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

## Vital Records Forms Mapping

This IG supports communicating information from an EHR system to the jurisdictional vital records offices and to NCHS for standard reporting forms:

Live Birth

- 2003 Revision of the U.S. Standard Certificate of Live Birth
- 2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births
- 2016 US Standard Facility Worksheet for the Live Birth Certificate
- 2016 US Standard Mother’s Worksheet for Child’s Birth Certificate

Fetal Death

- 2003 Revision of the U.S. Standard Report of Fetal Death
- 2019 US Standard Facility Worksheet for the Report of Fetal Death
- 2019 US Standard Patient’s Worksheet for the Report of Fetal Death

The following tables map the form elements to the appropriate profile or extension along with the containing specification:

- BFDR: Vital Records Birth and Fetal Death Reporting (this IG)
- VRCPL: Vital Records Common Profile Library
- US CORE: US Core Implementation Guide, 5.0.1
- ODH: Occupational Data for Health
- FHIR: extensions

The Profile/Extension column contains a link to the profile or extension that contains the specific data element. Where there are dot separated pieces in the link, the bolded part of the link is the target. The non-bolded parts of the link are for context:

- e.g. Encounter-birth.location.location.us-core-location.location.location
  - the specific data being mapped is recorded in the US Core Location profile and the link resolves to that profile
  - the US Core Location profile is referenced in the BFDR Encounter-birth profile in Encounter.location.location

The last two tables on this page map the Patient’s Worksheets to the Questionnaires.

Information on updates to the live birth and fetal death forms can be found at NVSS Revisions of the U.S. Standard Certificates and Reports and Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death

