Birth And Fetal Death (BFDR) - STU2-ballot
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Birth And Fetal Death (BFDR) - STU2-ballot, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0-Preview1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of and changes regularly. See the Directory of published versions

Questionnaire: Questionnaire - Mother's Worksheet for Child's Birth Certificate

Official URL: Version: 2.0.0-Preview1
Draft as of 2024-07-17 Computable Name: QuestionnaireMothersWorksheetChildsBirthCertificate
Other Identifiers: OID:2.16.840.1.113883.4.642.


Generated Narrative: Questionnaire Questionnaire-mothers-live-birth

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. QuestionnaireMothersWorksheetChildsBirthCertificateQuestionnaire
... introThe information you provide below will be used to create your child’s birth certificate. The birth certificate is a document that will be used for legal purposes to prove your child’s age, citizenship and parentage. This document will be used by your child throughout his/her life. State laws provide protection against the unauthorized release of identifying information from the birth certificates to ensure the confidentiality of the parents and their child. It is very important that you provide complete and accurate information to all of the questions. In addition to information used for legal purposes, other information from the birth certificate is used by health and medical researchers to study and improve the health of mothers and newborn infants. Items such as parent’s education, race, and smoking will be used for studies but will not appear on copies of the birth certificate issued to you or your child. All information on the mother should be for the woman who delivered the infant. In cases of surrogacy or gestational carrier, the information reported should be that for the surrogate or the gestational carrier, that is, the woman who delivered the infant.0..1display
1. What is your current legal name?0..1group
.... mother-first-nameFirst0..1string
.... mother-middle-nameMiddle0..1string
.... mother-last-nameLast0..1string
.... mother-suffixSuffix (Jr., III, etc.)0..1string
... child-name2. What will be your baby's legal name (as it should appear on the birth certificate)?0..1group
.... child-first-nameFirst0..1string
.... child-middle-nameMiddle0..1string
.... child-last-nameLast0..1string
.... child-suffixSuffix (Jr., III, etc.)0..1string
... mother-address3. Where do you usually live - that is - where is your household/residence located?0..1group
.... mother-nbr-streetComplete number and street (do not enter rural route numbers)0..1string
.... mother-apt-nbrApartment Number0..1string
.... mother-cityCity, Town, or Location0..1string
.... mother-countyCounty0..1string
.... mother-stateState (or U.S. Territory, Canadian Province)0..1choiceValue Set: States, Territories and Provinces Vital Records
.... mother-zipZip Code0..1string
.... mother-countryIf not in the United States, country0..1choiceValue Set: Residence Country Vital Records
... inside-city-limits4. Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?0..1choiceValue Set: Yes No Unknown Vital Records
... mother-mail5. What is your mailing address0..1group
.... mother-mail-sameSame as residence [Go to next question]0..1boolean
.... mother-mail-nbr-streetComplete number and street0..1stringEnable When: mother-mail-same =
.... mother-mail-apt-nbrApartment Number0..1stringEnable When: mother-mail-same =
.... mother-mail-po-boxP.O. Box0..1stringEnable When: mother-mail-same =
.... mother-mail-cityCity, Town, or Location0..1stringEnable When: mother-mail-same =
.... mother-mail-stateState (or U.S. Territory, Canadian Province)0..1choiceEnable When: mother-mail-same =
Value Set: States, Territories and Provinces Vital Records
.... mother-mail-zipZip Code0..1stringEnable When: mother-mail-same =
.... mother-mail-countryIf not in the United States, country0..1choiceEnable When: mother-mail-same =
Value Set: Residence Country Vital Records
... mother-dob6. What is your date of birth?0..1date
... mother-birthplace7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following:0..1group
.... mother-birthplace-stateState0..1choiceValue Set: US States Vital Records
.... mother-birthplace-territoryor U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas0..1choiceValue Set: US Territories Vital Records
.... mother-birthplace-countryor Foreign country0..1choiceValue Set: Birthplace Country Vital Records
