Please submit electronically or fax completed form to (530) 889-7192 within five days of the child’s birth to allow our office to ensure the records are registered within 21 days of birth, as required by 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.”

THIS CHILD

SECTION ONE

1A. NAME OF CHILD - FIRST

1B. MIDDLE NAME

1C. NAME OF CHILD - LAST

2. SEX Value is not selected

3A. PLURALITY

Single

Twin

Triplet

3B. IF MULTIPLE, BIRTH ORDER

1st

2nd

3rd

4A. DATE OF BIRTH

4B. TIME OF BIRTH - 24 HOUR

ARE THE PARENTS MARRIED OR IN A SRDP

YES

NO

PLACE OF BIRTH

PLACE OF BIRTH - CATEGORY Value is not selected

5A. PLACE OF BIRTH - NAME OF FACILITY

5B. STREET ADDRESS

5C. CITY

5D. ZIP CODE

5E. COUNTY

5F. DID THE PLACE OF BIRTH MATCH THE PLANNED PLACE OF BIRTH Value is not selected

PARENT GIVING BIRTH

9A. FIRST NAME

9B. MIDDLE

9C. LAST - BIRTH NAME

9D. RELATIONSHIP TO CHILD Value is not selected

9E. BIRTH STATE/FOREIGN COUNTRY

9F. DATE OF BIRTH

9G. SOCIAL SECURITY NUMBER

9H. IS MOTHER GENETIC MOTHER OF CHILD? Value is not selected

22A. HISPANIC, LATINO, OR SPANISH Value is not selected

22B. HISPANIC ORIGIN Value is not selected

22C. OTHER HISPANIC ORIGIN

21. RACE - UP TO THREE

23C. EDUCATION - HIGHEST LEVEL / DEGREE Value is not selected

23A. USUAL OCCUPATION

23B. KIND OF BUSINESS OR INDUSTRY - NO BUSINESS NAMES

24. PHYSICAL ADDRESS - STREET AND NUMBER, OR LOCATION - DO NOT USE PO BOX

24C. CITY

24E. ZIP CODE

24B. COUNTY

PARENT NOT GIVING BIRTH

6A. FIRST NAME

6B. MIDDLE

6C. LAST - BIRTH NAME

6D. RELATIONSHIP TO CHILD Value is not selected

7. BIRTH STATE/FOREIGN COUNTRY

8. DOB

SOCIAL SECURITY NUMBER

19A. HISPANIC, LATINO, OR SPANISH Value is not selected

19B. HISPANIC ORIGIN Value is not selected

19C. OTHER HISPANIC ORIGIN

18. RACE - UP TO THREE

20C EDUCATION - HIGHEST LEVEL / DEGREE Value is not selected

20A. USUAL OCCUPATION

20B. KIND OF BUSINESS OR INDUSTRY - NO BUSINESS NAME

WAS THIS BIRTH ATTENDED BY A LICENSED MIDWIFE OR PHYSICIAN? Value is not selected

PLEASE NOTE - For births not attended by a licensed midwife please provide the office with proof that birth occurred in Placer County and a pregnancy verification from a licensed Doctor, Midwife or Clinic. The witness of the birth has to be present for the appointment. For more information, please call the office at (530) 889-7158.