### 2003 Revision of the U.S. Standard Certificate of Live Birth Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2003 Revision of the U.S. Standard Certificate of Live Birth | Local File No. | Composition-provider-live-birth-report.extension.Extension-live-birth-local-file-number | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | Birth Number | Composition-provider-live-birth-report.extension.Extension-live-birth-certificate-number | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 1. Child’s Name | Patient-child-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 2. Child’s Time of Birth | Patient-child-vr.extension.patient-birthTime | FHIR
2003 Revision of the U.S. Standard Certificate of Live Birth | 3. Child’s Sex | Patient-child-vr.extension.us-core-birthsex | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 4. Child’s Date Of Birth | Patient-child-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 5. Facility Name / Address | Encounter-birth.location.location.us-core-location.location.location | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 6. City, Town, Or Location Of Birth | Patient-child-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Certificate of Live Birth | 7. County Of Birth | Patient-child-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Certificate of Live Birth | 8a. Mother’s Current Legal Name | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 8b. Mother’s Date Of Birth | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 8c. Mother’s Name Prior To First Marriage | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 8d. Mother’s Birthplace | Patient-child-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Certificate of Live Birth | 9a. Residence of Mother - State | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9b. Mother’s County | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9c. Mother’s City, Town, or Location | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9d. Mother’s Street And Number | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9e. Mother’s Apt. No. | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9f. Mother’s Zip Code | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 9g. Mother’s Residence Inside City Limits? | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 10a. Father’s Current Legal Name | RelatedPerson-father-natural-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 10b. Father’s Date Of Birth | RelatedPerson-father-natural-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 10c. Father’s Birthplace | Extension-relatedperson-birthplace-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 11. Certifier’s Name | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 11. Certifier’s Title | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 12. Date Certified | Encounter-birth.participant:certifier.period.start | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 13. Date Filed By Registrar | Composition-provider-live-birth-report.extension.Extension-date-filed-by-registrar | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 14. Mother’s Mailing Address | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 15. Mother Married? | Observation-mother-married-during-pregnancy | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 16. Social Security Number Requested for Child? | Observation-ssn-requested-for-child | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 17. Facility Id. | Encounter-birth.us-core-location.identifier | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 18. Mother’s Social Security Number | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 19. Father’s Social Security Number | RelatedPerson-father-natural-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 20. Mother’s Education | Observation-parent-education-level-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 21. Mother of Hispanic Origin? | Patient-child-vr.extension.us-core-ethnicity | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 22. Mother’s Race | Patient-child-vr.extension.us-core-race | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 23. Father’s Education | Observation-parent-education-level-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 24. Father of Hispanic Origin? | Patient-child-vr.extension.us-core-ethnicity | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 25. Father’s Race | Patient-child-vr.extension.us-core-race | US CORE
2003 Revision of the U.S. Standard Certificate of Live Birth | 26. Place Where Birth Occurred | Encounter-birth.location.physicalType | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 26.a. Home Birth: Planned to deliver at home? | Observation-planned-to-deliver-at-home | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 27. Attendant’s Name | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 27. Attendant’s Title | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 27. Attendant’s NPI | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 28. Mother Transferred for Maternal Medical or Fetal Indications for Delivery? | Encounter-maternity.hospitalization.admitSource (Y if present, N if not present) | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 29a. Date Of First Prenatal Care Visit | Observation-date-of-first-prenatal-care-visit | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 30. Total Number Of Prenatal Visits For This Pregnancy | Observation-number-prenatal-visits-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 31. Mother’s Height | Observation-mother-height-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 32. Mother’s Prepregnancy Weight | Observation-mother-prepregnancy-weight-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 33. Mother’s Weight At Delivery | Observation-mother-delivery-weight-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 34. Did Mother Get WIC Food For Herself During This Pregnancy? | Observation-mother-received-wic-food | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 35. Number of Previous Live Births | Observation-number-births-now-dead-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 36. Number of Other Pregnancy Outcomes | Observation-number-other-pregnancy-outcomes-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 37. Cigarette Smoking Before And During Pregnancy | Observation-cigarette-smoking-before-during-pregnancy | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 38. Principal Source of Payment for This Delivery | Coverage-principal-payer-for-delivery | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 39. Date Last Normal Menses Began | Observation-last-menstrual-period-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 40. Mother’s Medical Record Number | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.1. Risk factors in this pregnancy: Diabetes - Prepregnancy | Condition-prepregnancy-diabetes-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.2. Risk factors in this pregnancy: Diabetes - Gestational | Condition-gestational-diabetes-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.3. Risk factors in this pregnancy: Hypertension - Prepregnancy | Condition-prepregnancy-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.4. Risk factors in this pregnancy: Hypertension - Gestational | Condition-gestational-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.5. Risk factors in this pregnancy: Eclampsia | Condition-eclampsia-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.6. Risk factors in this pregnancy: Previous preterm births | Observation-previous-preterm-birth-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.8. Risk factors in this pregnancy: Pregnancy resulted from infertility treatment | Procedure-infertility-treatment-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.9. Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination | Procedure-artificial-insemination-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.10. Risk factors in this pregnancy: Assisted reproductive technology | Procedure-assisted-fertilization-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.11. Risk factors in this pregnancy: previous cesarean delivery | Observation-previous-cesarean-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 41.12. Risk factors in this pregnancy: None of the above | Observation-none-of-specified-pregnancy-risk-factors-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 42. Infections present and/or treated during this pregnancy | Condition-infection-present-during-pregnancy | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 43. Obstetric Procedures | Procedure-obstetric | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.1. Characteristics of Labor and Delivery: Induction of labor | Procedure-induction-of-labor | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.2. Characteristics of Labor and Delivery: Augmentation of labor | Procedure-augmentation-of-labor | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.4. Characteristics of Labor and Delivery: Steroids for fetal lung maturation | Observation-steroids-fetal-lung-maturation | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.5. Characteristics of Labor and Delivery: Antibiotics received by the mother during labor | Observation-antibiotics-during-labor | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.6. Characteristics of Labor and Delivery: Clinical chorioamnionitis | Condition-chorioamnionitis | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.9. Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor | Procedure-epidural-or-spinal-anesthesia | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 45.10. Characteristics of Labor and Delivery: None of the above | Observation-none-of-specified-characteristics-labor-delivery | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 46.C. Fetal presentation at birth | Observation-fetal-presentation | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 46.D. Final route and method of delivery | Procedure-final-route-method-delivery | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 46.D.1. If cesarean, was a trial of labor attempted? | Observation-labor-trial-attempted | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.1. Maternal Morbidity: Maternal transfusion | Procedure-blood-transfusion | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.2. Maternal Morbidity: Third or fourth degree perineal laceration | Condition-perineal-laceration | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.3. Maternal Morbidity: Ruptured uterus | Condition-ruptured-uterus | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.4. Maternal Morbidity: Unplanned hysterectomy | Procedure-unplanned-hysterectomy | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.5. Maternal Morbidity: Admission to intensive care unit | Observation-icu-admission | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 47.7. Maternal Morbidity: None of the above | Observation-none-of-specified-maternal-morbidities | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 48. Newborn Medical Record Number | Patient-child-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 49. Birthweight | Observation-birth-weight-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 50. Obstetric Estimate of Gestation | Observation-gestational-age-at-delivery-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 51. Apgar Score: | Observation-apgar-score-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 52. Plurality | Patient-child-vr.multipleBirth[x].extension.patient-multipleBirthTotal | FHIR
2003 Revision of the U.S. Standard Certificate of Live Birth | 53. If Not Single Birth - Born First, Second, Third, etc. (Specify) | Patient-child-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.1. Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery | Procedure-assisted-ventilation-following-delivery | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.2. Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours | Procedure-assisted-ventilation-more-than-six-hours | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.3. Abnormal Conditions of the Newborn: NICU admission | Observation-nicu-admission | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.4. Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy | Procedure-surfactant-replacement-therapy | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.5. Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis | Procedure-antibiotic-suspected-neonatal-sepsis | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction | Condition-seizure | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 54.8 Abnormal Conditions of the Newborn: None of the above | Observation-none-of-specified-abnormal-conditions-of-newborn | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 55. Congenital Anomalies of the Newborn | Condition-congenital-anomaly-of-newborn | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 56. Was Infant Transferred Within 24 Hours Of Delivery? | Encounter-birth.hospitalization.dischargeDisposition | BFDR
2003 Revision of the U.S. Standard Certificate of Live Birth | 57. Is Infant Living At Time of Report? | Observation-infant-living-vr | VRCPL
2003 Revision of the U.S. Standard Certificate of Live Birth | 58. Is The Infant Being Breastfed At Discharge? | Observation-infant-breastfed-at-discharge | BFDR