... mother-education8. What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).0..1choiceDefinition: Observation.value
Value Set: Education Level Vital Records
... mother-ethnicity9. Are you Spanish/Hispanic/Latina?0..1boolean
... mother-ethnicity-mexicanAre you Mexican, Mexican-American?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-puerto-ricanAre you Puerto Rican?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-cubanAre you Cuban?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-otherAre you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).0..1booleanEnable When: mother-ethnicity =
.... mother-ethnicity-other-literal(specify)0..1stringEnable When: mother-ethnicity-other =
... mother-race10. What is your race? (Please check one or more races to indicate what you consider yourself to be).0..1group
.... mother-race-whiteWhite0..1boolean
.... mother-race-black-or-aaBlack or African American0..1boolean
.... mother-race-aianAmerican Indian or Alaskan Native0..1boolean
..... mother-race-aian-tribe(name of enrolled or principal tribe)0..1stringEnable When: mother-race-aian =
.... mother-race-asian-indianAsian Indian0..1boolean
.... mother-race-chineseChinese0..1boolean
.... mother-race-filipinoFilipino0..1boolean
.... mother-race-japaneseJapanese0..1boolean
.... mother-race-koreanKorean0..1boolean
.... mother-race-vietnameseVietnamese0..1boolean
.... mother-race-other-asianOther Asian0..1boolean
..... mother-race-other-asian-literal(specify)0..1stringEnable When: mother-race-other-asian =
.... mother-race-native-hawaiianNative Hawaiian0..1boolean
.... mother-race-guamanian-or-chamorroGuamanian or Chamorro0..1boolean
.... mother-race-samoanSamoan0..1boolean
.... mother-race-other-pacific-islanderOther Pacific Islander0..1boolean
..... mother-race-other-pacific-islander-specify(specify)0..1stringEnable When: mother-race-other-pacific-islander =
.... mother-race-otherOther (specify)0..1boolean
..... mother-race-other-specify(specify)0..1stringEnable When: mother-race-other =
... receive-wic11. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?0..1choiceDefinition: Observation.code
Value Set: Yes No Unknown Vital Records
... infertility-treatment12. Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)0..1boolean
.... drugs-ai-iiIf yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?0..1boolean
.... art-ivf-giftIf yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?0..1boolean
... mothers-height13. What is your height?0..1group
.... mothers-height-feetFeet0..1quantity
.... mothers-height-inchesInches0..1quantity
... mothers-prepregnancy-weight14. What was your prepregnancy weight in lbs, that is, your weight immediately before you became pregnant?0..1quantity
... mothers-smoking15. How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.0..1group
.... mothers-smoking-3-months-priorThree months before pregnancy0..1group
..... mothers-smoking-3-months-prior-cig# of cigarettes*0..1integer
..... mothers-smoking-3-months-prior-pck# of packs0..1integer
.... mothers-smoking-trimester-1First three months of pregnancy0..1group
..... mothers-smoking-trimester-1-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-1-pck# of packs0..1integer
.... mothers-smoking-trimester-2Second three months of pregnancy0..1group
..... mothers-smoking-trimester-2-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-2-pck# of packs0..1integer
.... mothers-smoking-trimester-3Third trimester of pregnancy0..1group
..... mothers-smoking-trimester-3-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-3-pck# of packs0..1integer
.... cigarette-note*refers to tobacco products only, NOT e-cigarettes.0..1display
... mother-ever-married16. Question 'Have you ever been married?' removed.0..1display
... mother-prior-name17. What name did you use prior to your first marriage?0..1group
.... mother-prior-first-nameFirst0..1string
.... mother-prior-middle-nameMiddle0..1string
.... mother-prior-last-nameLast0..1string
.... mother-prior-suffixSuffix (Jr., III, etc.)0..1string
... married-conception18. Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]0..1boolean