CONFIDENTIAL INFORMATION FOR PUBLIC HEALTH USE ONLY

BIRTH ATTENDENT INFORMATION

13A. ATTENDANT'S NAME

13B. LICENSE NUMBER

MEDICAL AND HEALTH DATA BIRTH PARENT AND NEWBORN

SECTION TWO

DID BIRTH PARENT RECEIVE WIC (WOMEN INFANT CHILDREN) WHILE PREGNANT WITH THIS CHILD? Value is not selected

DID MOTHER SMOKE PRIOR TO PREGNANCY Value is not selected

NUMBER SMOKED PRIOR TO PREGNANCY PER DAY Value is not selected

DID MOTHER SMOKE DURING FIRTS TRIMESTER Value is not selected

NUMBER SMOKED DURING FIRST TRIMESTER PER DAY Value is not selected

DID MOTHER SMOKE DURING SECOND TRIMESTER Value is not selected

NUMBER SMOKED DURING SECOND TRIMESTER PER DAY Value is not selected

DID MOTHER SMOKE DURING THIRD TRIMESTER Value is not selected

NUMBER SMOKED DURING THIRD TRIMESTER PER DAY Value is not selected

BIRTH PARENT PRE-PREGNANCY WEIGHT

BIRTH PARENT DELIVERY WEIGHT

BIRTH PARENT HEIGHT

APGAR SCORE 00-10 | AT 1 MINUTE

APGAR SCORE 00-10 | AT 5 MINUTE

APGAR SCORE 00-10 | AT 10 MINUTE

25A. DATE OF LAST MENSTRUAL PERIOD, DD/MM/YYYY

25AA. DATE FIRST PRENATAL CARE VISIT, DD/MM/YYYY

25B. MONTH PRENATAL CARE BEGAN Value is not selected

25BA. DATE OF LAST PRENATAL CARE VISIT, DD/MM/YYYY

25C. NUMBER OF PRENATAL VISITS

25D. SOURCE OF PAYMENT FOR PRENATAL CARE Value is not selected

26. BIRTH WEIGHT (GRAMS)

26A. OBSTETRIC ESTIMATION OF GESTATION AT DELIVERY

26B. HEARING SCREENING Value is not selected

PREGNANCY HISTORY - LIVE BIRTHS (DO NOT INCLUDE THIS CHILD)

27A. PREVIOUS LIVE BIRTHS - NUMBER NOW LIVING

27B. PREVIOUS LIVE BIRTHS - NUMBER NOW DEAD

27C. DATE OF LAST LIVE BIRTH, DD/MM/YYYY - if no previous births enter n/a

PREGNANCY HISTORY - PREGNANCY LOSSES, EXCLUDE INDUCED ABORTIONS

27D. MISCARRIAGES EXCLUDE INDUCED ABORTIONS | # < 20 WEEKS

27E. MISCARRIAGES EXCLUDE INDUCED ABORTIONS | # > 20 WEEKS

27F. DATE OF LAST TERMINATION (MO/YR) - if no previous losses enter n/a

THIS BIRTH - METHOD OF DELIVERY

A. DELVERY ROUTE Value is not selected

B. PREVIOUS CESAREAN

C. FETAL PRESENTATION Value is not selected

D. FORCEPS ATTEMPTED, BUT UNSUCESSFUL Value is not selected

E. VACUUM ATTEMPTED, BUT UNSUCESSFUL Value is not selected

28B. SOURCE OF PAYMENT FOR DELIVERY Value is not selected

29. COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES - ENTER 00 IF NO CODES TO ENTER

30. COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY - ENTER 00 IF NO CODES TO ENTER

31. ABNORMAL CONDITIONS AND PROCEDURES RELATED TO THE NEWBORN - ENTER 00 IF NO CODES TO ENTER

ADDITIONAL INFORMATION FOR NEWBORN SCREENING FORM

SECTION THREE - NEWBORN PRIMARY CARE PROVIDER INFORMATION

32A. NEWBORN CARE PROVIDER - LAST NAME

32B. NEWBORN CARE PROVIDER - FIRST NAME

32C. NPI/LICENSE #

32D. ADDRESS – STREET, CITY, STATE, ZIP

32E. NEWBORN CARE PROVIDER - PHONE NUMBER

32F. NEWBORN CARE PROVIDER - FAX NUMBER

32G. NEWBORN SCREENING TEST PERFORMED

Yes

No

32H. DATE OF TEST OR DATE OF TEST REFUSAL DD/MM/YYYY

32I. WHERE WAS TEST DONE - LOCATION OF HEEL STICK

32J. Ten-digit NBS form number (TRF)

OPTIONAL AND SHOULD ONLY BE PROVIDED BY BIRTH PARENT IDENTIFIED IN QUESTIONS 9A-9C

SECTION FOUR - THIS INFORMATION IS CONFIDENTIAL AND DOES NOT PRINT ON THE BIRTH CERTIFICATE

WHAT SEX APPEARS ON YOUR ORIGINAL BIRTH CERTIFICATE?

