Questionnaire-mothers-live-birth
type: Questionnaire
node role: treeRoot
id:
  v: Questionnaire-mothers-live-birth
meta:
  version id:
    v: 11
  last updated:
    v: 2023-04-06T00:35:49.604Z
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire Questionnaire-mothers-live-birth version: versionId: id (PrimitiveType/Questionnaire.meta.versionId): native = id -> 11; Last updated: 2023-04-06 00:35:49+0000 LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> QuestionnaireMothersWorksheetChildsBirthCertificate This Questionnaire represents the [Mother's Worksheet for Child's Birth Certificate](https://www.cdc.gov/nchs/data/dvs/moms-worksheet-2016-508.pdf). Questionnaire https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-mothers-live-birth#1.1.0 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 mother-current-legal-name 1. What is your current legal name? 0..1 group mother-first-name First 0..1 string mother-middle-name Middle 0..1 string mother-last-name Last 0..1 string m…
url:
  v: https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-mothers-live-birth
version:
  v: 1.1.0
name:
  v: QuestionnaireMothersWorksheetChildsBirthCertificate
title:
  v: Questionnaire - Mother's Worksheet for Child's Birth Certificate
status:
  v: draft
experimental:
  v: false
subject type:
  v: Patient
date:
  v: 2024-07-09T14:11:31+00:00
publisher:
  v: IHE International
contact:
  name:
    v: IHE Quality, Research and Public Health Committee
  telecom:
    system:
      v: url
    value:
      v: https://www.ihe.net/ihe_domains/quality_research_and_public_health
description:
  v: This Questionnaire represents the [Mother's Worksheet for Child's Birth Certificate](https://www.cdc.gov/nchs/data/dvs/moms-worksheet-2016-508.pdf).
jurisdiction:
  coding:
    system:
      v: http://unstats.un.org/unsd/methods/m49/m49.htm
    code:
      v: 001
purpose:
  v: Purpose
item:
  link id:
    v: intro
  text:
    v: 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.
  type:
    v: display
item:
  link id:
    v: mother-current-legal-name
  prefix:
    v: 1
  text:
    v: What is your current legal name?
  type:
    v: group
  repeats:
    v: false
  item:
    link id:
      v: mother-first-name
    text:
      v: First
    type:
      v: string
  item:
    link id:
      v: mother-middle-name
    text:
      v: Middle
    type:
      v: string
  item:
    link id:
      v: mother-last-name
    text:
      v: Last
    type:
      v: string
  item:
    link id:
      v: mother-suffix
    text:
      v: Suffix (Jr., III, etc.)
    type:
      v: string
item:
  link id:
    v: child-name
  prefix:
    v: 2
  text:
    v: What will be your baby's legal name (as it should appear on the birth certificate)?
  type:
    v: group
  repeats:
    v: false
  item:
    link id:
      v: child-first-name
    text:
      v: First
    type:
      v: string
  item:
    link id:
      v: child-middle-name
    text:
      v: Middle
    type:
      v: string
  item:
    link id:
      v: child-last-name
    text:
      v: Last
    type:
      v: string
  item:
    link id:
      v: child-suffix
    text:
      v: Suffix (Jr., III, etc.)
    type:
      v: string
item:
  link id:
    v: mother-address
  prefix:
    v: 3
  text:
    v: Where do you usually live - that is - where is your household/residence located?
  type:
    v: group
  item:
    link id:
      v: mother-nbr-street
    text:
      v: Complete number and street (do not enter rural route numbers)
    type:
      v: string
  item:
    link id:
      v: mother-apt-nbr
    text:
      v: Apartment Number
    type:
      v: string
  item:
    link id:
      v: mother-city
    text:
      v: City, Town, or Location
    type:
      v: string
  item:
    link id:
      v: mother-county
    text:
      v: County
    type:
      v: string
  item:
    link id:
      v: mother-state
    text:
      v: State (or U.S. Territory, Canadian Province)
    type:
      v: string
  item:
    link id:
      v: mother-zip
    text:
      v: Zip Code
    type:
      v: string
  item:
    link id:
      v: mother-country
    text:
      v: If not in the United States, country
    type:
      v: string
item:
  link id:
    v: inside-city-limits
  prefix:
    v: 4
  text:
    v: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
  type:
    v: choice

