Birth Registration Handbook

Vital

Statistics

Section

Birth

Registration

Handbook

Edition Oct. 2019

Table of Contents

1 GENERAL INFORMATION........................................................................................... 1

1.1 INTRODUCTION.................................................................................................. 1

1.2 REGISTRATION REQUIREMENTS................................................................... 1

1.3 CONFIDENTIALITY / CERTIFIED COPIES...................................................... 2

1.4 PENALTIES........................................................................................................... 2

1.5 LICENSED INSTITUTION RESPONSIBILITIES............................................... 3

1.6 MIDWIFE RESPONSIBILITIES........................................................................... 4

1.7 NON-LICENSED INSTITUTION RESPONSIBILITIES..................................... 5

1.7.1 NON-INSTITUTIONAL BIRTH ATTENDED BY A REGISTERED,

CERTIFIED, OR DOCUMENTED HEALTH CARE PROVIDER................................ 5

1.7.2 NON-INSTITUTIONAL BIRTH NOT ATTENDED BY A REGISTERED,

CERTIFIED, OR DOCUMENTED HEALTH CARE PROVIDER. .............................. 6

1.8 ACKNOWLEDGEMENT OF PATERNITY (AOP)............................................. 8

1.9 PATERNITY REGISTRY….................................................................................. 9

1.10 NOTICE OF INTENT TO CLAIM PATERNITY................................................. 9

1.11 ARTIFICIAL INSEMINATION.......................................................................... 10

1.12 GESTATIONAL AGREEMENTS (AKA SURROGACY) ................................ 10

1.13 FOUNDLINGS .................................................................................................... 11

2 TXEVER BIRTH WORKSHEETS ............................................................................... 12

2.1 ITEM-BY-ITEM INSTRUCTIONS .................................................................... 12

2.1.1 ITEM-BY-ITEM INSTRUCTION OVERVIEW ............................................ 12

2.2 GENERAL – (TAB 1) ......................................................................................... 12

2.3 MOTHER 1 – (TAB 2) ........................................................................................ 19

2.4 FATHER 1 – (TAB 4) ......................................................................................... 25

2.5 FATHER 2 – (TAB 5) ......................................................................................... 30

2.6 MEDICAL 1 – (TAB 6) ....................................................................................... 33

2.7 MEDICAL 2 – (TAB 7) ....................................................................................... 36

2.8 CERTIFIER – (TAB 8) ........................................................................................ 43

2.9 INTENDED MOTHER – (TAB 9) [SURROGATE OPTION ONLY] .............. 46

2.10 INTENDED FATHER – (TAB 10) [SURROGATE OPTION ONLY] .............. 51

3 CORRECTIONS TO BIRTH CERTIFICATE RECORDS ............................................ 54

3.1 ERRORS DETECTED BEFORE LEGAL AND STATISTICAL RELEASE: ........... 54

3.2 ERRORS DETECTED AFTER LEGAL RELEASE: .................................................. 54

3.3 AMENDMENT TO AND SUPPLEMENTAL BIRTH RECORDS. ........................... 54

3.3.1 GENERAL INFORMATION ................................................................................ 54

3.3.2 PROCEDURES FOR AMENDING CERTIFICATE OF BIRTH ........................ 55

3.3.3 INSTRUCTIONS FOR COMPLETING THE APPLICATION TO AMEND

CERTIFICATE OF BIRTH (VS-170) ................................................................................. 55

3.3.4 INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A NEW

BIRTH CERTIFICATE BASED ON PARENTAGE (VS-166) ......................................... 61

4 DELETED 5/20/2020........................................................................................................... 63

5 DELAYED FILING OF BIRTH RECORDS ...................................................................... 63

5.1 INSTRUCTIONS FOR FILING DELAYED CERTIFICATES OF BIRTH

REGISTRATION BY STATE REGISTRAR.......................................................................... 64

5.1.1 FOR A CHILD OVER 1 YEAR BUT LESS THAN 4 YEARS BORN IN A

LICENSED INSTITUTION ................................................................................................. 64

5.1.2 FOR A CHILD OVER 1 YEAR BUT LESS THAN 4 YEARS NOT BORN IN

A LICENSED INSTITUTION ............................................................................................. 64

5.1.3 FOR A CHILD 4 YEARS OLD, BUT LESS THAN 15 YEARS OLD …........... 64

5.1.4 FOR A PERSON 15 YEARS OR OLDER ........................................................... 64

5.1.5 DOCUMENTARY EVIDENCE FOR DELAYED REGISTRATION OF BIRTH

……………………………………………………………………………...……. 65

5.1.6 SUGGESTED TYPES OF SUPPORTING DOCUMENTS ................................. 65

5.2 REGISTRATION BY JUDICIAL ORDER (BIRTHS) ................................................ 67

6 REVISION HISTORY ......................................................................................................... 68

7 LIST OF APPENDIXES ...................................................................................................... 69

1 GENERAL INFORMATION

1.1 INTRODUCTION

This handbook describes birth registration in the Texas vital registration system. It provides

instructions for completing and filing birth certificates along with related permits.

A birth certificate is a permanent legal record of an individual’s birth. The birth certificate is

an individual’s basic claim and proof of citizenship, identification, and relationship to his or

her parent(s). It serves as the primary document for individuals to enter school, play little

league sports, obtain a social security number and account, a driver’s license, a marriage

license, a passport, and to prove citizenship to be qualified to work in this country.

In addition to being the primary document of identification for an individual, a birth

certificate provides information used in a variety of medical and health-related research

efforts. Birth statistics are used to assess the general health of Texas citizens. Birth statistics

also help identify adequacy of prenatal care, pregnancy outcome based on birth weight and

length of gestation, abnormal conditions of mothers and babies and specific geographic

concerns.

Because birth statistics are no more accurate than the information submitted on the birth

certificate it is very important that all birth certificates be completed and filed with accuracy

and promptness.

1.2 REGISTRATION REQUIREMENTS

A Certificate of Birth (VS-111) must be filled within five (5) days of the date of birth for

every live birth in Texas [HSC §192.003 (d)]. The Certificate of Birth should be registered

with the State of Texas – Vital Statistics Section though the TxEVER system. Persons

responsible for registering births will need to sign up for TxEVER and will receive a user ID

and password. To sign up for TxEVER, go to www.dshs.texas.gov/vs.

The Texas Administrative Code (TAC) defines a “live birth” as the complete expulsion or

extraction from its mother of a product of conception, irrespective of the duration of

pregnancy, which, after such separation, breathes or shows any other evidence of life such as

beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary

muscles, whether or not the umbilical cord has been cut or the placenta is attached; each

product of such a birth is considered live born [25 TAC §181.1(18)]. A Certificate of Birth

must be filed for all live births regardless of length of gestation or chance of survival. Should

the infant die after being determined a live birth, a Certificate of Death (VS-112) must also

be filed. For instructions on completing a Certificate of Death, see the Handbook on Death

Registration.

When a fetal death occurs, then a certificate of birth would not be filed, but the Certificate of

Fetal Death (VS-113) would be filed. The Texas Administrative Code defines a “fetal death”

as death prior to the complete expulsion or extraction from its mother of a product of

conception, irrespective of the duration of pregnancy; the death is indicated by the fact that

after such separation, the fetus does not breathe or show any other evidence of life such as

beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary

muscles [25 TAC §181.1 (11)]. See the Handbook on Fetal Death Registration for

instructions on completing the Certificate of Fetal Death.

