Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn LinkID Text Definition Answer QuestionnaireResponse-mothers-live-birth-jada-quinn Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate #xD; mother-current-legal-name What is your current legal name? #xD; mother-first-name First Jada #xD; mother-middle-name Middle Ann #xD; mother-last-name Last Quinn #xD; child-name What will be your baby's legal name (as it should appear on the birth certificate)? #xD; child-first-name First Baby #xD; child-middle-name Middle G #xD; child-last-name Last Quinn #xD; mother-address Where do you usually live - that is - where is your household/residence located? #xD; mother-nbr-street Complete number and street (do not enter rural route numbers) 1875 West Morton Avenue #xD; mother-city City, Town, or Location Salt Lake City #xD; mother-county County Salt Lake #xD; mother-state State (or U.S. Territory, Canadian Province) UT #xD; mother-zip Zip Code 84116 #xD; inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? v2 Y/N Indicator Y: Yes #xD; mother-mail What is your mailing address #xD; mother-mail-same Same as residence [Go to next question] false #xD; mother-mail-nbr-street Complete number and street 1848 South 1300 East #xD; mother-mail-city City, Town, or Location Salt Lake City #xD; mother-mail-state State (or U.S. Territory, Canadian Province) UT #xD; mother-mail-zip Zip Code 84401 #xD; mother-dob What is your date of birth? 1985-01-15 #xD; mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: #xD; mother-birthplace-state State UT #xD; mother-education 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). Education Level POSTG: Doctoral or post graduate education #xD; mother-ethnicity false #xD; mother-race #xD; mother-race-white White true #xD; mother-race-aian American Indian or Alaskan Native true #xD; receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? v2 Y/N Indicator Y: Yes #xD; infertility-treatment Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) true #xD; drugs-ai-ii If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? false #xD; art-ivf-gift If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? true #xD; mothers-height What is your height? #xD; mothers-height-feet Feet 5 ft (Details: UCUM codeft = 'ft') #xD; mothers-height-inches Inches 7 [in_i] (Details: UCUM code[in_i] = '[in_i]') #xD; mothers-prepregnancy-weight 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]') #xD; mothers-smoking 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. #xD; mothers-smoking-3-months-prior Three months before pregnancy #xD; mothers-smoking-3-months-prior-cig # of cigarettes* 0 #xD; mothers-smoking-3-months-prior-pck # of packs 1 #xD; mothers-smoking-trimester-1 First three months of pregnancy #xD; mothers-smoking-trimester-1-cig # of cigarettes* 3 #xD; mothers-smoking-trimester-1-pck # of packs 0 #xD; mothers-smoking-trimester-2 Second three months of pregnancy #xD; mothers-smoking-trimester-2-cig # of cigarettes* 1 #xD; mothers-smoking-trimester-2-pck # of packs 0 #xD; mothers-smoking-trimester-3 Third trimester of pregnancy #xD; mothers-smoking-trimester-3-cig # of cigarettes* 0 #xD; mothers-smoking-trimester-3-pck # of packs 0 #xD; mother-prior-name What name did you use prior to your first marriage? #xD; mother-prior-first-name First Jada #xD; mother-prior-middle-name Middle Ann #xD; mother-prior-last-name Last King #xD; married-conception 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] true #xD; father-current-legal-name What is the current legal name of your baby's father? #xD; father-first-name First James #xD; father-middle-name Middle Brandon #xD; father-last-name Last Quinn #xD; father-dob What the father's date of birth? 1983-09-27 #xD; father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: #xD; father-birthplace-state State NY #xD; father-education 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). Education Level POSTG: Doctoral or post graduate education #xD; father-ethnicity false #xD; father-race #xD; father-race-white White true #xD; parents-ssn 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. #xD; mother-ssn What is your Social Security Number? 132-22-5986 #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. 132-22-5987 #xD; baby-ssn Do you want a Social Security Number issued for your baby? [If yes, please sign request below false #xD; informant-name If other than the mother, what is the name of the person providing information for this worksheet? #xD; informant-first-name First Jane #xD; informant-last-name Last King #xD; informant-relationship What is your relationship to the baby's mother? Local BFDR Codes rel_otherrelative: Other relative #xD; Documentation for this format
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:
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).
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))?
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.
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]
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).
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
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?