Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn version: versionId: id (PrimitiveType/QuestionnaireResponse.meta.versionId): element = id -> versionId=id[11]; Last updated: 2023-06-21 21:34:58+0000 LinkID Text Definition Answer QuestionnaireResponse-mothers-live-birth-jada-quinn Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate mother-current-legal-name What is your current legal name? mother-first-name First Jada mother-middle-name Middle Ann mother-last-name Last Quinn child-name What will be your baby's legal name (as it should appear on the birth certificate)? child-first-name First Baby child-middle-name Middle G child-last-name Last Quinn mother-address Where do you usually live - that is - where is your household/residence located? mother-nbr-street Complete number and street (do not enter rural route numbers) 1875 West Morton Avenue mother-city City, Town, or Location Salt Lake City mother-county County Salt Lake mother-state State (or U.S. Territory, Canadian Province) UT mother-zip Zip Code 84116 inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? expandedYes-NoIndicator Y: Yes mother-mail What is your mailing address mother-mail-same Same as residence [Go to next question] false mother-mail-nbr-street Complete number and street 1848 South 1300 East mother-mail-city City, Town, or Location Salt Lake City mother-mail-state State (or U.S. Territory, Canadian Province) UT mother-mail-zip Zip Code 84401 mother-dob What is your date of birth? 1985-01-15 mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: mother-birthplace-state State UT 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). unknown PHC1455: Doctorate Degree or Professional Degree mother-ethnicity Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. mother-shl Are you Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino mother-race What is your race? (Please check one or more races to indicate what you consider yourself to be). mother-race-category Race categories Race & Ethnicity - CDC 2106-3: White mother-detailed-race Extended race codes Race & Ethnicity - CDC 1004-1: American Indian receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? expandedYes-NoIndicator Y: Yes infertility-treatment Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b) true drugs-ai-ii If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination? false art-ivf-gift If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))? true mothers-height What is your height? mothers-height-feet Feet 5 ft (Details: UCUM codeft = 'ft') mothers-height-inches Inches 7 [in_i] (Details: UCUM code[in_i] = '[in_i]') mothers-prepregnancy-weight lbs 145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]') 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. mothers-smoking-3-months-prior Three months before pregnancy mothers-smoking-3-months-prior-cig # of cigarettes* 0 mothers-smoking-3-months-prior-pck # of packs 1 mothers-smoking-trimester-1 First three months of pregnancy mothers-smoking-trimester-1-cig # of cigarettes* 3 mothers-smoking-trimester-1-pck # of packs 0 mothers-smoking-trimester-2 Second three months of pregnancy mothers-smoking-trimester-2-cig # of cigarettes* 1 mothers-smoking-trimester-2-pck # of packs 0 mothers-smoking-trimester-3 Third trimester of pregnancy mothers-smoking-trimester-3-cig # of cigarettes* 0 mothers-smoking-trimester-3-pck # of packs 0 mother-prior-name What name did you use prior to your first marriage? mother-prior-first-name First Jada mother-prior-middle-name Middle Ann mother-prior-last-name Last King 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 father-current-legal-name What is the current legal name of your baby's father? father-first-name First James father-middle-name Middle Brandon father-last-name Last Quinn father-dob What the father's date of birth? 1983-09-27 father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: father-birthplace-state State NY 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). unknown PHC1455: Doctorate Degree or Professional Degree father-ethnicity Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. father-shl Is the father Spanish/Hispanic/Latina Race & Ethnicity - CDC 2186-5: Not Hispanic or Latino father-race What is the father's race? (Please check one or more races to indicate what he considers himself to be). father-race-category Race categories Race & Ethnicity - CDC 2106-3: White 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. mother-ssn What is your Social Security Number? 132-22-5986 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 baby-ssn Do you want a Social Security Number issued for your baby? [If yes, please sign request below false informant-name If other than the mother, what is the name of the person providing information for this worksheet? informant-first-name First Jane informant-last-name Last King informant-relationship What is your relationship to the baby's mother? unknown PHC1497: Other relative 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).
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” 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.
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).
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
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?