The birth certificate must be filed by the attendant at birth. If the birth occurs in a licensed

institution (hospital or birthing center), an administrator may file the birth certificate. If the

birth occurs in a non-licensed institution (occurs outside of a licensed institution) and was

attended by a registered, certified or documented health care provider (doctor, Midwife,

EMT) the birth may be registered by the attendant or by the local registrar after he/she have

presented their professional documentation. If the birth occurs in a non-licensed institution

and a registered attendant is not present, the birth should be registered by the father or mother

of the child or the owner/ householder of the premises where the birth occurred.

Documentation is required from the parent(s) before a birth certificate may be filed. Chapter

2 of this handbook provides detailed filing information.

Births must be filed using TxEVER or the forms prescribed by the Department of State

Health Services (DSHS), Vital Statistics Section. The most-recent revision of the form must

be used.

1.3 CONFIDENTIALITY / CERTIFIED COPIES

Requests for information registered in the TxEVER system on Certificates of Birth is

considered confidential. Certified copies may be issued only to properly qualified applicants

who have submitted proof of their identification and have fully identified the record

requested.

The fact of birth (name, date, and place) of an individual is public knowledge; however, the

birth certificate is not. A birth certificate is a confidential record for the first 75 years after

filing and may be released only to a properly qualified applicant [HSC §191.051 (a); 25 TAC

§181.1(2); GC §552.115]. A certified copy of a birth certificate includes only the upper

“legal” portion down to and including the registrant’s signature.

In addition to the demographic information, information held under the section entitled

“Confidential Information for Medical and Public Health Use” are confidential and are not

considered open records for the purpose of the open records law. That information, including

parents’ signatures and social security numbers, are not included in a certified copy and may

not be released or made public on subpoena or otherwise, except for statistical purpose,

where no person, patient, or facility is identified [HSC §192.002 (b)].

1.4 PENALTIES

It is a Class A misdemeanor if a person knowingly discloses the medical or health

information, or knowingly induces or causes another to disclose information. It is a Class C

misdemeanor if a person refuses or fails to furnish any correct information in the person’s

possession affecting a certificate. It is also a Class C misdemeanor if a person fails, neglects,

or refuses to fill out and file a birth certificate with TxEVER, the local registrar or deliver the

certificate upon request to the person with the duty to file it. To falsely obtain, use, or alter

another person’s Certificate of Birth is a third degree felony.

1.5 LICENSED INSTITUTION RESPONSIBILITIES

A birth that occurs in a licensed institution (hospital, birthing center) may be registered in

TxEVER by the hospital administrator, the birthing center administrator, or a designee of the

appropriate administrator in lieu of the physician or midwife in attendance of the birth [HSC

§192.003 (b)].

The responsibilities of the person registering the birth at a licensed institution (hospital,

birthing center) in the birth registration process are as follows:

• Obtain information needed for completion of the birth certificate from appropriate

sources. Sources include the mother of the child, mother’s physician, infant’s physician,

or medical records. Information may be obtained from the immediate family or other

sources, as needed.

• Complete a Certificate of Birth for each live birth that occurs in the hospital or en route to

the hospital.

• If the parents are not married to each other, provide whenever possible an opportunity for

the father to acknowledge paternity, including the Acknowledgment of Paternity (AOP)

form and the required oral and written notification of rights and responsibilities.

• Inform the parents that they may request an application for child support services by

calling the Office of Attorney General at 1-800-252-8014.

• Review the certificate and AOP if applicable, for completeness and accuracy and fax into

VSS at 1-888-561-3138.

• Obtain the appropriate parents’ signatures on the Verification of Birth Facts document.

• File the certificate in TxEVER within five (5) days from the date of birth

[HSC§192.003].

• Cooperate with the Vital Statistics Section (VSS) and local registrars concerning queries

on certificate entries.

Instructions for filing a birth certificate in TxEVER can be found at www.dshs.texas.gov/vs

or contact help-TXEVE[email protected] for technical assistance.

1.6 MIDWIFE RESPONSIBILITIES

A birth that is performed with a Midwife may be registered in TxEVER by the midwife or

designated registrant. If the midwife is not a TxEVER participant, he/she will need to file the

birth certificate with the local registrar of the registration district in which the birth occurs

[HSC §192.003(a)].

Midwives must be documented each March with the Texas Department of State Health

Services (DSHS – formerly TDH) [Title 25 TAC §37.175]. The Certificate of Birth should be

filed in TxEVER or with each local registrar in whose district he or she intends to deliver

births [Title 25 TAC §81.26 (1)] after his/her health department documents have been

provided to the local registrar.

The responsibilities of the midwife in the birth registration process are as follows:

• Midwives must be documented each March with the Texas Department of Health [Title

25 TAC §37.175].

• Obtain information needed for completion of the birth certificate from appropriate

sources. Sources include the mother of the child, mother’s physician, infant’s physician,

or medical records. Information may be obtained from the immediate family or other

sources, as needed.

• Complete a Certificate of Birth for each live birth that the midwife attended.

• If the parents are not married to each other, provide whenever possible an opportunity for

the father to acknowledge paternity, including the Acknowledgment of Paternity (AOP)

form and the required oral and written notification of rights and responsibilities.

• Inform the parents that they may request an application for child support services by

calling the Office of Attorney General at 1-800-252-8014.

• If applicable, review the certificate and AOP for completeness and accuracy.

• If applicable, fax AOP into VSS at 1-888-561-3138.

• Obtain the appropriate parents’ signatures on the Verification of Birth Facts document.

• File the certificate in TxEVER within five (5) days from the date of birth

[HSC§192.003].

• For a homebirth, the midwife assigns in TxEVER the Local Registrar having competent

jurisdiction where the birth occurred.

• Cooperate with the Vital Statistics Section (VSS) and local registrars concerning queries

on certificate entries.

Instructions for filing a birth certificate in TxEVER can be found at www.dshs.texas.gov/vs,

or contact help-TXEVE[email protected] for technical assistance.

1.7 NON-LICENSED INSTITUTION RESPONSIBILITIES

1.7.1 NON-INSTITUTIONAL BIRTH ATTENDED BY A REGISTERED,

CERTIFIED, OR DOCUMENTED HEALTH CARE PROVIDER.

A birth that occurs in a non-licensed institution (any institution that is not licensed) should be

registered by the attendant.

If the birth is attended by a registered, certified, or documented health care provider, such as

a midwife, doctor, or EMT, the birth may be registered by the attendant after he/she has

presented his/her professional documentation to the local registrar.

The responsibilities of the registered, certified, or documented health care provider in the

birth registration process are as follows:

• Presented his/her professional documentation to the local registrar.

• Obtain information needed for completion of the birth certificate from appropriate

sources. Sources include the mother of the child, mother’s physician, infant’s

physician, or medical records. Information may be obtained from the immediate

family or other sources, as needed.

• Complete a Certificate of Birth.

• If the parents are not married to each other, provide whenever possible an opportunity

for the father to acknowledge paternity, including the Acknowledgment of Paternity

(AOP) form and the required oral and written notification of rights and

responsibilities. Inform the parents that they may request an application for child

support services by calling the Office of Attorney General at 1-800-252-8014.

• If applicable, review the certificate and AOP for completeness and accuracy.

• If applicable, fax AOP into VSS at 1-888-561-3138.

• File the certificate in within five (5) days from the date of birth with the local registrar

[HSC §192.003].

• Cooperate with the Vital Statistics Section (VSS) and local registrars concerning

queries on certificate entries.

Instructions for filing a birth certificate in TxEVER can be found at www.dshs.texas.gov/vs,

or contact [email protected] for technical assistance.

1.7.2 NON-INSTITUTIONAL BIRTH NOT ATTENDED BY A REGISTERED,

CERTIFIED, OR DOCUMENTED HEALTH CARE PROVIDER.