### 2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | Mother’s medical record # | Patient-mother-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | Mother’s name | Patient-mother-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | Child’s name/medical record # | Patient-child-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 9. Number of previous live births now living | Observation-number-births-now-living-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 10. Number of previous live births now dead | Observation-number-births-now-dead-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 12. Number of other pregnancy outcomes | Observation-number-other-pregnancy-outcomes-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 17. Date of birth | Patient-child-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 18. Time of birth | Patient-child-vr.birthDate.extension.patient-birthTime | FHIR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 34. Order delivered in the pregnancy | Patient-child-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.1. Characteristics of Labor and Delivery: Induction of labor | Procedure-induction-of-labor | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.2. Characteristics of Labor and Delivery: Augmentation of labor | Procedure-augmentation-of-labor | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.3.. Characteristics of Labor and Delivery: Steroids for fetal lung maturation | Observation-steroids-fetal-lung-maturation | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.4. Characteristics of Labor and Delivery: Antibiotics received by the mother during labor | Observation-antibiotics-during-labor | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.5. Characteristics of Labor and Delivery: Clinical chorioamnionitis | Condition-chorioamnionitis | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.6. Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor | Procedure-epidural-or-spinal-anesthesia | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 26.7. Characteristics of Labor and Delivery: None of the above | Observation-none-of-specified-characteristics-labor-delivery | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 27.C. Method of delivery: Fetal presentation at birth | Observation-fetal-presentation | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 27.D. Method of delivery: Final route and method of delivery | Procedure-final-route-method-delivery | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 27.D.1. If cesarean, was a trial of labor attempted? | Observation-labor-trial-attempted | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.1. Maternal Morbidity: Maternal transfusion | Procedure-blood-transfusion | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.2. Maternal Morbidity: Third or fourth degree perineal laceration | Condition-perineal-laceration | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.3. Maternal Morbidity: Ruptured uterus | Condition-ruptured-uterus | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.4. Maternal Morbidity: Unplanned hysterectomy | Procedure-unplanned-hysterectomy | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.5. Maternal Morbidity: Admission to intensive care unit | Observation-icu-admission | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 28.6. Maternal Morbidity: None of the above | Observation-none-of-specified-maternal-morbidities | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 29. Birthweight | Observation-birth-weight-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 30. Obstetric estimate of gestation at delivery | Observation-gestational-age-at-delivery-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 31. Sex | Patient-child-vr.extension.us-core-birthsex | US CORE
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 32. Apgar score | Observation-apgar-score-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.1. Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery | Procedure-assisted-ventilation-following-delivery | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.2. Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours | Procedure-assisted-ventilation-more-than-six-hours | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.3. Abnormal Conditions of the Newborn: NICU admission | Observation-nicu-admission | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.4. Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy | Procedure-surfactant-replacement-therapy | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.5. Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis | Procedure-antibiotic-suspected-neonatal-sepsis | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction | Condition-seizure | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 36.7 Abnormal Conditions of the Newborn: None of the above | Observation-none-of-specified-abnormal-conditions-of-newborn | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 37. Congenital anomalies of the newborn | Condition-congenital-anomaly-of-newborn | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 38. Was infant transferred within 24 hours of delivery? | Encounter-birth.hospitalization.dischargeDisposition | BFDR
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 39. Is infant living at time of report? | Observation-infant-living-vr | VRCPL
2016 US Standard Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births | 40. Is infant being breastfed at discharge? | Observation-infant-breastfed-at-discharge | BFDR

