baby? Yes No
e) Birth control methods to use after your pregnancy? Yes No
f) What to do if your labor starts early? Yes No
g) How to keep from getting HIV (the virus that causes AIDS)? Yes No
h) Physical abuse to women by their husbands or partners? Yes No
FATHER/PARENT
Father/Parent’s First Name Father/Parent’s Middle Name(s) Father/Parent’s Last Name Suffix
(Jr., III, etc.)
31-33. What is the father/parent’s DATE OF BIRTH,
current AGE, and SEX?
34. What is the father/parent’s SOCIAL SECURITY NUMBER?
Providing parents’ Social Security numbers is required by Federal Law, 42 USC 405(c) (§205 (c) of the Social Security Act). The numbers will be
made available to the NYS Office of Temporary and Disability Assistance to assist with child support enforcement activities and to the Internal
Revenue Service through the Social Security Administration for the purpose of determining Earned Income Tax Credit compliance.
Father/Parent’s SSN Father/Parent does not have a SSN
____ ____ ____ – ____ ____ – ____ ____ ____ ____
Mother/Parent’s signature on previous page confirms that the above SSN is correct
City State
(If not in US, please indicate foreign country)
Foreign Country
35. Where was the father/parent BORN?
36. If the father/parent was born outside of the United
States, how long has he/she lived in the U.S.?
FATHER/PARENT’S BIRTHPLACE
White
Black or African American
American Indian or Alaska Native
(name of 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)
________________________
Occupation
(For example: cashier, bank teller, nurse, attorney, etc.)
Industry
(For example: restaurant, banking, health care, legal, etc.)
37. EDUCATION: What is the highest level of school that the
father/parent COMPLETED at the time of your baby’s delivery?
Check (
8
) ONE box only
38. What is the father/parent’s current/most recent OCCUPATION
(job)?
39. In what INDUSTRY did he/she perform this occupation (job)?
Do not give the name of the business, but write what type of business it is.
40. What is the father/parent’s ANCESTRY?
Check (
8
) ONE box only and specify what father/parent most considers
himself/herself to be.
41. What is the father/parent’s RACE?
Race is defined by U.S. Census. Hispanic is not a race according to the
U.S. Census. For Hispanic ancestry, please use Question 40.
Check (
8
) ALL that apply and specify where indicated.
FATHER/PARENT’S ATTRIBUTES
8th grade or less; none
9th-12th grade, no diploma
High school graduate or GED
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)
Hispanic
(For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)
Specify:
_____________________________________________________________________
NOT Hispanic
(For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)
Specify:
_____________________________________________________________________
AND
1) If married, ask the hospital what is necessary to ensure your spouse’s name appears as the legal
father/parent of your child on the birth certificate; OR
2) If married and your spouse is NOT the father/parent of the child, speak with the hospital Birth Registrar; OR
3) If you are not married, both you and the father must sign an ACKNOWLEDGMENT OF PATERNITY in the
presence of two unrelated witnesses; OR
4) If your circumstances are not covered by the above, speak with the hospital Birth Registrar.
FATHER/PARENT’S INFORMATION FOR LIVE BIRTH
To be Completed by Mother/Parent or Father/Parent
30. What is the NAME of your baby’s father/parent
prior to first marriage?
Please write Father/Parent’s name exactly as you would like it to appear on
the certificate. To change this information in the future, you will be required
to submit a correction application to the Health Department.
Date of
Father/Parent’s
Birth
____ ____ / ____ ____ / ____ ____ ____ ____
Month Day Year
Current
Age
____ ____
Sex
Female
Male
Never lived in U.S.
(go to next question)
Years lived in U.S.
___ ___
OR
If less than one year:
Months lived in U.S.
___ ___
If you want the name of the child’s father/parent to appear on the birth certificate you must provide
accurate and complete information below and submit completed form to the hospital Birth Registrar.
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Completed 14 February 2020

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