If there is no physician, midwife, or person acting as midwife in attendance at a

noninstitutional birth, documentation is required from the parent(s) before a birth certificate

may be filed.

In an effort to control fraudulent filings of birth records and to place control over blank

forms, the Texas Vital Statistics Section (VSS) and Texas Board of Health developed and

approved rules for filing birth certificates for children born outside licensed institutions [TAC

§181.26]. To insure uniform compliance throughout the state, VSS developed the following

administrative comments and instructions.

To file a birth certificate with the appropriate local registrar the following proof must be

presented to the local registrar by the person in attendance at the birth in the following order

of preference:

1. The father or mother of the child; or

2. The owner or householder of the premises where the birth occurs.

The registrar may provide to the person filing the birth record a “Mothers Work Sheet” in

order to gather the information to be placed on the birth record.

A birth certificate can be filed only upon personal presentation of the following evidence:

PROOF OF PREGNANCY, PRESENTED IN FOLLOWING ORDER OF

PREFERENCE;

• An affidavit (notarized) presented from a licensed, registered, or certified health care

provider who is qualified to determine pregnancy as part of the scope of his or her license

or registration, or certification; or

• An affidavit (notarized) along with photocopy of ID (for example, a driver’s license or

government ID, etc.) presented from one person, other than the parents, having

knowledge of the pregnancy/birth

PROOF THAT THE INFANT WAS BORN ALIVE;

• A medical record or a letter from a licensed, registered, or certified health care provider

or medical institution; or

• An affidavit (notarized) along with photocopy of ID (for example, a driver’s license or

government ID, etc.) presented from one person, other than the parents, having

knowledge of the pregnancy/birth.

PROOF THAT THE INFANT WAS BORN IN THE REGISTRATION DISTRICT;

• If the birth occurred outside the mother’s primary place of residence, proof shall consist

of an affidavit (notarized) along with a photocopy of ID from a person having

knowledge of the mother’s presence in the registration district on the date of the birth.

• If the birth occurred in the mother’s primary place of residence, proof of residence in

the following order of preference:

o A utility bill, telephone, or other bill, which includes the mother’s name and

address;

o A rent receipt which includes the mother’s name, address, and signature of the

mother’s landlord;

o A driver’s license, or state issued identification card, which includes the mother’s

current address on the face of the license or card;

o An envelope addressed to the mother at her place of residence, and post marked

prior to the date of birth; or

o An affidavit (notarized) attesting to the mother’s place of residence along with a

photocopy of ID from a person, other than the father, who was either living with

the mother at the time of the alleged birth, or has other knowledge of the mother’s

residency.

PROOF THAT THE INFANT WAS BORN ON THE DATE STATED.

• A medical record or a letter from a licensed, registered, or certified health care provider

or medical institution; or

• An affidavit (notarized) presented from one person along with photocopy of ID, other

than the parents, having knowledge of the pregnancy/birth.

OTHER SUPPLEMENTAL INFORMATION PROVING HOME BIRTH

At the discretion of the local registrar, these procedures may be supplemented with any

additional requirements needed to verify the circumstances of the birth. Additional

requirements may include, but are not limited to, one or more of the following:

• An unannounced visit by a public health nurse, other health professional, registrar staff,

or other person including city, county, state, or federal law enforcement officers, prior to

registering the birth. This paragraph does not permit nor give authority to enter these

premises unless permission is obtained from the occupant at the time of the visit;

• Multiple forms of identifying documents, with or without photographs, when the

documents described in this section are unavailable;

• Personal appearance of both parents, either together or separately; or

• Personal appearance of the infant whose birth certificate the parents are attempting to file

PERSONS AND/OR RECORDS NOT MEETING REQUIREMENTS FOR FILING

If the local registrar did not feel the documentation requirements were met, the local registrar

shall contact VSS Field services and provide their representative with a copy of the required

documentation for review.

The documentation that has been submitted as proof should be returned to the person filing

the record after the birth record is accepted.

Each local registrar must notify the Fraud Prevention Program of any suspicious documents

or records submitted or filed with his/her office.

If the individual(s) attempting to file the birth records of a child not born in an institution

cannot meet the four essential elements required for filing (proof of pregnancy, proof the

infant was born alive, proof the infant was born in the registration district, and proof the

infant was born on the date stated), the local registrar will forward the record and all

documentation to the State Registrar for his/her determination.

• The local registrar will send a cover letter with the documentation explaining why he/she

cannot accept the record for filing.

• The local registrar will give a letter to the parent(s) and/or person trying to file the record

telling them why he or she cannot accept the record for filing and that the request and

documentation have been sent to Austin for the State Registrar’s determination.

• Upon receipt of the birth record from the local registrar within one year of the date of

birth, the State Registrar will direct the Fraud Prevention Program to further verify or

investigate as necessary to determine to accept or not accept the documentation sent. If

the documentation is deemed unacceptable, the State Registrar will send a letter referring

the parent(s) to a Texas district court for a judicial determination and order to file a

Certificate of Birth. If the birth occurred more than a year before the parent(s) attempt to

file a delayed birth certificate, and the documentation is deemed unacceptable, the State

Registrar may refer the case to the county judge of the alleged county of birth for a

judicial decision [TAC §182.26(1), HSC §192.027].

1.8 ACKNOWLEDGEMENT OF PATERNITY (AOP)

When the biological father and mother are not married (or the marriage ended within 300

days of the child’s birth), this form is signed by both parents to establish a legal finding of

paternity. The biological father becomes the legal father and has all rights and duties of a

parent. His name may go on the birth certificate. A certified person will assist in the AOP

process. See the Acknowledgement of Paternity (AOP) handbook from the Office of

Attorney General (OAG) for details on the process.

1.9 PATERNITY REGISTRY

The Texas Vital Statistic Section has established a Paternity Registry for men to assert

voluntarily their parental rights. The purpose of the Paternity Registry is to “protect the

parental rights of fathers who affirmatively assume responsibility for children they have

fathered, and expedite adoptions of children whose biological fathers are unwilling to assume

responsibility for their children by registering with the registry or otherwise acknowledging

their children” [TFC §160.251(b) (1-2)].

A man is not required to register with the Paternity Registry. It is unnecessary for him to

completed an AOP with the child’s mother, or if he has been adjudicated to be the biological

father of the child by a court of competent jurisdiction. The Paternity Registry does provide

an opportunity for a father to assert his parental rights when he cannot complete the AOP or

be listed as the father on a child’s birth certificate.

1.10 NOTICE OF INTENT TO CLAIM PATERNITY

The Notice of Intent to Claim Paternity form is used to add the father’s name to the Paternity

Registry maintained by the Vital Statistic Section (VSS) [TFC 160.256]. A man who wishes

to claim paternity for a child he may have fathered can complete a “Notice of Intent to Claim

Paternity.” This form is used in situations where the father and mother do not have a

continuing relationship, and the man is not listed as the father on the birth certificate or AOP

or when the biological father is unable to sign the AOP because he and the mother cannot

obtain a denial of paternity from the man to whom she was married at or within 300 days

before the birth.

The Notice of Intent form must be filed before or within 30 days of the date of birth of a

child [TFC 160.256]. The man should also be encouraged to obtain legal advice and petition

the court for the establishment of legal paternity.

The Notice of Intent form will not legally establish paternity, nor can it be used to add a

man’s name to the child’s birth certificate. It is simply an assertion of belief that he is the

father of a child and wishes to preserve his rights as a parent.