### 2016 US Standard Facility Worksheet for the Live Birth Certificate Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2016 US Standard Facility Worksheet for the Live Birth Certificate | Mother’s medical record # | Patient-mother-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | Mother’s name | Patient-mother-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 1. Facility name / address | Encounter-birth.us-core-location.name/address | US CORE
2016 US Standard Facility Worksheet for the Live Birth Certificate | 2. Facility I.D. | Encounter-birth.us-core-location.identifier | US CORE
2016 US Standard Facility Worksheet for the Live Birth Certificate | 3. City, Town or Location of birth | Patient-child-vr.extension.patient-birthPlace | FHIR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 4. County of birth | Patient-child-vr.extension.patient-birthPlace | FHIR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 5. Place where birth occurred | Encounter-birth.location.physicalType | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 5.a. Home Birth: Planned to deliver at home? | Observation-planned-to-deliver-at-home | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 6. Date of first prenatal care visit | Observation-date-of-first-prenatal-care-visit | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 7. Total number of prenatal care visits for this pregnancy | Observation-number-prenatal-visits-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 8. Date last normal menses began | Observation-last-menstrual-period-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 9. Number of previous live births now living | Observation-number-births-now-living-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 10. Number of previous live births now dead | Observation-number-births-now-dead-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 11. Date of last live birth | Observation-date-of-last-live-birth | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 12. Number of other pregnancy outcomes | Observation-number-other-pregnancy-outcomes-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 13. Date of last other pregnancy outcome | Observation-date-of-last-other-pregnancy-outcome | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.1. Risk factors in this pregnancy: Diabetes - Prepregnancy | Condition-prepregnancy-diabetes-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.2. Risk factors in this pregnancy: Diabetes - Gestational | Condition-gestational-diabetes-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.3. Risk factors in this pregnancy: Hypertension - Prepregnancy | Condition-prepregnancy-hypertension-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.4. Risk factors in this pregnancy: Hypertension - Gestational | Condition-gestational-hypertension-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.5. Risk factors in this pregnancy: Eclampsia | Condition-eclampsia-hypertension-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.6. Risk factors in this pregnancy: Previous preterm births | Observation-previous-preterm-birth-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.7. Risk factors in this pregnancy: Pregnancy resulted from infertility treatment | Procedure-infertility-treatment-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.8. Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination | Procedure-artificial-insemination-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.9. Risk factors in this pregnancy: Assisted reproductive technology | Procedure-assisted-fertilization-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.10. Risk factors in this pregnancy: previous cesarean delivery | Observation-previous-cesarean-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 14.11. Risk factors in this pregnancy: None of the above | Observation-none-of-specified-pregnancy-risk-factors-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 15. Infections present and/or treated during this pregnancy | Condition-infection-present-during-pregnancy | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 16. Obstetric procedures | Procedure-obstetric | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 17. Date of birth | Patient-child-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 18. Time of birth | Patient-child-vr.birthDate.extension.patient-birthTime | FHIR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 19. Certifier’s name | Practitioner-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 19. Certifier’s title | Practitioner-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 20. Date certified | Encounter-birth.participant:certifier.period.start | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 21. Principal source of payment for this delivery | Coverage-principal-payer-for-delivery | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 22. Infant’s medical record number | Patient-child-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 23. Was the mother transferred to this facility for maternal medical or fetal indications for delivery? | Encounter-maternity.hospitalization.admitSource (Y if present, N if not present) | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 24. Attendant’s name | Practitioner-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 24. Attendant’s title | Practitioner-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 24. Attendant’s N.P.I. | Practitioner-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 25. Mother’s weight at delivery | Observation-mother-delivery-weight-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.1. Characteristics of Labor and Delivery: Induction of labor | Procedure-induction-of-labor | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.2. Characteristics of Labor and Delivery: Augmentation of labor | Procedure-augmentation-of-labor | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.3. Characteristics of Labor and Delivery: Steroids for fetal lung maturation | Observation-steroids-fetal-lung-maturation | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.4. Characteristics of Labor and Delivery: Antibiotics received by the mother during labor | Observation-antibiotics-during-labor | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.5. Characteristics of Labor and Delivery: Clinical chorioamnionitis | Condition-chorioamnionitis | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.6. Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor | Procedure-epidural-or-spinal-anesthesia | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 26.7. Characteristics of Labor and Delivery: None of the above | Observation-none-of-specified-characteristics-labor-delivery | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 27.C. Method of delivery: Fetal presentation at birth | Observation-fetal-presentation | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 27.D. Method of delivery: Final route and method of delivery | Procedure-final-route-method-delivery | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 27.D.1. Method of delivery: If cesarean, was a trial of labor attempted? | Observation-labor-trial-attempted | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.1. Maternal Morbidity: Maternal transfusion | Procedure-blood-transfusion | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.2. Maternal Morbidity: Third or fourth degree perineal laceration | Condition-perineal-laceration | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.3. Maternal Morbidity: Ruptured uterus | Condition-ruptured-uterus | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.4. Maternal Morbidity: Unplanned hysterectomy | Procedure-unplanned-hysterectomy | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.5. Maternal Morbidity: Admission to intensive care unit | Observation-icu-admission | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 28.6. Maternal Morbidity: None of the above | Observation-none-of-specified-maternal-morbidities | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 29. Birthweight | Observation-birth-weight-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 30. Obstetric estimate of gestation at delivery | Observation-gestational-age-at-delivery-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 31. Sex: | Patient-child-vr.extension.us-core-birthsex | US CORE
2016 US Standard Facility Worksheet for the Live Birth Certificate | 32. Apgar score | Observation-apgar-score-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 33. Plurality | Patient-child-vr.multipleBirthInteger.extension.patient-multipleBirthTotal | FHIR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 34. If not single birth, order delivered in the pregnancy | Patient-child-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 35. If not single birth, specify number of infants in this delivery born alive: | Observation-number-live-births-this-delivery-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.1. Abnormal Conditions of the Newborn: Assisted ventilation required immediately following delivery | Procedure-assisted-ventilation-following-delivery | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.2. Abnormal Conditions of the Newborn: Assisted ventilation required for more than six hours | Procedure-assisted-ventilation-more-than-six-hours | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.3. Abnormal Conditions of the Newborn: NICU admission | Observation-nicu-admission | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.4. Abnormal Conditions of the Newborn: Newborn given surfactant replacement therapy | Procedure-surfactant-replacement-therapy | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.5. Abnormal Conditions of the Newborn: Antibiotics received by the newborn for suspected neonatal sepsis | Procedure-antibiotic-suspected-neonatal-sepsis | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 36.6 Abnormal Conditions of the Newborn: Seizure or serious neurologic dysfunction | Condition-seizure | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 54.7 Abnormal Conditions of the Newborn: None of the above | Observation-none-of-specified-abnormal-conditions-of-newborn | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 37. Congenital anomalies of the newborn | Condition-congenital-anomaly-of-newborn | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 38. Was infant transferred within 24 hours of delivery? | Encounter-birth.hospitalization.dischargeDisposition | BFDR
2016 US Standard Facility Worksheet for the Live Birth Certificate | 39. Is infant living at time of report? | Observation-infant-living-vr | VRCPL
2016 US Standard Facility Worksheet for the Live Birth Certificate | 40. Is infant being breastfed at discharge? | Observation-infant-breastfed-at-discharge | BFDR

