Out of Hospital Birth Worksheet

Nevada County Out of Hospital Birth Worksheet
Please submit completed form within two days of child’s birth to allow our office to ensure the records are registered within 21 days of birth.

Health and Safety Code Section 102400

“Each live birth shall be registered with the local registrar of births and deaths for the district in which the birth occurred within 21 days following the date of the event.”
Child's Information
Name of Child

First NameMiddle NameLast Name
Sex
Sex
This Birth
If Multiple, This Child
Date and Time of Birth

MonthDayYear
24 hour clock Minutes
Place of Birth
PLACE OF BIRTH

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Parent Married at Time of Birth?
Birth Attendant Information
Attendant's Name

First NameLast Name
License #
License #
Primary Phone Number
Phone NumberFormat: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Attendant Email Address
example@example.com
Other Parent's Information
Name

First NameMiddle NameLast Name - On Birth Certificate
Birthplace
Birthplace
Date of Birth

MonthDayYear
Social Security Number
Social Security Number
Hispanic, Latino, or Spanish
Hispanic, Latino, or Spanish
Country of Origin
Country of Origin
Race - Up to Three
Race - Up to Three
Usual Occupation
Usual Occupation
Industry
Industry
Education - Highest Level / Degree
Education - Highest Level / Degree
Address

Street Address

County

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Parent Information
Name

First NameMiddle NameLast Name - On Birth Certificate
Date of Birth

MonthDayYear
Birthplace
Birthplace
Social Security Number
Social Security Number
Hispanic, Latino, or Spanish
Hispanic, Latino, or Spanish
Country of Origin
Country of Origin
Race - Up to Three
Race - Up to Three
Usual Occupation
Usual Occupation
Industry
Industry
Education - High Level/Degree
Education - High Level/Degree
Address - Same as above?
Address

Street Address

County

CityState

Zip Code
Phone Number
Phone NumberFormat: (000) 000-0000.
Mailing Address if Different From Above
Mailing Address if Different From Above
Medical and Health Data

Birth Parent and Newborn
Did Birth Parent Receive WIC (Women Infant Children) While Pregnant with This Child?
How Many Cigarettes Did the Mother Smoke During Pregnancy?
Three Months Prior to Pregnancy: # of cigarettes Cigarettes/day OR # of packs Packs/day
First Trimester of Pregnancy: # of cigarettes Cigarettes/day OR
# of packs Packs/day
Second Trimester of Pregnancy: # of cigarettes Cigarettes/day OR
# of packs Packs/day
Third Trimester of Pregnancy: # of cigarettes Cigarettes/day OR
# of packs Packs/day
APGAR Score 00-10
At 5 Minutes
At 10 Minutes
Birth Parent Pre-Pregnancy Birth Weight
Birth Parent Pre-Pregnancy Birth Weight
Birth Parent Delivery Weight
Birth Parent Delivery Weight
Birth Parent Height
Birth Parent Height
Date last Normal Menses Began

MonthDayYear
Month Prenatal Care Began
Month Prenatal Care Began
Date First Prenatal Care Visit

MonthDayYear
Date of Last Prenatal Care Visit

MonthDayYear
Number of Prenatal Care Visits
Source of Payment for Prenatal Care
Source of Payment for Prenatal Care
Birth Weight
Grams
Weeks Pregnant at Delivery
Weeks Pregnant at Delivery
Hearing Screening
Hearing Screening
Previous Live Births

Do Not Include This Child
Number Now Living
Number Now Deceased
Date of Last Live Birth

MonthDayYear
Miscarriages

Exclude Induced Abortions
Number Less than 20 Weeks
Number Greater than 20 Weeks
Date of Last Termination

MonthDayYear
Method of Delivery
Delivery Route
Delivery Route
Previous Cesarean
Previous Cesarean
Fetal Presentation at birth
Fetal Presentation at birth
Forceps
Vacuum
Source of Payment for Delivery
Source of Payment for Delivery
Complications and Procedures of Pregnancy and Concurrent Illnesses
Diabetes
Hypertension
Other Complications/Pregnancies
Obstetric Procedures
Pregnancy Resulted from Infertility Treatment
Infections Present and/or Treated During This Pregnancy
Prenatal Screening Done for Infectious Diseases
None or Other Complications/Procedures Not Listed
Epidemics and/or Disasters
Diabetes Code
Diabetes Code
Hypertension Code
Hypertension Code
Other Complications/Pregnancies Code
Other Complications/Pregnancies Code
Obstetric Procedures Code
Obstetric Procedures Code
Pregnancy Resulted from Infertility Treatment Code
Pregnancy Resulted from Infertility Treatment Code
Infections Present and/or Treated During This Pregnancy Code
Infections Present and/or Treated During This Pregnancy Code
Prenatal Screening Done for Infectious Diseases Code
Prenatal Screening Done for Infectious Diseases Code
None or Other Complications/Procedures Not Listed Code
None or Other Complications/Procedures Not Listed Code
Epidemics and/or Disasters Code
Epidemics and/or Disasters Code
Complications and Procedures of Labor and Delivery
Onset of Labor
Characteristics of Labor and Delivery
Complications of Placenta, Cord, and Membranes
Maternal Morbidity
None or Other Complications/Procedures Not Listed
Onset of Labor Code
Onset of Labor Code
Characteristics of Labor and Delivery Code
Characteristics of Labor and Delivery Code
Complications of Placenta, Cord, and Membranes Code
Complications of Placenta, Cord, and Membranes Code
Maternal Morbidity Code
Maternal Morbidity Code
None or Other Complications/Procedures Not Listed Code
None or Other Complications/Procedures Not Listed Code
Abnormal Conditions and Clinical Procedures Relating to the Newborn or Fetus
Abnormal Conditions (Newborn or Fetus)
Congenital Anomalies (Newborn or Fetus)
Additional Abnormal Conditions/Procedures (Newborn Only)
None or Other Abnormal Conditions/Procedures
Epidemics and/or Disasters
Abnormal Conditions (Newborn or Fetus) Code
Abnormal Conditions (Newborn or Fetus) Code
Congenital Anomalies (Newborn or Fetus) Code
Congenital Anomalies (Newborn or Fetus) Code
Additional Abnormal Conditions/Procedures (Newborn Only) Code
Additional Abnormal Conditions/Procedures (Newborn Only) Code
None or Other Abnormal Conditions/Procedures Not Listed Code
None or Other Abnormal Conditions/Procedures Not Listed Code
Epidemics and/or Disasters Code
Epidemics and/or Disasters Code
ADDITIONAL INFORMATION FOR NEWBORN SCREENING FORM