Male

Female

Unknown

Declined To Respond

HOW DO YOU IDENTIFY YOUR GENDER IDENTITY? Value is not selected

HOW DO YOU IDENTIFY YOUR SEXUAL ORIENTATION? Value is not selected

OPTIONAL AND SHOULD ONLY BE PROVIDED BY THE PARENT IDENTIFIED IN QUESTIONS 6A-6C

SECTION FIVE - THIS INFORMATION IS CONFIDENTIAL AND DOES NOT PRINT ON THE BIRTH CERTIFICATE

WHAT SEX APPEARS ON YOUR ORIGINAL BIRTH CERTIFICATE?

Male

Female

Unknown

Declined To Respond

HOW DO YOU IDENTIFY YOUR GENDER IDENTITY? Value is not selected

HOW DO YOU IDENTIFY YOUR SEXUAL ORIENTATION? Value is not selected

AFFIDAVIT OF BIRTH INFORMATION FOR OUT-OF-HOSPITAL BIRTHS

Affidavit

SECTION SIX

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 parent at the placer, 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 realized 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 verification

WRITTEN SIGNATURE

PRINTED NAME

DATE SIGNED

RELATIONSHIP TO CHILD

Mother

Father

Parent

PHONE NUMBER

PARENT EMAIL ADDRESS

Witness vertification

WRITTEN SIGNATURE

PRINTED NAME

DATE SIGNED

ADDRESS - STREET NAME AND NUMBER

CITY

STATE

ZIP

COUNTY

RELATIONSHIP TO CHILD

PHONE NUMBER

WITNESS EMAIL ADDRESS

STATE LICENSE NUMBER - IF APPLICABLE

ATTENDANT VERIFICATION (PHYSICIAN, CERTIFIED NURSE-MIDWIFE, OR LICENSED MIDWIFE)

WRITTEN SIGNATURE

ATTENDANT PRINTED NAME

DATE SIGNED

ADDRESS - STREET NAME AND NUMBER

CITY

STATE

ZIP

STATE LICENSE NUMBER

PHONE NUMBER

ATTENDANT EMAIL ADDRESS

ATTENDANT UPLOAD Please submit the following document: Physician/Midwife license, Attendant’s Photo ID, Newborn Screening Form, and Statement of attendant’s availability to attend registration appointment, signed by the attendant.

PRIVACY NOTIFICATION

The information entered on the worksheet will be transferred to the Certificate of Live Birth (VS 10D) and will be collected by the California Department of Public Health Vital Records, 1501 Capitol Avenue M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410, telephone number (916) 445-2684. This information is required by Division 102 of the Health and Safety Code. Every element on the worksheet is mandatory, except marked otherwise. Failure to comply by every person, except a parent informant, is a misdemeanor. The Certificate of Live Birth is open to public access except where prohibited by statute. The principal purposes of this record are to: 1) Establish a legal record of each vital event, 2) Provide certified copies for personal use, 3) Furnish information for demographic and epidemiological studies, and 4) Supply data to the National Center for Health Statistics for federal reports. The father's and the mother's Social Security numbers are included pursuant to Section 102425 (b) (14) of the Health and Safety Code, and may be used for child support enforcement purposes.

CONFIDENTIAL INFORMATION FOR PUBLIC HEALTH STATISTICAL USE ONLY

LOCAL REGISTRATION DISTRICT STAFF VERIFICATION

WRITTEN SIGNATURE

PRINTED NAME

DATE SIGNED

Registered

Clear

Denied

Clear

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Placer County Out of Hospital Birth Worksheet

THIS CHILD

PLACE OF BIRTH

PARENT GIVING BIRTH

PARENT NOT GIVING BIRTH

BIRTH ATTENDENT INFORMATION

MEDICAL AND HEALTH DATA BIRTH PARENT AND NEWBORN

THIS BIRTH - METHOD OF DELIVERY

ADDITIONAL INFORMATION FOR NEWBORN SCREENING FORM

OPTIONAL AND SHOULD ONLY BE PROVIDED BY BIRTH PARENT IDENTIFIED IN QUESTIONS 9A-9C

OPTIONAL AND SHOULD ONLY BE PROVIDED BY THE PARENT IDENTIFIED IN QUESTIONS 6A-6C

Affidavit

PRIVACY NOTIFICATION