### 2016 US Standard Mother’s Worksheet for Child’s Birth Certificate Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 1. What is your current legal name? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 2. What will be your baby’s legal name? | Patient-child-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 3. Where do you usually live–that is–where is your household/residence located? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 4. Is this household inside city limits? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 5. What is your mailing address? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 6. What is your date of birth? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 7. In what State, U.S. territory, or foreign country were you born? | Patient-mother-vr.extension.patient-birthPlace | FHIR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 8. What is the highest level of schooling that you will have completed at the time of delivery? | Observation-parent-education-level-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 9. Are you Spanish/Hispanic/Latina? | Patient-mother-vr.extension.us-core-ethnicity | US CORE
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 10. What is your race? | Patient-mother-vr.extension.us-core-race | US CORE
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 11. Did you receive WIC food for yourself because you were pregnant with this child? | Observation-mother-received-wic-food | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 12. Did this pregnancy result from infertility treatment? | Questionnaire-mothers-live-birth | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 13. What is your height? | Observation-mother-height-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 14. What was your prepregnancy weight, that is, your weight immediately before you became pregnant with this child? | Observation-mother-prepregnancy-weight-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 15. How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? | Observation-cigarette-smoking-before-during-pregnancy | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 17. What name did you use prior to your first marriage? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 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? | Observation-mother-married-during-pregnancy | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 19. What is the current legal name of your baby’s father? | RelatedPerson-father-natural-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 20. What is the father’s date of birth? | RelatedPerson-father-natural-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 21. In what State, U.S. territory, or foreign country was the father born? | Extension-relatedperson-birthplace-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 22. What is the highest level of schooling that the father will have completed at the time of delivery? | Observation-parent-education-level-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 23. Is the father Spanish/Hispanic/Latino? | RelatedPerson-father-natural-vr.extension.us-core-ethnicity | US CORE
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 24. What is the father’s race? | RelatedPerson-father-natural-vr.extension.us-core-race | US CORE
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 25a. What is your Social Security Number? | Patient-mother-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 25b. What is the father’s Social Security Number? | RelatedPerson-father-natural-vr | VRCPL
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 26a. Do you want a Social Security Number issued for your baby? | Observation-ssn-requested-for-child | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 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. | Questionnaire-mothers-live-birth | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 27a. If other than the mother, what is the name of the person providing information for this worksheet? | Questionnaire-mothers-live-birth | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 27b. What is your relationship to the baby’s mother? | Questionnaire-mothers-live-birth | BFDR

### 2003 Revision of the U.S. Standard Report of Fetal Death Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2003 Revision of the U.S. Standard Report of Fetal Death | Local File No. | Composition-provider-fetal-death-report.extension.Extension-fetal-death-local-file-number | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | State File Number | Composition-provider-fetal-death-report.extension.Extension-fetal-death-report-number | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 1. Name of Fetus | Patient-decedent-fetus-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 2. Time of Delivery | Patient-decedent-fetus-vr.birthDate.extension.patient-birthTime | FHIR
2003 Revision of the U.S. Standard Report of Fetal Death | 3. Sex | Patient-decedent-fetus-vr.extension.us-core-birthsex | US CORE
2003 Revision of the U.S. Standard Report of Fetal Death | 4. Date of Delivery | Patient-decedent-fetus-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 5a. City, Town, or Location of Delivery | Patient-decedent-fetus-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Report of Fetal Death | 5b. Zip Code of Delivery | Patient-decedent-fetus-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Report of Fetal Death | 6. County of Delivery | Patient-decedent-fetus-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Report of Fetal Death | 7. Place Where Delivery Occurred | Encounter-maternity.location.physicalType | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 7.a. Home Birth: Planned to deliver at home? | Observation-planned-to-deliver-at-home | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 8. Facility Name / address | Encounter-maternity.location.location.us-core-location.identifier | US CORE
2003 Revision of the U.S. Standard Report of Fetal Death | 9. Facility Id | Encounter-maternity.location.location.us-core-location.identifier | US CORE
2003 Revision of the U.S. Standard Report of Fetal Death | 10a. Mother’s Current Legal Name | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 10b. Mother’s Date of Birth | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 10c. Mother’s Name Prior to First Marriage | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 10d. Mother’s Birthplace | Patient-mother-vr.extension.patient-birthPlace | FHIR
2003 Revision of the U.S. Standard Report of Fetal Death | 11a. Residence of Mother-State | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11b. Residence of Mother-County | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11c. Residence of Mother-City, Town, Or Location | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11d. Residence of Mother-Street And Number | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11e. Residence of Mother-Apt. No. | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11f. Residence of Mother-Zip Code | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 11g. Residence of Mother-Inside City Limits? | Patient-mother-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 12a. Father’s Current Legal Name | RelatedPerson-father-natural-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 12b. Father’s Date of Birth | RelatedPerson-father-natural-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 12c. Father’s Birthplace | Extension-relatedperson-birthplace-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 13. Method of Disposition: | Observation-method-of-disposition | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 14. Attendant’s Name | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 14. Attendant’s Title | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 14. Attendant’s NPI | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 15. Name Of Person Completing Report | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 15. Title Of Person Completing Report | Practitioner-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 16. Date Report Completed | Composition-provider-fetal-death-report.date | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 17. Date Received By Registrar | Composition-provider-fetal-death-report.extension.Extension-date-received-by-registrar | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 18a. Initiating Cause/Condition | Condition-fetal-death-cause-or-condition | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 18b. Other Significant Causes or Conditions | Condition-fetal-death-other-cause-or-condition | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 18c. Weight of Fetus | Observation-birth-weight-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 18d. Obstetric Estimate of Gestation at Delivery | Observation-gestational-age-at-delivery-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 18e. Estimated Time of Fetal Death | Observation-estimated-fetal-death-time-point | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 18f. Was an Autopsy Performed? | Observation-autopsy-performed-indicator-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 18g. Was a Histological Placental Examination Performed? | Observation-histological-placental-exam-performed | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 18h. Were Autopsy or Histological Placental Examination Results Used in Determining the Cause of Fetal Death? | Observation-autopsy-histological-exam-results-used | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 19. Mother’s Education | Observation-parent-education-level-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 20. Mother of Hispanic Origin? | Patient-mother-vr.extension.us-core-ethnicity | US CORE
2003 Revision of the U.S. Standard Report of Fetal Death | 21. Mother’s Race | Patient-mother-vr.extension.us-core-race | US CORE
2003 Revision of the U.S. Standard Report of Fetal Death | 22. Mother Married? | Observation-mother-married-during-pregnancy | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 23a. Date of First Prenatal Care Visit | Observation-date-of-first-prenatal-care-visit | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 24. Total Number of Prenatal Visits For This Pregnancy | Observation-number-prenatal-visits-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 25. Mother’s Height | Observation-mother-height-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 26. Mother’s Prepregnancy Weight | Observation-mother-prepregnancy-weight-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 28. Did Mother Get WIC Food For Herself During This Pregnancy? | Observation-mother-received-wic-food | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 29a. Number of Previous Live Births: Now Living Number | Observation-number-births-now-living-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 29b. Number of Previous Live Births: Now Dead Number | Observation-number-births-now-dead-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 29c. Date of Last Live Birth | Observation-date-of-last-live-birth | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 31. Cigarette Smoking Before and During Pregnancy | Observation-cigarette-smoking-before-during-pregnancy | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 32. Date Last Normal Menses Began | Observation-last-menstrual-period-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 33. Plurality | Observation-plurality-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 34. If Not Single Birth-Born First, Second, Third, etc. | Patient-decedent-fetus-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.1. Risk factors in this pregnancy: Diabetes - Prepregnancy | Condition-prepregnancy-diabetes-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.2. Risk factors in this pregnancy: Diabetes - Gestational | Condition-gestational-diabetes-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.3. Risk factors in this pregnancy: Hypertension - Prepregnancy | Condition-prepregnancy-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.4. Risk factors in this pregnancy: Hypertension - Gestational | Condition-gestational-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.5. Risk factors in this pregnancy: Eclampsia | Condition-eclampsia-hypertension-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.8. Risk factors in this pregnancy: Pregnancy resulted from infertility treatment | Procedure-infertility-treatment-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.9. Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination | Procedure-artificial-insemination-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.10. Risk factors in this pregnancy: Assisted reproductive technology | Procedure-assisted-fertilization-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.11. Risk factors in this pregnancy: Previous cesarean delivery | Observation-previous-cesarean-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 36.12. Risk factors in this pregnancy: None of the above | Observation-none-of-specified-pregnancy-risk-factors-vr | VRCPL
2003 Revision of the U.S. Standard Report of Fetal Death | 38.C. Method of Delivery: Fetal presentation at delivery | Observation-fetal-presentation | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 38.D. Method of Delivery: Final route and method of delivery | Procedure-final-route-method-delivery | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 38.D.1. Method of Delivery: If cesarean, was a trial of labor attempted? | Observation-labor-trial-attempted | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 39.3. Maternal Morbidity: Ruptured uterus | Condition-ruptured-uterus | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 39.5. Maternal Morbidity: Admission to intensive care unit | Observation-icu-admission | BFDR
2003 Revision of the U.S. Standard Report of Fetal Death | 39.7. Maternal Morbidity: None of the above | Observation-none-of-specified-maternal-morbidities | BFDR

