Generated Narrative: Questionnaire Questionnaire-mothers-live-birth LinkID Text Cardinality Type Description & Constraints QuestionnaireMothersWorksheetChildsBirthCertificate Questionnaire http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-mothers-live-birth#2.0.0 #xD; intro The 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..1 display #xD; mother-current-legal-name 1. What is your current legal name? 0..1 group #xD; mother-first-name First 0..1 string #xD; mother-middle-name Middle 0..1 string #xD; mother-last-name Last 0..1 string #xD; mother-suffix Suffix (Jr., III, etc.) 0..1 string #xD; child-name 2. What will be your baby's legal name (as it should appear on the birth certificate)? 0..1 group #xD; child-first-name First 0..1 string #xD; child-middle-name Middle 0..1 string #xD; child-last-name Last 0..1 string #xD; child-suffix Suffix (Jr., III, etc.) 0..1 string #xD; mother-address 3. Where do you usually live - that is - where is your household/residence located? 0..1 group #xD; mother-nbr-street Complete number and street (do not enter rural route numbers) 0..1 string #xD; mother-apt-nbr Apartment Number 0..1 string #xD; mother-city City, Town, or Location 0..1 string #xD; mother-county County 0..1 string #xD; mother-state State (or U.S. Territory, Canadian Province) 0..1 choice Value Set: Value Set - States, Territories and Provinces Vital Records #xD; mother-zip Zip Code 0..1 string #xD; mother-country If not in the United States, country 0..1 choice Value Set: Value Set - Residence Country Vital Records #xD; inside-city-limits 4. Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? 0..1 choice Value Set: Value Set - Yes No Unknown Vital Records #xD; mother-mail 5. What is your mailing address 0..1 group #xD; mother-mail-same Same as residence [Go to next question] 0..1 boolean #xD; mother-mail-nbr-street Complete number and street 0..1 string Enable When: mother-mail-same = #xD; mother-mail-apt-nbr Apartment Number 0..1 string Enable When: mother-mail-same = #xD; mother-mail-po-box P.O. Box 0..1 string Enable When: mother-mail-same = #xD; mother-mail-city City, Town, or Location 0..1 string Enable When: mother-mail-same = #xD; mother-mail-state State (or U.S. Territory, Canadian Province) 0..1 choice Enable When: mother-mail-same = Value Set: Value Set - States, Territories and Provinces Vital Records #xD; mother-mail-zip Zip Code 0..1 string Enable When: mother-mail-same = #xD; mother-mail-country If not in the United States, country 0..1 choice Enable When: mother-mail-same = Value Set: Value Set - Residence Country Vital Records #xD; mother-dob 6. What is your date of birth? 0..1 date #xD; mother-birthplace 7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following: 0..1 group #xD; mother-birthplace-state State 0..1 choice Value Set: Value Set - US States Vital Records #xD; mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 choice Value Set: Value Set - US Territories Vital Records #xD; mother-birthplace-country or Foreign country 0..1 choice Value Set: Value Set - Birthplace Country Vital Records #xD; mother-education 8. 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..1 choice Definition: Observation.value Value Set: Value Set - Education Level Vital Records #xD; mother-ethnicity 9. Are you Spanish/Hispanic/Latina? 0..1 boolean #xD; mother-ethnicity-mexican Are you Mexican, Mexican-American? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-puerto-rican Are you Puerto Rican? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-cuban Are you Cuban? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-other Are you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian). 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-other-literal (specify) 0..1 string Enable When: mother-ethnicity-other = #xD; mother-race 10. What is your race? (Please check one or more races to indicate what you consider yourself to be). 