UV_Vital Records Birth and Fetal Death Reporting
1.1.0 - STU 1.1

UV_Vital Records Birth and Fetal Death Reporting, published by IHE International. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/fhir-bfdr/ and changes regularly. See the Directory of published versions

## Example QuestionnaireResponse: QuestionnaireResponse - Mother's Worksheet for Child's Birth Certificate: Jada Ann Quinn

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