### 2019 US Standard Facility Worksheet for the Report of Fetal Death Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2019 US Standard Facility Worksheet for the Report of Fetal Death | Patient’s medical record # | Patient-mother-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | Patient’s name | Patient-mother-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 1. Facility name | Encounter-maternity.location.location.us-core-location.name | US CORE
2019 US Standard Facility Worksheet for the Report of Fetal Death | 1. Facility address | Encounter-maternity.location.location.us-core-location.address | US CORE
2019 US Standard Facility Worksheet for the Report of Fetal Death | 2. Facility I.D. (National Provider Identifier) | Encounter-maternity.location.location.us-core-location.identifier | US CORE
2019 US Standard Facility Worksheet for the Report of Fetal Death | 3. City, Town or Location of delivery | Patient-decedent-fetus-vr.extension.patient-birthPlace | FHIR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 4. County of delivery | Patient-decedent-fetus-vr.extension.patient-birthPlace | FHIR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 5. Place of delivery | Encounter-maternity.location.physicalType | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 5.a. Planned to deliver at home | Observation-planned-to-deliver-at-home | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 6. Date of first prenatal care visit | Observation-date-of-first-prenatal-care-visit | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 7. Date last normal menses began: | Observation-last-menstrual-period-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 8. Number of previous live births now living | Observation-number-births-now-living-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 9. Number of previous live births now dead | Observation-number-births-now-dead-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 10. Date of last live birth | Observation-date-of-last-live-birth | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.1. Risk factors in this pregnancy: Diabetes - Prepregnancy | Condition-prepregnancy-diabetes-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.2. Risk factors in this pregnancy: Diabetes - Gestational | Condition-gestational-diabetes-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.3. Risk factors in this pregnancy: Hypertension - Prepregnancy | Condition-prepregnancy-hypertension-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.4. Risk factors in this pregnancy: Hypertension - Gestational | Condition-gestational-hypertension-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.5. Risk factors in this pregnancy: Eclampsia | Condition-eclampsia-hypertension-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.6. Risk factors in this pregnancy: Pregnancy resulted from infertility treatment | Procedure-infertility-treatment-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.7. Risk factors in this pregnancy: Fertility-enhancing drugs, artificial insemination or intrauterine insemination | Procedure-artificial-insemination-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.8. Risk factors in this pregnancy: Assisted reproductive technology | Procedure-assisted-fertilization-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.9. Risk factors in this pregnancy: previous cesarean delivery | Observation-previous-cesarean-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 11.10. Risk factors in this pregnancy: None of the above | Observation-none-of-specified-pregnancy-risk-factors-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 12. Date of delivery | Patient-decedent-fetus-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 13. Time of delivery | Patient-decedent-fetus-vr.extension.patient-birthTime | FHIR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 14. Name of person completing report | Practitioner-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 14. Title of person completing report | Practitioner-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 15. Date report completed | Composition-provider-fetal-death-report.date | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 16. Attendant’s name | Practitioner-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 16. Attendant’s title | Practitioner-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 16. Attendant’s N.P.I. | Practitioner-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 17.A. Method of Delivery: Fetal presentation at delivery | Observation-fetal-presentation | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 17.B. Method of Delivery: Final route and method of delivery | Procedure-final-route-method-delivery | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 18.1. Maternal Morbidity: Ruptured uterus | Condition-ruptured-uterus | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 18.2. Maternal Morbidity: Admission to intensive care unit | Observation-icu-admission | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 18.3. Maternal Morbidity: None of the above | Observation-none-of-specified-maternal-morbidities | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 19. Weight of fetus | Observation-birth-weight-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 20. Obstetric estimate of gestation at delivery | Observation-gestational-age-at-delivery-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 21. Sex | Patient-decedent-fetus-vr.extension.us-core-birthsex | US CORE
2019 US Standard Facility Worksheet for the Report of Fetal Death | 22. Plurality | Patient-decedent-fetus-vr.multipleBirth[x].extension.patient-multipleBirthTotal | FHIR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 23. If not single delivery, order delivered in the pregnancy | Patient-decedent-fetus-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 24. If not single delivery, specify number of fetal losses in this delivery | Observation-number-fetal-deaths-this-delivery-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 25. Method of Disposition | Observation-method-of-disposition | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 26. Initiating Cause/Condition | Condition-fetal-death-cause-or-condition | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 27. Other Significant Causes or Conditions | Condition-fetal-death-other-cause-or-condition | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 28. Was an autopsy performed? | Observation-autopsy-performed-indicator-vr | VRCPL
2019 US Standard Facility Worksheet for the Report of Fetal Death | 29. Was a histological placental examination performed? | Observation-histological-placental-exam-performed | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 30. Were autopsy or histological placental examination results used in determining the cause of fetal death? | Observation-autopsy-histological-exam-results-used | BFDR
2019 US Standard Facility Worksheet for the Report of Fetal Death | 31. Estimated time of fetal death | Observation-estimated-fetal-death-time-point | BFDR