0..1 group #xD; mother-race-white White 0..1 boolean #xD; mother-race-black-or-aa Black or African American 0..1 boolean #xD; mother-race-aian American Indian or Alaskan Native 0..1 boolean #xD; mother-race-aian-tribe (name of enrolled or principal tribe) 0..1 string Enable When: mother-race-aian = #xD; mother-race-asian-indian Asian Indian 0..1 boolean #xD; mother-race-chinese Chinese 0..1 boolean #xD; mother-race-filipino Filipino 0..1 boolean #xD; mother-race-japanese Japanese 0..1 boolean #xD; mother-race-korean Korean 0..1 boolean #xD; mother-race-vietnamese Vietnamese 0..1 boolean #xD; mother-race-other-asian Other Asian 0..1 boolean #xD; mother-race-other-asian-literal (specify) 0..1 string Enable When: mother-race-other-asian = #xD; mother-race-native-hawaiian Native Hawaiian 0..1 boolean #xD; mother-race-guamanian-or-chamorro Guamanian or Chamorro 0..1 boolean #xD; mother-race-samoan Samoan 0..1 boolean #xD; mother-race-other-pacific-islander Other Pacific Islander 0..1 boolean #xD; mother-race-other-pacific-islander-specify (specify) 0..1 string Enable When: mother-race-other-pacific-islander = #xD; mother-race-other Other (specify) 0..1 boolean #xD; mother-race-other-specify (specify) 0..1 string Enable When: mother-race-other = #xD; receive-wic 11. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? 0..1 choice Definition: Observation.code Value Set: Value Set - Yes No Unknown Vital Records #xD; infertility-treatment 12. Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) 0..1 boolean #xD; drugs-ai-ii If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? 0..1 boolean #xD; art-ivf-gift If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? 0..1 boolean #xD; mothers-height 13. What is your height? 0..1 group #xD; mothers-height-feet Feet 0..1 quantity #xD; mothers-height-inches Inches 0..1 quantity #xD; mothers-prepregnancy-weight 14. What was your prepregnancy weight in lbs, that is, your weight immediately before you became pregnant? 0..1 quantity #xD; mothers-smoking 15. 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..1 group #xD; mothers-smoking-3-months-prior Three months before pregnancy 0..1 group #xD; mothers-smoking-3-months-prior-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-3-months-prior-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-1 First three months of pregnancy 0..1 group #xD; mothers-smoking-trimester-1-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-1-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-2 Second three months of pregnancy 0..1 group #xD; mothers-smoking-trimester-2-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-2-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-3 Third trimester of pregnancy 0..1 group #xD; mothers-smoking-trimester-3-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-3-pck # of packs 0..1 integer #xD; cigarette-note *refers to tobacco products only, NOT e-cigarettes. 0..1 display #xD; mother-ever-married 16. Question 'Have you ever been married?' removed. 0..1 display #xD; mother-prior-name 17. What name did you use prior to your first marriage? 0..1 group #xD; mother-prior-first-name First 0..1 string #xD; mother-prior-middle-name Middle 0..1 string #xD; mother-prior-last-name Last 0..1 string #xD; mother-prior-suffix Suffix (Jr., III, etc.) 0..1 string #xD; married-conception 18. 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..1 boolean #xD; paternity-ack If 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..1 boolean Enable When: married-conception = #xD; father-current-legal-name 19. What is the current legal name of your baby's father? 0..1 group #xD; father-first-name First 0..1 string #xD; father-middle-name Middle 0..1 string #xD; father-last-name Last 0..1 string #xD; father-suffix Suffix (Jr., III, etc.) 0..1 string #xD; father-dob 20. What the father's date of birth? 0..1 date #xD; father-birthplace 21. In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: 0..1 group #xD; father-birthplace-state State 0..1 choice Value Set: Value Set - US States Vital Records #xD; father-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 choice Value Set: Value Set - US Territories Vital Records #xD; father-birthplace-country or Foreign country 0..1 choice Value Set: Value Set - Birthplace Country Vital Records #xD; father-education 22. 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..1 choice Value Set: Value Set - Education Level Vital Records #xD; father-ethnicity 23. Is the father Spanish/Hispanic/Latina? 0..1 boolean #xD; father-ethnicity-mexican Is the father Mexican, Mexican-American? 0..1 boolean #xD; father-ethnicity-puerto-rican Is the father Puerto Rican? 0..1 boolean #xD; father-ethnicity-cuban Is the father Cuban? 0..1 boolean #xD; father-ethnicity-other Is the father of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian). 0..1 boolean Enable When: father-ethnicity = #xD; father-ethnicity-other-literal (specify) 0..1 string Enable When: father-ethnicity-other = #xD; father-race 24. What is the father's race? (Please check one or more races to indicate what he considers himself to be). 