.... paternity-ackIf no, has a paternity acknowledgment been completed? (That is, have you and the father signed a form [insert name of State paternity acknowledgment form] in which the father accepted legal responsibility for the child?) If you were not married, or if a paternity acknowledgment has not been completed, information about the father cannot be included on the birth certificate. Information about the procedures for adding the father’s information to the Birth Certificate after it has been filed can be obtained from the State Vital Statistics Office. [If yes, please go to question 19; If no, please go to question 25]0..1booleanEnable When: married-conception =
19. What is the current legal name of your baby's father?0..1group
.... father-first-nameFirst0..1string
.... father-middle-nameMiddle0..1string
.... father-last-nameLast0..1string
.... father-suffixSuffix (Jr., III, etc.)0..1string
... father-dob20. What the father's date of birth?0..1date
... father-birthplace21. In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:0..1group
.... father-birthplace-stateState0..1choiceValue Set: US States Vital Records
.... father-birthplace-territoryor U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas0..1choiceValue Set: US Territories Vital Records
.... father-birthplace-countryor Foreign country0..1choiceValue Set: Birthplace Country Vital Records
... father-education22. What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).0..1choiceValue Set: Education Level Vital Records
... father-ethnicity23. Is the father Spanish/Hispanic/Latina?0..1boolean
... father-ethnicity-mexicanIs the father Mexican, Mexican-American?0..1boolean
... father-ethnicity-puerto-ricanIs the father Puerto Rican?0..1boolean
... father-ethnicity-cubanIs the father Cuban?0..1boolean
... father-ethnicity-otherIs the father of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).0..1booleanEnable When: father-ethnicity =
.... father-ethnicity-other-literal(specify)0..1stringEnable When: father-ethnicity-other =
... father-race24. What is the father's race? (Please check one or more races to indicate what he considers himself to be).0..1group
.... father-race-whiteWhite0..1boolean
.... father-race-black-or-aaBlack or African American0..1boolean
.... father-race-aianAmerican Indian or Alaskan Native0..1boolean
..... father-race-aian-tribe(name of enrolled or principal tribe)0..1stringEnable When: father-race-aian =
.... father-race-asian-indianAsian Indian0..1boolean
.... father-race-chineseChinese0..1boolean
.... father-race-filipinoFilipino0..1boolean
.... father-race-japaneseJapanese0..1boolean
.... father-race-koreanKorean0..1boolean
.... father-race-vietnameseVietnamese0..1boolean
.... father-race-other-asianOther Asian0..1boolean
..... father-race-other-asian-literal(specify)0..1stringEnable When: father-race-other-asian =
.... father-race-native-hawaiianNative Hawaiian0..1boolean
.... father-race-guamanian-or-chamorroGuamanian or Chamorro0..1boolean
.... father-race-samoanSamoan0..1boolean
.... father-race-other-pacific-islanderOther Pacific Islander0..1boolean
..... father-race-other-pacific-islander-specify(specify)0..1stringEnable When: father-race-other-pacific-islander =
.... father-race-otherOther (specify)0..1boolean
..... father-race-other-specify(specify)0..1stringEnable When: father-race-other =
... parents-ssn25. Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.0..1group
.... mother-ssnWhat is your Social Security Number?0..1string
.... father-ssnWhat is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.0..1string
... baby-ssn26a. Do you want a Social Security Number issued for your baby? [If yes, please sign request below0..1boolean
... baby-ssn-sig26b. I request that the Social Security Administration assign a Social Security number to the child named on this form and authorize the State to provide the Social Security Administration with the information from this form which is needed to assign a number. (Either parent, or the legal guardian, may sign.)0..1group
.... baby-ssn-sig-parentSignature of infant's mother or father0..1attachment
.... baby-ssn-sig-dateDate0..1date
... informant-noteIf you are the Mother, please STOP here. If other than the mother please answer the following questions:0..1display
... informant-name27a. If other than the mother, what is the name of the person providing information for this worksheet?0..1group
.... informant-first-nameFirst0..1string
.... informant-middle-nameMiddle0..1string
.... informant-last-nameLast0..1string
.... informant-suffixSuffix (Jr., III, etc.)0..1string
... informant-relationship27a. What is your relationship to the baby's mother?0..1open-choiceValue Set: Informant Relationship to Mother

doco Documentation for this format