### 2019 US Standard Patient’s Worksheet for the Report of Fetal Death Mapping

Form | Element | Profile/Extension | Location
--- | --- | --- | ---
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | Patient’s Medical Record # | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | Patient’s Name | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 1. Would you like to name the child? | Patient-decedent-fetus-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 2. What is your current legal name? | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 3. Where do you usually live (household/residence location)? | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 4. Is this household inside city limits? | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 5. What is your mailing address? | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 6. What is your date of birth? | Patient-mother-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 7. In what State, U.S. territory, or foreign country were you born? | Patient-mother-vr.extension.patient-birthPlace | FHIR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 8. What is the highest level of schooling that you have completed at the time of delivery? | Observation-parent-education-level-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 9. Are you Spanish/Hispanic/Latina? | Patient-mother-vr.extension.us-core-ethnicity | US CORE
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 10. What is your race? | Patient-mother-vr.extension.us-core-race | US CORE
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 11. What is the current legal name of your baby’s father? | RelatedPerson-father-natural-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 12. What is the father’s date of birth? | RelatedPerson-father-natural-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 13. In what State, U.S. territory, or foreign country was the father born? | Extension-relatedperson-birthplace-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 14. Did you receive WIC (Women, Infants & Children) food for yourself during this pregnancy? | Observation-mother-received-wic-food | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 15. What is your height? | Observation-mother-height-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 16. What was your prepregnancy weight? | Observation-mother-prepregnancy-weight-vr | VRCPL
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 17. How many cigarettes OR packs of cigarettes did you smoke on an average day during each time period? | Observation-cigarette-smoking-before-during-pregnancy | BFDR

