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 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 mother-suffix Suffix (Jr., III, etc.) 0..1 string child-name 2. What will be your baby's legal name (as it should appear on the birth certificate)? 0..1 group child-first-name First 0..1 string child-middle-name Middle 0..1 string child-last-name Last 0..1 string child-suffix Suffix (Jr., III, etc.) 0..1 string mother-address 3. Where do you usually live - that is - where is your household/residence located? 0..1 group mother-nbr-street Complete number and street (do not enter rural route numbers) 0..1 string mother-apt-nbr Apartment Number 0..1 string mother-city City, Town, or Location 0..1 string mother-county County 0..1 string mother-state State (or U.S. Territory, Canadian Province) 0..1 string mother-zip Zip Code 0..1 string mother-country If not in the United States, country 0..1 string 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: Yes No Unknown (YNU) mother-mail 5. What is your mailing address 0..1 group mother-mail-same Same as residence [Go to next question] 0..1 boolean mother-mail-nbr-street Complete number and street 0..1 string Enable When: mother-mail-same = mother-mail-apt-nbr Apartment Number 0..1 string Enable When: mother-mail-same = mother-mail-po-box P.O. Box 0..1 string Enable When: mother-mail-same = mother-mail-city City, Town, or Location 0..1 string Enable When: mother-mail-same = mother-mail-state State (or U.S. Territory, Canadian Province) 0..1 string Enable When: mother-mail-same = mother-mail-zip Zip Code 0..1 string Enable When: mother-mail-same = mother-mail-country If not in the United States, country 0..1 string Enable When: mother-mail-same = mother-dob 6. What is your date of birth? 0..1 date mother-birthplace 7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following: 0..1 group mother-birthplace-state State 0..1 string mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 string mother-birthplace-country or Foreign country 0..1 string 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: Vital Records Education Level (NCHS) mother-ethnicity 9. Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. 0..1 group mother-shl Are you Spanish/Hispanic/Latina 0..* choice Value Set: OMB Ethnicity Categories mother-detailed-shl If Spanish/Hispanic/Latina, check the appropriate box. 0..1 choice Enable When: mother-shl = Value Set: Detailed ethnicity mother-race 10. What is your race? (Please check one or more races to indicate what you consider yourself to be). 0..1 group mother-race-category Race categories 0..* choice Value Set: OMB Race Categories mother-detailed-race Extended race codes 0..* choice Value Set: Detailed Race 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: Yes No Unknown (YNU) infertility-treatment 12. Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) 0..1 boolean drugs-ai-ii 12a. If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? 0..1 boolean art-ivf-gift 12b. If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? 0..1 boolean mothers-height 13. What is your height? 0..1 group mothers-height-feet Feet 0..1 quantity mothers-height-inches Inches 0..1 quantity mothers-prepregnancy-weight 14. lbs 0..1 quantity 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 mothers-smoking-3-months-prior Three months before pregnancy 0..1 group mothers-smoking-3-months-prior-cig # of cigarettes* 0..1 integer mothers-smoking-3-months-prior-pck # of packs 0..1 integer mothers-smoking-trimester-1 First three months of pregnancy 0..1 group mothers-smoking-trimester-1-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-1-pck # of packs 0..1 integer mothers-smoking-trimester-2 Second three months of pregnancy 0..1 group mothers-smoking-trimester-2-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-2-pck # of packs 0..1 integer mothers-smoking-trimester-3 Third trimester of pregnancy 0..1 group mothers-smoking-trimester-3-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-3-pck # of packs 0..1 integer cigarette-note *refers to tobacco products only, NOT e-cigarettes. 0..1 display mother-ever-married 16. Question 'Have you ever been married?' removed. 0..1 display mother-prior-name 17. What name did you use prior to your first marriage? 0..1 group mother-prior-first-name First 0..1 string mother-prior-middle-name Middle 0..1 string mother-prior-last-name Last 0..1 string mother-prior-suffix Suffix (Jr., III, etc.) 0..1 string 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 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 = father-current-legal-name 19. What is the current legal name of your baby's father? 0..1 group father-first-name First 0..1 string father-middle-name Middle 0..1 string father-last-name Last 0..1 string father-suffix Suffix (Jr., III, etc.) 0..1 string father-dob 20. What the father's date of birth? 0..1 date 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 father-birthplace-state State 0..1 string father-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 string father-birthplace-country or Foreign country 0..1 string 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: Vital Records Education Level (NCHS) father-ethnicity 23. Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. 0..1 group father-shl Is the father Spanish/Hispanic/Latina 0..* choice Value Set: Ethnicity father-detailed-shl If Spanish/Hispanic/Latina, check the appropriate box. 0..1 choice Enable When: father-shl = Value Set: Detailed Ethnicity 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 father-race-category Race categories 0..* choice Value Set: OMB Race Categories father-detailed-race Extended race codes 0..* choice Value Set: Race Value Set 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 mother-ssn 25a. What is your Social Security Number? 0..1 string 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 baby-ssn 26a. Do you want a Social Security Number issued for your baby? [If yes, please sign request below 0..1 boolean 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 baby-ssn-sig-parent Signature of infant's mother or father 0..1 attachment baby-ssn-sig-date Date 0..1 date informant-note If you are the Mother, please STOP here. If other than the mother please answer the following questions: 0..1 display informant-name 27a. If other than the mother, what is the name of the person providing information for this worksheet? 0..1 group informant-first-name First 0..1 string informant-middle-name Middle 0..1 string informant-last-name Last 0..1 string informant-suffix Suffix (Jr., III, etc.) 0..1 string informant-relationship 27a. What is your relationship to the baby's mother? 0..1 open-choice Value Set: Informant Relationship to Mother (NCHS) Documentation for this format
Questionnaire - Mother's Worksheet for Child's Birth Certificate
IHE Quality, Research and Public Health Committee
This Questionnaire represents the [Mother's Worksheet for Child's Birth Certificate](https://www.cdc.gov/nchs/data/dvs/moms-worksheet-2016-508.pdf).
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 Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
If Spanish/Hispanic/Latina, check the appropriate box.
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))?
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 Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
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?