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*
This Birth*

SingleTwinTriplet
If Multiple, This Child

1st2nd3rd
Date and Time of Birth*

MonthDayYear
Date
24 hour clock Minutes
Place of Birth
PLACE OF BIRTH

ResidenceBirthing CenterOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Parent Married at Time of Birth?*

YesNo
Birth Attendant Information
Attendant's Name*

First NameLast Name
License #*
Primary Phone Number*
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*
Date of Birth*

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

Street Address

County

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Birth Parent Information
Name*

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

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

YesNo
Address

Street Address

County

CityState

Zip Code
Phone Number*
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?

YesNoUnknown
How Many Cigarettes Did the Mother Smoke During Pregnancy?
Three Months Prior to Pregnancy: Cigarettes/day OR Packs/day
First Trimester of Pregnancy: Cigarettes/day OR
Packs/day
Second Trimester of Pregnancy: Cigarettes/day OR
Packs/day
Third Trimester of Pregnancy: Cigarettes/day OR
Packs/day
APGAR Score 00-10
At 5 Minutes
At 10 Minutes
Birth Parent Pre-Pregnancy Birth Weight
Birth Parent Delivery Weight
Birth Parent Height
Date last Normal Menses Began

MonthDayYear
Date
Month Prenatal Care Began
Date First Prenatal Care Visit

MonthDayYear
Date
Date of Last Prenatal Care Visit

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

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

MonthDayYear
Date
Miscarriages

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

MonthDayYear
Date
Method of Delivery
Delivery Route
Previous Cesarean
Fetal Presentation at birth
Forceps

YesNo
Vacuum

YesNo
Source of Payment for Delivery
Complications and Procedures of Pregnancy and Concurrent Illnesses
Diabetes

09 Prepregnancy (Diagnosis prior to this pregnancy)31 Gestational (Diagnosis in this pregnancy)
Hypertension

03 Prepregnancy (Chronic)01 Gestational (PIH, Preeclampsia)02 Eclampsia
Other Complications/Pregnancies

32 Large fibroids33 Asthma34 Multiple pregnancy (more than 1 fetus this pregnancy)35 Intrauterine growth restricted birth this pregnancy23 Previous preterm birth (less than 37 weeks gestation)36 Other previous poor pregnancy outcomes (Includes perinatal death, small-for-gestational age/intrauterine growth restricted birth, large for gestational age, etc.)
Obstetric Procedures

24 Cervical cerclage28 Tocolysis37 External cephalic version—Successful38 External cephalic version—Failed39 Consultation with specialist for high risk obstetric services
Pregnancy Resulted from Infertility Treatment

40 Fertility-enhancing drugs, artificial insemination or intrauterine insemination41 Assisted reproductive technology (e.g., in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT)
Infections Present and/or Treated During This Pregnancy

42 Chlamydia43 Gonorrhea44 Group B streptococcus18 Hepatitis B (acute infection or carrier)45 Hepatitis C16 Herpes simplex virus (HSV)46 Syphilis47 Cytomegalovirus (Fetal Death Only)48 Listeria (Fetal Death Only)49 Parvovirus (Fetal Death Only)50 Toxoplasmosis (Fetal Death Only)
Prenatal Screening Done for Infectious Diseases

51 Chlamydia52 Gonorrhea53 Group B streptococcal infection54 Hepatitis B55 Human immunodeficiency virus (offered)56 Syphilis
None or Other Complications/Procedures Not Listed

00 None30 Other Pregnancy Complications/Procedures not Listed
Epidemics and/or Disasters

91 COVID-19 Confirmed92 COVID-19 Presumed
Diabetes Code
Hypertension Code
Other Complications/Pregnancies Code
Obstetric Procedures Code
Pregnancy Resulted from Infertility Treatment Code
Infections Present and/or Treated During This Pregnancy Code
Prenatal Screening Done for Infectious Diseases Code
None or Other Complications/Procedures Not Listed Code
Epidemics and/or Disasters Code
Complications and Procedures of Labor and Delivery
Onset of Labor

10 Premature rupture of membranes (greater than or equal to 12 hours)07 Precipitous labor (less than 3 hours)08 Prolonged labor (greater than or equal to 20 hours)
Characteristics of Labor and Delivery