The following is a list of examples (not all-inclusive) in which the man may use the Notice of

Intent to Claim Paternity form to register his assertion of paternity to protect his rights:

• A man and woman have a consenting sexual relationship for a brief period of time, and

they have no further contact. The man understands the woman may have become

pregnant, and he wishes to assert his paternity for the possible child. He would complete

the Notice of Intent to Claim Paternity form to register his assertion.

• A man and woman do not agree that he is the father of her child. The man wishes to

assert his paternity.

• More than one man claims to be the father of the child. Each man would complete a

separate Notice of Intent.

• The mother refuses to complete and sign the AOP form.

• The mother was married at or within 300 days before the child’s birth and the mother and

biological father cannot obtain a denial of paternity from her current or former husband.

1.11 ARTIFICIAL INSEMINATION

According to the Texas Family Code, Chapter 160, Subchapter H. on children conceived by

means of assisted reproduction, if a husband and wife consent to the artificial insemination of

the wife, any resulting child is the child of the couple; the resulting child is not the child of

the donor, unless the donor is the husband of the woman. The consent must be in writing and

must be acknowledged. If the mother of the child was married at the time of conception or

the birth of the child, the husband of the mother is presumed to be the father of the child

unless otherwise determined by a court of competent jurisdiction [TFC §160.701-707].

1.12 GESTATIONAL AGREEMENTS (AKA SURROGACY)

An increasing number of births are occurring as the result of a surrogate agreement. In these

situations, the question usually arises as to what parent’s names are to be shown on the

original birth certificate.

In accordance to the Texas Family Code, Chapter 160, Subchapter I., a gestational agreement

is an agreement between a woman, known as the “gestational mother,” and the intended

parents of a child in which the woman relinquishes all rights as a parent of a child conceived

by means of assisted reproduction and that provides that the intended parents become the

parents of the child [TFC §160.752(a)].

In other words, if a woman, who has signed a gestational agreement, is implanted with a

fertilized egg and delivers an infant, her name should not appear on the record of birth as the

mother of the child.; Instead, the name of the intended mother should appear as the mother;

this will permits for the establishment of the parent-child relationship. This rule applies also

in the establishment of the father-child relationship; this means that the intended father shall

be named as the father of the child. Note that both intended parents must be married to each

other, and they must sign the gestational agreement.[F(1]

Note: the gestational agreement does not apply to the birth of a child conceived by means of

sexual intercourse.

In accordance with TFC §160.755-761, the intended parents should file a petition for the

validation of the agreement with the court. Also, if the court did not validate the gestational

agreement or if the intended parents failed to file a notice of birth with the court of competent

jurisdiction, the court shall order that the intended parents are the child’s parents and are

financially responsible for the child [TFC §160.760-762].

If the court does not provide with such a decision, the “gestational mother” should be named

as the mother of the child on the record of birth. In addition, if the gestational mother is

married, her husband would be considered to be the presumed father of the child.[F(2]

[C(3]

1.13 FOUNDLINGS

The Texas Family Code allows for a designated emergency infant care provider, such as a

hospital, to take possession of a child who appears to be 60 days old or younger if the child is

voluntarily delivered to the provider by the child's parent and the parent did not express an

intent to return for the child.

The emergency infant care provider has no legal duty to seek, in any manner, to determine

the identity of the infant’s parents; this shall permit the infant’s parents to remain anonymous

and to guarantee them a legal immunity, and it shall provide the child with a chance for

his/her adoption and a normal life.

The emergency infant care provider shall act to provide the infant with protection and shall

inform the Texas Department of Family and Protective Services (DFPS) with the 24 hours of

taking possession of the infant. Accordingly, DFPS assigns a caseworker, whose role is to act

for the best interest of the infant.

According to DFPS Handbook, §2351-Baby Moses, the caseworker must inform the hospital

staff of the intention to name the infant within five calendar days. This ensures for the filing

of the infant’s birth certificate. Should the caseworker not provide the hospital with a name,

the infant’s name may be entered in TxEVER as “Infant Doe.” Enter “unknown” for required

text fields. Use a question mark for required numeric fields. Select “UNKNOWN” for “Did

Mother relinquish rights to child?” Finally, on the Certifier tab, the attendant can be the

emergency room physician, the chief medical officer, or hospital administrator. As a last

resort, the case social worker may be entered as attendant [TFC §262.301-303; §262.308-

309; §263.407; ].

DFPS Handbook, §2351-Baby

Moses

[F(4]

2 TXEVER BIRTH WORKSHEETS

One method of collecting the information for a birth certificate includes the use of

worksheets. Many hospitals are currently using worksheets of various types and formats.

VSS has developed three worksheets in a format that will aid in the collection of this

information. Hospitals may use these worksheets as they are, modify them, or develop their

own in whatever format they deem most useful.

The mother’s worksheet on birth certificate, VS-109.1, is for information supplied by the

mother, either by having her fill it out, or by having the hospital staff interview her and fill in

the information for her. This worksheet is available in Spanish (VS-109a.1). The medical

data worksheet, VS-109.2, is provided for hospital personnel to collect medical information

about the mother and child. The worksheets are available from at www.dshs.texas.gov/vs.

2.1 ITEM-BY-ITEM INSTRUCTIONS

2.1.1 ITEM-BY-ITEM INSTRUCTION OVERVIEW

The TxEVER birth registration consists of 8 tabs (sections) – General; Mother 1; Mother 2;

Father 1; Father 2; Medical 1; Medical 2 and Certifier.

The best way to fill in the information is to use the tab key on the computer keyboard to

move forward after a blank is filled in (type – tab). This will assure that you do not skip any

blanks or miss any pop-up information. Some information blanks contain drop down choices

and others will need information typed into the blank.

The blanks are color-coded. The yellow blanks request information; once the information is

entered the box will turn white. The blue blanks will pre-populate information based on

previous entries.

2.2

RECORD TYPE

Registration will vary according to record type selected. One of the choices must be selected.

• Born at Facility;

• Born En Route to Facility;

• Foundling; or

• Home Birth (Hospital / Birth Center will not automatically propagate).

GENERAL – (TAB 1)

[F(5]

Note: Hospitals and Birthing Centers may not file a Home Birth.

SURROGATE

This function is for Gestational Agreements. In selecting this button, the drop down list will

be activated and two additional tab will appear; these tabs are “Intended Mother” and

“Intended Father.”

If this function is activated, select one of the two option:

• “1 Parent Court Ordered Surrogacy” if the gestational agreement is validated by one

intended parent—this selection will deactivate the “Intended Father” tab; or “2

Parent Court Ordered Surrogacy” if the gestational agreement is validated by the two

intended parents.

MOTHER’S MEDICAL RECORD NUMBER

This is a mandatory – to save item and must be filled out before the record can be saved. This

number is generated

by the registering entity (hospital, birthing center, local registrar).

DATE AOP SENT

If the father of the child is required to fill out an Authorization of Paternity form, the date it is

sent in appear here.

If this form is not used, then this date will remain empty.

CHILD’S PLACE OF BIRTH

The hospital or birth center name and address will automatically populate when selecting

“Born at Facility” or “Born En Route to Facility” above in record type.

Midwives can enter the place of birth through the “Add on the Fly” (AOF) process when

attending a non-institutional birth. Name the place where the birth occurred. Delivery in

places of business or public places are examples of places that would be entered through the

AOF process.

A birthing center located in and operated by a hospital is considered part of the hospital, and

births in such a center should be reported as occurring in the hospital. Licensed birthing

centers include those facilities that are operated independently from hospitals

(autonomously).

The “Clinic/Doctor’s Office” category includes other non-hospital outpatient facilities where

births occasionally occur.

Accurately entering the birth Place of Birth information permits analysis of the number and

characteristics of births by type of facility, and it is helpful in determining the level of

utilization and characteristics of births occurring in such facilities.