0..1 group #xD; father-race-white White 0..1 boolean #xD; father-race-black-or-aa Black or African American 0..1 boolean #xD; father-race-aian American Indian or Alaskan Native 0..1 boolean #xD; father-race-aian-tribe (name of enrolled or principal tribe) 0..1 string Enable When: father-race-aian = #xD; father-race-asian-indian Asian Indian 0..1 boolean #xD; father-race-chinese Chinese 0..1 boolean #xD; father-race-filipino Filipino 0..1 boolean #xD; father-race-japanese Japanese 0..1 boolean #xD; father-race-korean Korean 0..1 boolean #xD; father-race-vietnamese Vietnamese 0..1 boolean #xD; father-race-other-asian Other Asian 0..1 boolean #xD; father-race-other-asian-literal (specify) 0..1 string Enable When: father-race-other-asian = #xD; father-race-native-hawaiian Native Hawaiian 0..1 boolean #xD; father-race-guamanian-or-chamorro Guamanian or Chamorro 0..1 boolean #xD; father-race-samoan Samoan 0..1 boolean #xD; father-race-other-pacific-islander Other Pacific Islander 0..1 boolean #xD; father-race-other-pacific-islander-specify (specify) 0..1 string Enable When: father-race-other-pacific-islander = #xD; father-race-other Other (specify) 0..1 boolean #xD; father-race-other-specify (specify) 0..1 string Enable When: father-race-other = #xD; parents-ssn 25. 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..1 group #xD; mother-ssn What is your Social Security Number? 0..1 string #xD; father-ssn What 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..1 string #xD; baby-ssn 26a. Do you want a Social Security Number issued for your baby? [If yes, please sign request below 0..1 boolean #xD; baby-ssn-sig 26b. 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..1 group #xD; baby-ssn-sig-parent Signature of infant's mother or father 0..1 attachment #xD; baby-ssn-sig-date Date 0..1 date #xD; informant-note If you are the Mother, please STOP here. If other than the mother please answer the following questions: 0..1 display #xD; informant-name 27a. If other than the mother, what is the name of the person providing information for this worksheet? 0..1 group #xD; informant-first-name First 0..1 string #xD; informant-middle-name Middle 0..1 string #xD; informant-last-name Last 0..1 string #xD; informant-suffix Suffix (Jr., III, etc.) 0..1 string #xD; informant-relationship 27a. What is your relationship to the baby's mother? 0..1 open-choice Value Set: Informant Relationship to Mother #xD; Documentation for this format
Questionnaire - Mother's Worksheet for Child's Birth Certificate
The 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.
What will be your baby's legal name (as it should appear on the birth certificate)?
Where do you usually live - that is - where is your household/residence located?
Complete number and street (do not enter rural route numbers)
State (or U.S. Territory, Canadian Province)
Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
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).
Are you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).
What is your race? (Please check one or more races to indicate what you consider yourself to be).
Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)
If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?
If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?
What was your prepregnancy weight in lbs, that is, your weight immediately before you became pregnant?
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.
*refers to tobacco products only, NOT e-cigarettes.
Question 'Have you ever been married?' removed.
What name did you use prior to your first marriage?
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]
If 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]
What is the current legal name of your baby's father?
In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
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).
Is the father Mexican, Mexican-American?
Is the father of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).
What is the father's race? (Please check one or more races to indicate what he considers himself to be).
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.
What 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.
Do you want a Social Security Number issued for your baby? [If yes, please sign request below
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.)
If you are the Mother, please STOP here. If other than the mother please answer the following questions:
If other than the mother, what is the name of the person providing information for this worksheet?
What is your relationship to the baby's mother?