Newborn Primary Care Provider Information
Pediatrician Name

FIRST NAMELAST NAME
NPI/LICENSE
NPI/LICENSE
ADDRESS – STREET, CITY, STATE, ZIP
ADDRESS – STREET, CITY, STATE, ZIP
FAX NUMBER
FAX NUMBER
Phone Number
Phone NumberFormat: (000) 000-0000.
Newborn Screening Test Performed
Date of Test

MonthDayYear
Where Test Was Done
Where Test Was Done
Confidential Information for Public Health Statistical Use Only
Should only be provided by the birth parent
Are you the genetic mother?
What sex appears on your original birth certificate?
How do you describe your gender identity?
How do you describe your gender identity?
How do you describe your sexual orientation?
How do you describe your sexual orientation?
Should only be provided by the other parent
What sex appears on your original birth certificate?
How do you describe your gender identity?
How do you describe your gender identity?
How do you describe your sexual orientation?
How do you describe your sexual orientation?
Please submit completed form within two days of child’s birth to allow our office to ensure the records are registered within 21 days of birth.

Health and Safety Code Section 102400

“Each live birth shall be registered with the local registrar of births and deaths for the district in which the birth occurred within 21 days following the date of the event.”
FOR QUESTIONS OR ASSISTANCE,

PLEASE CALL VITAL RECORDS AT: 530-265-7264 or by email: vital.records@nevadacountyca.gov
Request Information on Community Resources
If you would like any information on community resources, check the appropriate box(es) below
Informant and Birth Certification Information

Parent or Informant Information
Informant 1 Legal Name
Informant 1 Legal Name
Informant 1 Relationship to Child
Informant 1 Relationship to Child
Informant 2 Legal Name
Informant 2 Legal Name
Informant 2 Relationship to Child
Informant 2 Relationship to Child
Will attendant/certifier be available for signing within 21 days of birth?
Affidavit of Birth Information for Out-of-Hospital Births

This Affidavit is to be signed at the Local Health Office
I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the child named herein was born alive to the stated mother at the place, date, and time shown on this worksheet.

This worksheet was completed with the understanding that the facts so stated herein afford a full, complete, and truthful representation of facts and what my testimony shall be should I be asked or directed to testify to the facts herein in a court of law. I realize that any false statement of facts or information made herein could subject me to the risk of criminal liability, including, but not limited to, prosecution for perjury.
Parent Name
Parent Name
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Witness Name
Witness Name
Witness Relationship to Child
Witness Relationship to Child
Witness Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Witness Address

Street Address

County

CityState

Zip Code
Attendant Name (physician, certified nurse-midwife, or licensed midwife)
Attendant Name (physician, certified nurse-midwife, or licensed midwife)
Attendant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Attendant Address

Street Address

County

CityState

Zip Code
Attendant State License Number
Attendant State License Number
Should be Empty:

Nevada County Out of Hospital Birth Worksheet

Child's Information

Place of Birth

Birth Attendant Information

Other Parent's Information

Birth Parent Information

Medical and Health Data

How Many Cigarettes Did the Mother Smoke During Pregnancy?

APGAR Score 00-10

Previous Live Births

Miscarriages

Method of Delivery

Complications and Procedures of Pregnancy and Concurrent Illnesses

Complications and Procedures of Labor and Delivery

Abnormal Conditions and Clinical Procedures Relating to the Newborn or Fetus

ADDITIONAL INFORMATION FOR NEWBORN SCREENING FORM

Confidential Information for Public Health Statistical Use Only

Should only be provided by the birth parent

Should only be provided by the other parent

Request Information on Community Resources

Informant and Birth Certification Information

Affidavit of Birth Information for Out-of-Hospital Births