link id:
  v: mother-mail
prefix:
  v: 5
text:
  v: What is your mailing address
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-mail-same
  text:
    v: Same as residence [Go to next question]
  type:
    v: boolean
item:
  link id:
    v: mother-mail-nbr-street
  text:
    v: Complete number and street
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-apt-nbr
  text:
    v: Apartment Number
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-po-box
  text:
    v: P.O. Box
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-city
  text:
    v: City, Town, or Location
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-state
  text:
    v: State (or U.S. Territory, Canadian Province)
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-zip
  text:
    v: Zip Code
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-country
  text:
    v: If not in the United States, country
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false

link id:
  v: mother-dob
prefix:
  v: 6
text:
  v: What is your date of birth?
type:
  v: date
repeats:
  v: false

link id:
  v: mother-birthplace
prefix:
  v: 7
text:
  v: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-birthplace-state
  text:
    v: State
  type:
    v: string
item:
  link id:
    v: mother-birthplace-territory
  text:
    v: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
  type:
    v: string
item:
  link id:
    v: mother-birthplace-country
  text:
    v: or Foreign country
  type:
    v: string

link id:
  v: mother-education
definition:
  v: http://hl7.org/fhir/us/vr-common-library/StructureDefinition/Observation-parent-education-level-vr#Observation.value
code: https://loinc.org/rdf/57712-2
  system:
    v: http://loinc.org
  code:
    v: 57712-2
  display:
    v: Highest level of education Mother
prefix:
  v: 8
text:
  v: 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).
type:
  v: choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582

link id:
  v: mother-ethnicity
prefix:
  v: 9
text:
  v: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-shl
  text:
    v: Are you Spanish/Hispanic/Latina
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/omb-ethnicity-category
    link: http://hl7.org/fhir/us/core/ValueSet/omb-ethnicity-category
item:
  link id:
    v: mother-detailed-shl
  text:
    v: If Spanish/Hispanic/Latina, check the appropriate box.
  type:
    v: choice
  enable when:
    question:
      v: mother-shl
    operator:
      v: =
    answer: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2135-2
  repeats:
    v: false
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/detailed-ethnicity
    link: http://hl7.org/fhir/us/core/ValueSet/detailed-ethnicity

link id:
  v: mother-race
prefix:
  v: 10
text:
  v: What is your race? (Please check one or more races to indicate what you consider yourself to be).
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-race-category
  text:
    v: Race categories
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
    link: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
item:
  link id:
    v: mother-detailed-race
  text:
    v: Extended race codes
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/detailed-race
    link: http://hl7.org/fhir/us/core/ValueSet/detailed-race

link id:
  v: receive-wic
definition:
  v: https://profiles.ihe.net/QRPH/bfdr/StructureDefinition/Observation-mother-received-wic-food#Observation.code
prefix:
  v: 11
text:
  v: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
type:
  v: choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888

link id:
  v: infertility-treatment
prefix:
  v: 12
text:
  v: Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)
type:
  v: boolean
item:
  link id:
    v: drugs-ai-ii
  prefix:
    v: 12a
  text:
    v: If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?
  type:
    v: boolean
  repeats:
    v: false
item:
  link id:
    v: art-ivf-gift
  prefix:
    v: 12b
  text:
    v: If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?
  type:
    v: boolean
  repeats:
    v: false

link id:
  v: mothers-height
prefix:
  v: 13
text:
  v: What is your height?
type:
  v: group
item:
  link id:
    v: mothers-height-feet
  text:
    v: Feet
  type:
    v: quantity
  repeats:
    v: false
item:
  link id:
    v: mothers-height-inches
  text:
    v: Inches
  type:
    v: quantity
  repeats:
    v: false

link id:
  v: mothers-prepregnancy-weight
prefix:
  v: 14
text:
  v: lbs
type:
  v: quantity
repeats:
  v: false

link id:
  v: mothers-smoking
prefix:
  v: 15
text:
  v: 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.
type:
  v: group
item:
  link id:
    v: mothers-smoking-3-months-prior
  text:
    v: Three months before pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-3-months-prior-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-3-months-prior-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-1
  text:
    v: First three months of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-1-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-1-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-2
  text:
    v: Second three months of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-2-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-2-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-3
  text:
    v: Third trimester of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-3-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-3-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: cigarette-note
  text:
    v: *refers to tobacco products only, NOT e-cigarettes.
  type:
    v: display

link id:
  v: mother-ever-married
prefix:
  v: 16
text:
  v: Question 'Have you ever been married?' removed.
type:
  v: display