11 Induction of Labor12 Augmentation of labor32 Non-vertex presentation33 Steroids (glucocorticoids) for fetal lung maturation received by the mother prior to delivery34 Antibiotics received by the mother during labor35 Clinical chorioamnionitis diagnosed during labor or maternal temperature greater than or equal to 38°C (100.4°F)19 Moderate/heavy meconium staining of the amniotic fluid36 Fetal intolerance of labor such that one or more of the following actions was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery37 Epidural or spinal anesthesia during labor25 Mother transferred for delivery from another facility for maternal medical or fetal indications
Complications of Placenta, Cord, and Membranes

38 Rupture of membranes prior to onset of labor13 Abruptio placenta39 Placental insufficiency20 Prolapsed cord17 Chorioamnionitis
Maternal Morbidity

24 Maternal blood transfusion40 Third or fourth degree perineal laceration41 Ruptured uterus42 Unplanned hysterectomy43 Admission to ICU44 Unplanned operating room procedure following delivery
None or Other Complications/Procedures Not Listed

00 None31 Other Labor/Delivery Complications/Procedures not Listed
Onset of Labor Code
Characteristics of Labor and Delivery Code
Complications of Placenta, Cord, and Membranes Code
Maternal Morbidity 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)

66 Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)
Congenital Anomalies (Newborn or Fetus)

01 Anencephaly02 Meningomyelocele/Spina bifida76 Cyanotic congenital heart disease77 Congenital diaphragmatic hernia78 Omphalocele79 Gastroschisis80 Limb reduction defect (excluding congenital amputation and dwarfing syndromes)28 Cleft palate alone29 Cleft lip alone30 Cleft palate with cleft lip57 Down’s Syndrome—Karyotype confirmed81 Down’s Syndrome—Karyotype pending82 Suspected chromosomal disorder—Karyotype confirmed83 Suspected chromosomal disorder—Karyotype pending35 Hypospadias88 Aortic stenosis89 Pulmonary stenosis90 Atresia62 Additional and unspecified congenital anomalies not listed above
Additional Abnormal Conditions/Procedures (Newborn Only)

71 Assisted ventilation required immediately following delivery85 Assisted ventilation required for more than 6 hours73 NICU admission86 Newborn given surfactant replacement therapy87 Antibiotics received by the newborn for suspected neonatal sepsis70 Seizure or serious neurological dysfunction74 Newborn transferred to another facility within 24 hours of delivery
None or Other Abnormal Conditions/Procedures

00 None (Newborn or Fetus)75 Other Conditions/Procedures not Listed (Newborn Only)67 Other Conditions/Procedures not Listed (Fetal Death Only)
Epidemics and/or Disasters

91 COVID-19 Confirmed92 COVID-19 Presumed
Abnormal Conditions (Newborn or Fetus) Code
Congenital Anomalies (Newborn or Fetus) Code
Additional Abnormal Conditions/Procedures (Newborn Only) Code
None or Other Abnormal Conditions/Procedures Not Listed Code
Epidemics and/or Disasters Code
ADDITIONAL INFORMATION FOR NEWBORN SCREENING FORM

Newborn Primary Care Provider Information
Pediatrician Name

FIRST NAMELAST NAME
NPI/LICENSE
ADDRESS – STREET, CITY, STATE, ZIP
FAX NUMBER
Phone Number
Newborn Screening Test Performed

YesNo
Date of Test

MonthDayYear
Date
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?*

YesNoUnknownDecline to respond
What sex appears on your original birth certificate?*

MaleFemaleUnknownDecline to respond
How do you describe your gender identity?*
How do you describe your sexual orientation?*
Should only be provided by the other parent
What sex appears on your original birth certificate?*

MaleFemaleUnknownDecline to respond
How do you describe your gender identity?*
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

Healthy Babies ProgramP.A.R.T.N.E.R.S Family Resource CenterFood Bank of Nevada CountyMother Child and Adolescent HealthWICChild ImmunizationAdult ImmunizationChildren’s Mental Health ServicesAdult Mental Health ServicesDrug and Alcohol ServicesHousing AssistanceMedi-Cal InsuranceCalFresh (Food Stamps)Cash Assistance for FamiliesEmployment ServicesChild Support Services
Informant and Birth Certification Information

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

YesNoUnknown
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 Phone Number*
Please enter a valid phone number.
Relationship to Child*

Birth ParentOther Parent
Witness Name*
Witness Relationship to Child*
Witness Phone Number*
Please enter a valid phone number.
Witness Address*

Street Address

County

CityState

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

Street Address

County

CityState

Zip Code
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