NAME OF FACILITY

Enter the full name of the facility (hospital or birthing center) in which the birth occurred. It

is very important to be consistent in entering the hospital name; there should be no variations.

The name of the facility will be the legal name. The facility name will pre-populate in

TxEVER when “born at facility” is selected.

If the mother is en route to the hospital when the child is born and the hospital is the first

place where the child is removed from the conveyance, “En route” should be indicated. In

this case, the hospital should complete the birth record to show the name of the city or town

in which the facility of destination is located.

If it has been determined that the child was not first removed from conveyance at the

hospital, the birth record should filed by the parent(s) with the local registrar of the city,

town, village, or location where the child was first removed from the conveyance.

If the birth occurred at home, enter the house number and street name of the place where the

birth occurred. If the birth occurred at some place other than those described above, enter the

number and street name of the location.

The hospital name is used for follow up and query programs by the Texas Vital Statistics

Section and is of historical value to the parents and child.

PLACE OF BIRTH

Type – Enter the type of facility

State – Enter the state where the birth occurred County – Enter the county where the birth

occurred.

City – Enter the city or town in which the infant was born. If outside the city limits, enter the

Justice of the Peace precinct number. Spell out the word “Precinct,” do not abbreviate.

If the mother is en route to the hospital and the child is born in a moving vehicle, the birth

record should be completed to show the name of the city or town in which the facility of

destination is located. “En route” should be shown followed by the name of the facility of

destination.

For a birth occurring in international airspace or international waters on a flight or voyage

that ends in Texas, complete a Texas birth certificate, but enter the actual place of birth in, as

far as it can be determined. For a birth occurring at sea or in flight, it should be marked

“Other” and show “At Sea” or “In Flight.” and should show the name of the vessel or aircraft

e.g., SS Everett Hill (at sea) or - Global Airlines Flight 263” (in flight), along with the

latitude and longitude where the birth occurred. Show the county where the infant was first

removed from the vessel or aircraft. Show the city where the infant was first removed. It is

important that the left hand margin of the certificate contain some citation of the page and

volume number of the ship’s log.

If a baby is found in this state and the place of birth is unknown, a Texas birth certificate

should be completed. The place where the baby was found should be considered the place of

birth.

CHILD’S INFORMATION

TIME OF BIRTH

Enter either military time or standard time; select “am” or “pm.”

Enter the exact time (hour and minute) the child was born according to local time. If daylight

saving time was the official prevailing time when the birth occurred, it should be used to

record the time of birth. Be sure to indicate whether the time of birth is A.M. or P.M. One

minute after 12 noon is entered as “12:01pm,” and one minute after midnight is entered as

“12:01am.” Births occurring at midnight should be recorded as “12:00am,” (or “12 mid” in

Certificate Manager), and births occurring at noon should be recorded as “12:00pm” (or “12

noon” in Certificate Manager).

In cases of plural births, the exact time at which each infant was delivered should be recorded

as the hour and minute of birth for that infant.

DATE OF BIRTH

This is a mandatory-to-save item and must be filled out before the record can be saved. The

date must be entered in the following format MM/DD/YYYY.

Enter the exact month, day, and year that the infant was born.

Pay particular attention to the entry of the month, day, or year when the birth occurs around

midnight or on December 31. Consider a birth at midnight to have occurred at the end of the

day rather than at the beginning of the next day.

PLURALITY

This is a mandatory-to-save item and must be filled out before the record can be saved. If a

single birth is indicated, the following field indicating birth order will auto-populate, and the

user may continue tabbing through to the next field. In a birth order field, a selection must be

made.

PLURALITY-BIRTH ORDER

This is a mandatory – to – save item and must be filled out before the record can be saved.

Specify the birth as single, twin, triplet, quadruplet, etc.

Specify the order in which the infant being reported was born: first, second, third, etc.

NUMBER OF INFANTS ALIVE

When plurality is greater than one, the “Number of Infants Alive” field is activated. Select

from the list.

When a plural delivery occurs, prepare and file a separate certificate for each infant born

alive. File certificates relating to the same plural delivery at the same time. However, if

holding the completed certificates while waiting for incomplete ones would

result in late filing, the completed certificates should be filed first.

These items are related to other items on the certificate (for example, period of gestation and

birth weight) that have important health implications. This information is also used to study

multiple deliveries and high-risk infants who may require additional medical attention.

MOTHERS CURRENT LEGAL NAME

TITLE PREFERENCE:

Select from the drop down list one of these three option—as per the mother’s choice:

“Mother,” “Father,” “Parent.”

FIRST NAME:

Enter the mother’s first name.

MIDDLE NAME:

Enter the mother’s middle name. If there is no middle name, leave this item blank; do not

enter NMI, NMN, etc.

LAST NAME:

Enter the mother’s last name.

SUFFIX:

Enter any suffixes following the last name.

CHILDS CURRENT LEGAL NAME

FIRST NAME:

Enter the infant’s first name. If the parents have not selected a given name for the infant,

enter “Infant.” Do not enter the last name of the mother as the child’s first name. Do not

leave this item blank.

MIDDLE NAME:

Enter the infant’s middle name and any names other than First and Last. If there is no middle

name, leave this item blank; do not enter NMI, NMN, etc.

LAST NAME:

Enter the infant’s last name. The child’s last name does not have to be the same as either

parent. Also, enter any suffixes following the last name.

No numerical characters can be used in names [Example: 123456789], but you may spell

out a number in a name. [Example: One, Two, Three, etc.] No obscenities or non-

alphabetic characters are permitted.

Special Characters that are used in languages other than English are not permitted.

[Examples: è, é, ê, ë, å, ä, ã, ü, ø, ö, ó, ć, etc.]

Parents may name the infant any name they desire as long as it will fit in the space provided

on the certificate.

The parent(s) do not have to give the child their surname; for instance, John Jones and Mary

Brown, husband and wife, may name their child Tommy Green, Jr.

A mother may give her child a supposed father’s name without his name appearing on the

birth certificate as the father.

A last name may be hyphenated, as in Jones-Brown.

MOTHERS ADDRESS (RESIDENCE)

RESIDENCE ADDRESS:

The mother’s residence is the place where her household is located. This is not necessarily

the same as her home state, voting residence, mailing address, or legal residence.

The state, county, city and street address should be for the place where the mother actually

lives. Never enter a temporary residence, such as one used during a visit, business trip or

vacation.

Residence for a short time at the home of a relative, friend, or home for unwed mothers for

awaiting the birth of the child is considered temporary and should not be entered here.

However, place of residence during a tour of military duty or during attendance at a college

is not considered temporary and should be entered on the certificate as the mother’s place of

residence.

Enter the number and street name of the mother’s residence, Rural Route number, or

description that will aid in identifying the location.

RESIDENCE STATE:

Enter the state in which the mother lives. This may differ from the state for her mailing

address. If the mother is not a U.S. resident, enter the name of the country.

APT. #:

Enter the apartment number, if appropriate.

STATE/FOREIGN COUNTRY/TERRITORY:

This field is a Type-Ahead Combo box. Select from the drop down list. If your selection is

not on the list, it may be entered via “Add on the Fly” (AOF) process. County: Enter the

name of the county in which the mother lives. That county pick list will automatically

populate with the counties that are in the state that was specified in the previous field.

CITY /TOWN OR LOCATION:

Enter the city or town in which the mother resides. Do not enter the word “Rural” if outside

city limits; enter only the city name. This field is a Type-Ahead Combo box.

The city/town or location pick list will automatically populate with the cities/towns that are

in the county that was specified in the previous field. Select a city from the list. If the city is

not on the list, it may be entered via “add on the fly” (AOF) process.