link id:
  v: mother-prior-name
prefix:
  v: 17
text:
  v: What name did you use prior to your first marriage?
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-prior-first-name
  text:
    v: First
  type:
    v: string
item:
  link id:
    v: mother-prior-middle-name
  text:
    v: Middle
  type:
    v: string
item:
  link id:
    v: mother-prior-last-name
  text:
    v: Last
  type:
    v: string
item:
  link id:
    v: mother-prior-suffix
  text:
    v: Suffix (Jr., III, etc.)
  type:
    v: string

link id:
  v: married-conception
prefix:
  v: 18
text:
  v: 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]
type:
  v: boolean
repeats:
  v: false
item:
  link id:
    v: paternity-ack
  text:
    v: 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]
  type:
    v: boolean
  enable when:
    question:
      v: married-conception
    operator:
      v: =
    answer:
      v: false

link id:
  v: father-current-legal-name
prefix:
  v: 19
text:
  v: What is the current legal name of your baby's father?
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-first-name
  text:
    v: First
  type:
    v: string
item:
  link id:
    v: father-middle-name
  text:
    v: Middle
  type:
    v: string
item:
  link id:
    v: father-last-name
  text:
    v: Last
  type:
    v: string
item:
  link id:
    v: father-suffix
  text:
    v: Suffix (Jr., III, etc.)
  type:
    v: string

link id:
  v: father-dob
prefix:
  v: 20
text:
  v: What the father's date of birth?
type:
  v: date
repeats:
  v: false

link id:
  v: father-birthplace
prefix:
  v: 21
text:
  v: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-birthplace-state
  text:
    v: State
  type:
    v: string
item:
  link id:
    v: father-birthplace-territory
  text:
    v: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
  type:
    v: string
item:
  link id:
    v: father-birthplace-country
  text:
    v: or Foreign country
  type:
    v: string

link id:
  v: father-education
code: https://loinc.org/rdf/87300-0
  system:
    v: http://loinc.org
  code:
    v: 87300-0
  display:
    v: Highest level of education Father
prefix:
  v: 22
text:
  v: 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).
type:
  v: choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582

link id:
  v: father-ethnicity
prefix:
  v: 23
text:
  v: Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-shl
  text:
    v: Is the father Spanish/Hispanic/Latina
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
    link: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.837
item:
  link id:
    v: father-detailed-shl
  text:
    v: If Spanish/Hispanic/Latina, check the appropriate box.
  type:
    v: choice
  enable when:
    question:
      v: father-shl
    operator:
      v: =
    answer: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2135-2
  repeats:
    v: false
  answer value set:
    v: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877
    link: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.877

link id:
  v: father-race
prefix:
  v: 24
text:
  v: What is the father's race? (Please check one or more races to indicate what he considers himself to be).
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-race-category
  text:
    v: Race categories
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
    link: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
item:
  link id:
    v: father-detailed-race
  text:
    v: Extended race codes
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914
    link: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.14914

link id:
  v: parents-ssn
prefix:
  v: 25
text:
  v: 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.
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-ssn
  prefix:
    v: 25a
  text:
    v: What is your Social Security Number?
  type:
    v: string
  repeats:
    v: false
item:
  link id:
    v: father-ssn
  text:
    v: 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.
  type:
    v: string
  repeats:
    v: false

link id:
  v: baby-ssn
prefix:
  v: 26a
text:
  v: Do you want a Social Security Number issued for your baby? [If yes, please sign request below
type:
  v: boolean
repeats:
  v: false

link id:
  v: baby-ssn-sig
prefix:
  v: 26b
text:
  v: 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.)
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: baby-ssn-sig-parent
  text:
    v: Signature of infant's mother or father
  type:
    v: attachment
  repeats:
    v: false
item:
  link id:
    v: baby-ssn-sig-date
  text:
    v: Date
  type:
    v: date
  repeats:
    v: false

link id:
  v: informant-note
text:
  v: If you are the Mother, please STOP here. If other than the mother please answer the following questions:
type:
  v: display

link id:
  v: informant-name
prefix:
  v: 27a
text:
  v: If other than the mother, what is the name of the person providing information for this worksheet?
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: informant-first-name
  text:
    v: First
  type:
    v: string
item:
  link id:
    v: informant-middle-name
  text:
    v: Middle
  type:
    v: string
item:
  link id:
    v: informant-last-name
  text:
    v: Last
  type:
    v: string
item:
  link id:
    v: informant-suffix
  text:
    v: Suffix (Jr., III, etc.)
  type:
    v: string

link id:
  v: informant-relationship
prefix:
  v: 27a
text:
  v: What is your relationship to the baby's mother?
type:
  v: open-choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7580
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7580