### 2016 US Standard Mother’s Worksheet for Child’s Birth Certificate Questionnaire Mapping

Form | Element | Questionnaire | Location
--- | --- | --- | ---
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 1. What is your current legal name? | Questionnaire-mothers-live-birth.item.linkId=mother-current-legal-name | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 2. What will be your baby’s legal name? | Questionnaire-mothers-live-birth.item.linkId=child-name | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 3. Where do you usually live–that is–where is your household/residence located? | Questionnaire-mothers-live-birth.item.linkId=mother-address | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 4. Is this household inside city limits? | Questionnaire-mothers-live-birth.item.linkId=inside-city-limits | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 5. What is your mailing address? | Questionnaire-mothers-live-birth.item.linkId=mother-mail | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 6. What is your date of birth? | Questionnaire-mothers-live-birth.item.linkId=mother-dob | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 7. In what State, U.S. territory, or foreign country were you born? | Questionnaire-mothers-live-birth.item.linkId=mother-birthplace | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 8. What is the highest level of schooling that you will have completed at the time of delivery? | Questionnaire-mothers-live-birth.item.linkId=mother-education | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 9. Are you Spanish/Hispanic/Latina? | Questionnaire-mothers-live-birth.item.linkId=mother-ethnicity | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 10. What is your race? | Questionnaire-mothers-live-birth.item.linkId=mother-race | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 11. Did you receive WIC food for yourself because you were pregnant with this child? | Questionnaire-mothers-live-birth.item.linkId=receive-wic | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 12. Did this pregnancy result from infertility treatment? | Questionnaire-mothers-live-birth.item.linkId=infertility-treatment | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 13. What is your height? | Questionnaire-mothers-live-birth.item.linkId=mothers-height | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 14. What was your prepregnancy weight, that is, your weight immediately before you became pregnant with this child? | Questionnaire-mothers-live-birth.item.linkId=mothers-prepregnancy-weight | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 15. How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? | Questionnaire-mothers-live-birth.item.linkId=mothers-smoking | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 17. What name did you use prior to your first marriage? | Questionnaire-mothers-live-birth.item.linkId=mother-prior-name | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 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? | Questionnaire-mothers-live-birth.item.linkId=married-conception | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 19. What is the current legal name of your baby’s father? | Questionnaire-mothers-live-birth.item.linkId=father-current-legal-name | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 20. What is the father’s date of birth? | Questionnaire-mothers-live-birth.item.linkId=father-dob | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 21. In what State, U.S. territory, or foreign country was the father born? | Questionnaire-mothers-live-birth.item.linkId=father-birthplace | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 22. What is the highest level of schooling that the father will have completed at the time of delivery? | Questionnaire-mothers-live-birth.item.linkId=father-education | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 23. Is the father Spanish/Hispanic/Latino? | Questionnaire-mothers-live-birth.item.linkId=father-ethnicity | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 24. What is the father’s race? | Questionnaire-mothers-live-birth.item.linkId=father-race | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 25a. What is your Social Security Number? | Questionnaire-mothers-live-birth.item.linkId=mother-ssn | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 25b. What is the father’s Social Security Number? | Questionnaire-mothers-live-birth.item.linkId=father-ssn | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 26a. Do you want a Social Security Number issued for your baby? | Questionnaire-mothers-live-birth.item.linkId=baby-ssn | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 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. | Questionnaire-mothers-live-birth.item.linkId=baby-ssn-sig | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 27a. If other than the mother, what is the name of the person providing information for this worksheet? | Questionnaire-mothers-live-birth.item.linkId=informant-name | BFDR
2016 US Standard Mother’s Worksheet for Child’s Birth Certificate | 27b. What is your relationship to the baby’s mother? | Questionnaire-mothers-live-birth.item.linkId=informant-relationship | BFDR

### 2019 US Standard Patient’s Worksheet for the Report of Fetal Death Questionnaire Mapping

Form | Element | Questionnaire | Location
--- | --- | --- | ---
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | Patient’s Medical Record # | Questionnaire-patients-fetal-death.source | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | Patient’s Name | Questionnaire-patients-fetal-death.source | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 1. Would you like to name the child? | Questionnaire-patients-fetal-death.item.linkId=child-name | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 2. What is your current legal name? | Questionnaire-patients-fetal-death.item.linkId=mother-current-legal-name | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 3. Where do you usually live (household/residence location)? | Questionnaire-patients-fetal-death.item.linkId=mother-address | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 4. Is this household inside city limits? | Questionnaire-patients-fetal-death.item.linkId=inside-city-limits | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 5. What is your mailing address? | Questionnaire-patients-fetal-death.item.linkId=mother-mail | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 6. What is your date of birth? | Questionnaire-patients-fetal-death.item.linkId=mother-dob | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 7. In what State, U.S. territory, or foreign country were you born? | Questionnaire-patients-fetal-death.item.linkId=mother-birthplace | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 8. What is the highest level of schooling that you have completed at the time of delivery? | Questionnaire-patients-fetal-death.item.linkId=mother-education | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 9. Are you Spanish/Hispanic/Latina? | Questionnaire-patients-fetal-death.item.linkId=mother-ethnicity | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 10. What is your race? | Questionnaire-patients-fetal-death.item.linkId=mother-race | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 11. What is the current legal name of your baby’s father? | Questionnaire-patients-fetal-death.item.linkId=father-current-legal-name | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 12. What is the father’s date of birth? | Questionnaire-patients-fetal-death.item.linkId=father-dob | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 13. In what State, U.S. territory, or foreign country was the father born? | Questionnaire-patients-fetal-death.item.linkId=father-birthplace | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 14. Did you receive WIC (Women, Infants & Children) food for yourself during this pregnancy? | Questionnaire-patients-fetal-death.item.linkId=receive-wic | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 15. What is your height? | Questionnaire-patients-fetal-death.item.linkId=mothers-height | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 16. What was your prepregnancy weight? | Questionnaire-patients-fetal-death.item.linkId=mothers-prepregnancy-weight | BFDR
2019 US Standard Patient’s Worksheet for the Report of Fetal Death | 17. How many cigarettes OR packs of cigarettes did you smoke on an average day during each time period? | Questionnaire-patients-fetal-death.item.linkId=mothers-smoking | BFDR