ZIP CODE:

The zip code pick list will automatically populate with the zip codes that are associated with

the city that was specified in the previous field. Select a zip code from the list. If the zip code

is not on the list, it may be entered via “add on the fly” (AOF) process

ZIP CODE EXTENSION:

If a zip code extension is applicable, it may be entered in this field. Otherwise, leave this

field blank.

Note: Statistics on births are tabulated by place of residence of the mother. This makes it

possible to compute birth rates based on the population residing in that area. Data on births

by place of residence of the mother are used to prepare population estimates and projections.

These data are used in planning for and evaluating community services and facilities,

including maternal and child health programs, schools, etc. Private businesses and industries

also use these data for estimating demands for services. Inside city limits is used to properly

assign to either the city or the remainder of the county.

SAME AS RESIDENCE ADDRESS (MAILING ADDRESS)

This field is a type-ahead Combo box. If the mothers mailing address is the same as her

residence address, the remaining fields under mother’s mailing address will auto-populate,

and the users may tab through to the next screen.

Note: if changes are made to the residence information fields, the changes will also be

reflected in the mailing address fields.

If the mother’s mailing address is NOT the same as her residence address, tab through to the

next field. Enter the mother’s mailing address only if it is different from her street address.

Enter the entire address, including the city, state, and zip code.

It is important to distinguish between the mothers mailing address and her residence address

because each serves a different purpose. They are not substitutes for one another.

This information is used to mail the social security card and approved public health

information / reminders to the mother.

2.3 MOTHER 1 – (TAB 2)

MOTHER’S DATE OF BIRTH

Enter the exact month, day and year that the mother was born. The date entered must be in

the following format: MM/DD/YYYY.

MOTHER’S AGE

This field will auto-fill based on the information entered in the previous field.

MOTHER’S BIRTH STATE, TERRITORY OR FOREIGN COUNTRY OF BIRTH

Select the state, territory, or foreign country of the mother’s birth. If it is not on the list, it

may be entered via “On the Fly” (AOF) process. Enter the mother’s place of birth.

If the mother was born in the United States, enter the name of the state; if the mother was

born in a foreign country or a U.S. territory, enter the name of the country or territory.

If no information is available regarding place of birth, enter “Unknown” in this item. If the

mother was born in the United States or a U.S. Territory, but the exact state or territory is

unknown, enter “United States.”

If the mother was born in a foreign country, but the country is unknown, enter “Foreign.”

This item provides information on recent immigrant groups, such as Asian and Pacific

Islanders, and is used for tracing family histories. It is also used to compare the childbearing

characteristics of women who were born in the United States with those of foreign-born

women.

MOTHERS SSN

Enter the mother’s social security number. A parent may refuse to give his or her social

security number, but it is strongly recommended it be obtained if possible.

In some instances, one or both may not have social security numbers. Should they refuse to

provide their number, or not have a number, leave this field blank; do not enter “unknown.”

SSN FOR BABY

Mark the “Yes” box if the parent wants a Social Security number issued for the baby; mark

“No” if the parent does not. Answering “yes” to this question will enable the Social Security

Letter and will make the record eligible to be included in the SSA Extract.

If the “Yes” block is not checked or the child does not have a name, no social security

number will be issued by the Social Security Administration through the birth registration

process.

It will take approximately two weeks from the time of electronic transmission for the parent

to receive the social security card from the Social Security Administration.

MOTHER RELINQUISH RIGHTS

Select from the list. Mother Relinquish Date This field will only enable if the answer to the

previous question is “yes.” The date entered must be in the following format:

MM/DD/YYYY.

MOTHER’S EDUCATION.

Select from the list. Enter the total number of years of education completed. If education is

unknown, enter “Unknown.” For no education, enter “None.”

A person who enrolls in college but does not complete one full year should not be identified

with any college education in this item.

Do not include beauty, barber, trade, business, technical, pre-kindergarten, kindergarten, or

other special schools when determining highest grade completed. Zero (0) indicates no

regular schooling; 1-12 indicates years of elementary/secondary school completed; 13-16

represent 1-4 years of college; and 17+ indicates graduate education beyond a bachelor’s

degree.

Education is correlated with fertility and birth outcome, and is used as an indicator of

socioeconomic status. This item is also used to measure the effect of education and social

economic status on health, childbearing, and infant mortality.

MOTHER’S OCCUPATION AND INDUSTRY

Enter the mother’s occupation during most of her working life (e.g., homemaker, student,

teacher, clerk, programmer, attorney, realtor, artist, nurse, etc.). If occupation is unknown,

enter “Unknown.” For no occupation, enter “None.” Many women specify “housewife”

because they stopped working after pregnancy began or shortly before birth. Ask them if they

were working any time in the last two years. Do not use “self-employed.”

MOTHER’S TYPE OF BUSINESS

Enter the kind of business or industry related to the mother’s occupation (e.g., ranching,

retail, consulting, education, farming, government, manufacturing, etc.). If the kind of

business is unknown, enter “Unknown.” For no kind of business, enter “None.”

MOTHER OF HISPANIC ORIGIN

Check one (1) from the list. If “yes,” other Spanish? Hispanic? Latino” is checked, enter the

Hispanic Origin in the specify field. Mark “Yes” or “No” to indicate whether the mother is of

Hispanic origin. Enter the country(ies) of Hispanic origin. If the mother indicates that she is

of multiple Hispanic origins, enter the origins as reported, separated by commas (for

example, Mexican, Puerto Rican).

This item is not a part of the Race item; a person of Hispanic origin may be of any race.

Each question, Race and Hispanic origin, should be asked and treated as an independent item.

Hispanics comprise the second largest ethnic minority in this country. This item provides

data to measure differences in fertility and pregnancy outcome as well as variations in health

care for people of Hispanic and non-Hispanic origin. Without collection of data on persons of

Hispanic origin, it is impossible to obtain valid demographic and health information on this

important group of Americans.

Note: Information on race/ethnicity is essential in producing data for various populations. It

is used to study cultural variations in access to health care and pregnancy outcomes (infant

mortality and birth weight). Race/ethnicity is an important variable in planning for and

evaluating the effectiveness of health programs and in preparing population estimates.

MOTHER’S RACE FRAME

Enter the race of the mother as obtained from the parents or other informant. For Asians and

Pacific Islanders, enter the national origin of the mother, such as Chinese, Japanese, Korean,

Filipino, Samoan, Vietnamese, or Hawaiian.

Check one or more races to indicate how the mother identifies herself.

• 01 White

• 02 Black or African American

• 03 American Indian or Alaska Native If “American Indian or Alaska Native”

is checked, enter the name of the enrolled or principle tribe in the field.

• 04 Asian Indian

• 05 Chinese

• 06 Filipino

• 07 Japanese

• 08 Korean

• 09 Vietnamese

• 10 Other Asian If “Other Asian” is checked, enter the “other Asian” race in

the “specify field.”

• 11 Native Hawaiian

• 12 Guamanian or Chamorro

• 13 Samoan

• 14 Other Pacific Islander If “Other Pacific Islander” is checked, enter the

“other pacific islander” race in the specify field.

• 15 Other If “Other” is checked, enter the “Other” race in the ‘Specify” field.

• 99 Unknown

MOTHER 2 – (TAB 3)

MOTHER’S HEALTH INFORMATION

DID THE MOTHER RECEIVE WIC FOOD FOR HERSELF BECAUSE SHE WAS

PREGNANT WITH THIS CHILD?

Select from the list.

MOTHER’S HEIGHT MOTHER’S WEIGHT (POUNDS)

• Pre-pregnancy – enter the pre-pregnancy weight in pounds.

• At Delivery – enter the mother’s weight at the time of the delivery in pounds.

Note: This will indicate the amount of weight in pounds gained by the mother during the

pregnancy.

CIGARETTE SMOKING BEFORE AND DURING PREGNANCY

Enter the approximate amount in a single cigarette count or in packs per day. Enter “0” if a

non-smoker. This section is divided into four quarters; three months before, first three

months; second three months and third trimester. Each section will need to be answered.

Note: Smoking during pregnancy may have an adverse impact on pregnancy outcome. This

information is used to evaluate the relationship between certain lifestyle factors and

pregnancy outcome and to determine at what levels these factors clearly begin to affect

pregnancy outcome.

MOTHER’S MARITAL STATUS

The following choices are available.

• Never married – if this selection is made, focus will automatically advance to the

“Paternity Affidavit” field.

• Widowed – If this selection is made, focus will automatically advance to the “Married

within 300 days” field.

• Divorced – If this selection is made, focus will automatically advance to the “Married

within 300 days” field.

• Currently Married – If this selection is made, focus will automatically advance to the

“Paternity Affidavit” field.

Note: Common law marriage is a legal marriage in Texas. If the parent’s state they are

married by virtue of common law, as long as they are not married to another party and they

both are at least 18 years of age, then the person completing the birth certificate should not

question the validity of the marriage. A woman is legally married even if she is separated.

However, a person is no longer legally married when the divorce is granted by a judge.

• Married but refusing Husband Information – If this selection is made, TxEVER will

assume that there will not be a Paternity Acknowledgement attached to the record and

will disable both the fathers and presumed fathers information.

Note: This information is used to monitor the differences in health and fertility between

married and unmarried women.

MARRIED WITHIN 300 DAYS

The following choices are available.

• Yes – If this selection is made, focus will automatically advance to the “Paternity

Affidavit” field.

• No – If this selection is made, focus will automatically advance to the “Paternity

Affidavit” field.

• Yes, but refusing Father’s Information – If this selection is made, TxEVER will assume

that there will not be a Paternity Acknowledgement attached to the record and will

disable both the fathers and presumed fathers information.

AOP

Select from the list.

MOTHERS NAME PRIOR TO FIRST MARRIAGE

The following fields are available

FIRST NAME:

Enter the mother’s first name.

MIDDLE NAME:

Enter the mother’s middle name. If there is no middle name, leave this item blank; do not

enter NMI, NMN, etc.

LAST NAME:

Enter the mother’s last name prior to her first marriage.

SUFFIX:

Enter any suffixes following the last name

Note: The mother’s maiden surname is important because it remains constant throughout her

life, in contrast to other names, which may change because of marriage or divorce. This is

also the basic link to the child’s maternal lineage.

2.4 FATHER 1 – (TAB 4)

If the mother is married at the time birth, (or was married and the marriage ended not more

than 300 days before the birth), the husband or former husband of the mother is presumed to

be the father of the child. [FC §160.201(b)(1), FC

§160.204] If the husband or former husband actually is the father of the child, his information

can be added to the birth certificate, and no signatures or Acknowledgment of Paternity are

required.

If the parents state that they are married by common law, VSS will accept the birth certificate

without an AOP as long as “Mother Married” is checked “Yes.” However; the Office of the

Attorney General recommends that an AOP be signed in cases involving common-law

marriage because of the difficulty of proving a common-law marriage if it is ever challenged.

When the parents are not married, or the mother is married to someone other than the father

(or was married and the marriage ended within 300 days before the birth of the child),

paternity may be voluntarily established by using a witnessed Acknowledge of Paternity,

Form VS-159.1 (AOP). If the form is properly completed and attached to the birth certificate,

the father’s information can be included on the birth certificate.

If a man believes he is the father and the mother does not agree, he may file a Notice of

Intent to Claim Paternity VS-130 before or within 30 days from the date of the child’s birth.

It will not legally establish paternity or allow him to be named on the birth certificate, but it

allows him to assert that he believes he is the father and wishes to preserve his rights as a

parent.

If you have a question about whether to add the father’s name to the birth certificate, or when

and how to complete the AOP see the section of this handbook on “Paternity.”

FATHER’S CURRENT LEGAL NAME

TITLE PREFERENCE:

Select from the drop down list one of these three option—as per the mother’s choice:

“Mother,” “Father,” “Parent.”

FIRST NAME:

Enter the father’s first name.

MIDDLE NAME:

Enter the father’s middle name. If there is no middle name leave this item blank; do not enter

NMI, NMN, etc.

LAST NAME:

Enter the father’s last name.

SUFFIX:

Enter any suffixes following the last name.

FATHER’S NAME PRIOR TO FIRST MARRIAGE

FIRST NAME:

Enter the father’s first name.

MIDDLE NAME:

Enter the father’s middle name. If there is no middle name leave this item blank; do not enter

NMI, NMN, etc.

LAST NAME:

Enter the father’s last name.

SUFFIX:

Enter any suffixes following the last name.

FATHER’S DATE OF BIRTH

The date entered must be in the following format; MM/DD/YYYY. Enter the exact month,

day, and year that the father was born. If unknown, tab through this section.

FATHER’S BIRTH STATE, TERRITORY, OR FOREIGN COUNTRY

• Select the state, territory, or foreign country of the father’s birth. If not on the list, it may

be entered via “Add on the fly” (AOF) process.

• Enter the father’s place of birth. If the father was born in the United States, enter the

name of the state. If the father was born in a foreign country or a U.S. territory, enter the

name of the country or territory.

• If no information is available regarding place of birth, tab through this section. If the

father was born in the United States or a U.S. Territory, but the exact state or territory is

unknown; enter “United States.”

• If the father was born in a foreign country, but the country is unknown, enter “Foreign.”

FATHER’S SSN

Enter the father’s social security number.

Note: A parent may refuse to give his or her social security number, but it is strongly

recommended it be obtained if possible. In some instances, one or both may not have social

security numbers. Should they refuse to provide their number, or not have number, leave this

field blank; do not enter “unknown.”

FATHER’S EDUCATION

Select from the list.

Enter the total number of years of education completed. If education is unknown, enter

“Unknown.” For no education, enter “None.” A person who enrolls in college but does not

complete one full year should not be identified with any college education in this item. Do

not include beauty, barber, trade, business, technical, pre-kindergarten, kindergarten, or other

special schools when determining highest grade completed.

Note: Education is correlated with fertility and birth outcome, and is used as an indicator of

socioeconomic status. This item is also used to measure the effect of education and social

economic status on health, childbearing, and infant mortality.

FATHER’S OCCUPATION AND INDUSTRY

Enter the father’s occupation during most of his working life (e.g., homemaker, student,

teacher, clerk, programmer, attorney, realtor, artist, nurse, etc.). If occupation is unknown,

enter “Unknown.” For no occupation, enter “None.” Do not use “self-employed.”

FATHER’S TYPE OF BUSINESS (INDUSTRY)

Enter the kind of business or industry related to the occupation (e.g., ranching, retail,

consulting, education, farming, government, manufacturing, etc.). If the kind of business is

unknown, enter “Unknown.” For no kind of business, enter “None.”

FATHER OF HISPANIC ORIGIN

Check one (1) from the list. If “yes,” other Spanish? Hispanic? Latino” is checked, enter the

Hispanic Origin in the specify field. Mark “Yes” or “No” to indicate whether the father is of

Hispanic origin. Enter the country (ies) of Hispanic origin. If the father indicates that he is of

multiple Hispanic origins, enter the origins as reported, separated by commas (for example,

Mexican, Puerto Rican).This item is not a part of the Race item; a person of Hispanic origin

may be of any race.

Each question, Race and Hispanic origin, should be asked and treated as an independent item.

Hispanics comprise the second largest ethnic minority in this country. This item provides

data to measure differences in fertility and pregnancy outcome as well as variations in health

care for people of Hispanic and non-Hispanic origin. Without collection of data on persons of

Hispanic origin, it is impossible to obtain valid demographic and health information on this

important group of Americans.

FATHER’S RACE CHECK

Enter the race of the father as obtained from the parents or other informant. For Asians and

Pacific Islanders, enter the national origin of the father, such as Chinese, Japanese, Korean,

Filipino, Samoan, Vietnamese, or Hawaiian.

Check one or more races to indicate how the mother identifies herself.

• 01 White

• 02 Black or African American

• 03 American Indian or Alaska Native If “American Indian or Alaska Native” is

checked, enter the name of the enrolled or principle tribe in the field.

• 04 Asian Indian

• 05 Chinese

• 06 Filipino

• 07 Japanese

• 08 Korean

• 09 Vietnamese

• 10 Other Asian If “Other Asian” is checked, enter the “other Asian” race in the

“specify field.”

• 11 Native Hawaiian

• 12 Guamanian or Chamorro 13 Samoan

• 11 Other Pacific Islander If “Other Pacific Islander” is checked, enter the “other

pacific islander” race in the specify field.

• 12 Other If “Other” is checked, enter the “Other” race in the ‘Specify” field. 99

Unknown

Note: Information on race/ethnicity is essential in producing data for various populations. It

is used to study cultural variations in access to health care and pregnancy outcomes (infant

mortality and birth weight). Race/ethnicity is an important variable in planning for and

evaluating the effectiveness of health programs and in preparing population estimates.

2.5 FATHER 2 – (TAB 5)

PATERNITY – GENETIC TESTING

Select from the list.

FATHER’S MAILING ADDRESS

SAME AS MOTHER’S MAILING ADDRESS

If the father’s mailing address is the same as the mother’s mailing address, select “yes.” If his

address is different from the mother’s, enter the father’s complete mailing address, including

city, state, and zip code.

RESIDENCE ADDRESS

The father’s residence is the place where his household is located. This is not necessarily the

same as his home state, voting residence, mailing address, or legal residence. The state,

county, city and street address should be for the place where the father actually lives. Never

enter a temporary residence, such as one used during a visit, business trip or vacation.

Residence for a short time at the home of a relative, friend, or home for unwed mothers for

awaiting the birth of the child is considered temporary and should not be entered here.

However, place of residence during a tour of military duty or during attendance at a college

is not considered temporary and should be entered on the certificate as the father’s place of

residence.

Enter the number and street name of the father’s residence, Rural Route number, or

description that will aid in identifying the location.

RESIDENCE STATE

Enter the state in which the father lives. This may differ from the state for his mailing

address. If the father is not a U.S. resident, enter the name of the country.

APT. #:

Enter the apartment number, if appropriate.

STATE/FOREIGN COUNTRY/TERRITORY

This field is a Type-Ahead Combo box. Select from the drop down list. If your selection is

not on the list, it may be entered via “Add on the Fly” (AOF) process.

COUNTY

Enter the name of the county in which the father lives. That county pick list will

automatically populate with the counties that are in the state that was specified in the

previous field.

CITY /TOWN OR LOCATION

Enter the city or town in which the father resides. Do not enter the word “Rural” if outside

city limits; enter only the city name. This field is a Type-Ahead Combo box. The city/town

or location pick list will automatically populate with the cities/towns that are in the county

that was specified in the previous field. Select a city from the list. If the city is not on the list,

it may be entered via “add on the fly” (AOF) process.

ZIP CODE

The zip code pick list will automatically populate with the zip codes that are associated with

the city that was specified in the previous field. Select a zip code from the list. If the zip code

is not on the list, it may be entered via “add on the fly” (AOF) process.

ZIP CODE EXTENSION

If a zip code extension is applicable, it may be entered in this field. Otherwise, leave this

field blank.

PRESUMED FATHER’S INFORMATION

If the mother is married at the time birth, (or was married and the marriage ended not more

than 300 days before the birth), the husband or former husband of the mother is presumed to

be the father of the child.

PRESUMED FATHER’S DATE OF BIRTH

The date entered must be in the following format; MM/DD/YYYY. Enter the exact month,

day, and year that the presumed father was born. If unknown, tab through this section.

PRESUMED FATHER’S SSN

Enter the presumed father’s social security number.

PRESUMED FATHER’S CURRENT LEGAL NAME

FATHER’S FIRST NAME

Enter the presumed father’s first name.

FATHER’S MIDDLE NAME

Enter the presumed father’s middle name. If there is no middle name leave this item blank;

do not enter NMI, NMN, etc.

FATHER’S LAST NAME

Enter the presumed father’s last name.

FATHER’S SUFFIX

Enter any suffixes following the last name.

PRESUMED FATHER’S MAILING ADDRESS

It is important to distinguish between the presumed father’s mailing address and his residence

address because each serves a different purpose. They are not substitutes for one another.

ADDRESS

Enter the number and street name of the presumed father’s mailing address, Rural Route

number, or description that will aid in identifying the location.

RESIDENCE STATE

Enter the state in which the presumed father’s receives mail. If the presumed father is not a

U.S. resident, enter the name of the country.

APT. #:

Enter the apartment number, if appropriate.

STATE/FOREIGN COUNTRY/TERRITORY

This field is a Type-Ahead Combo box. Select from the drop down list. If your selection is

not on the list, it may be entered via “Add on the Fly” (AOF) process.

COUNTY

Enter the name of the county in which the presumed father receives mail. That county pick

list will automatically populate with the counties that are in the state that was specified in the

previous field.

CITY /TOWN OR LOCATION

Enter the city or town in which the presumed father receives mail. Do not enter the word

“Rural” if outside city limits; enter only the city name.

This field is a Type-Ahead Combo box. The city/town or location pick list will automatically

populate with the cities/towns that are in the county that was specified in the previous field.

Select a city from the list. If the city is not on the list, it may be entered via “add on the fly”

(AOF) process.

ZIP CODE

The zip code pick list will automatically populate with the zip codes that are associated with

the city that was specified in the previous field.

Select a zip code from the list. If the zip code is not on the list, it may be entered via “add on

the fly” (AOF) process.

ZIP CODE EXTENSION

If a zip code extension is applicable, it may be entered in this field. Otherwise, leave this

field blank.

2.6 MEDICAL 1 – (TAB 6)

PRENATAL CARE

PRENATAL CARE?

If the mother had no pre-natal care, select “No” from the drop down list.

If the mother had pre-natal care, select “Yes” from the drop down list.

If the mother’s pre-natal history is unknown, select “unknown” from the drop down list.

Pregnancy history fields will be disabled if you answered “No” or “Unknown.”

DATE OF FIRST VISIT

Enter the date of this pregnancy in which the mother first received care from a physician or

other health professional, or attended a prenatal clinic. The date must be entered in the

following format: MM/DD/YYYY.

The month of pregnancy in which prenatal care began is measured from the date last normal

menses began and not from the date of conception.

DATE OF LAST VISIT

Enter the date of this pregnancy in which the mother last received care from a physician or

other health professional, or attended a prenatal clinic. The date must be entered in the

following format: MM/DD/YYYY.

TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

Enter the number of prenatal visits the mother had for this pregnancy. Enter the number of

visits made to a health care provider for supervision of the pregnancy. If the answer is

“None,” or unknown this item will be disabled.

This information is used to determine the relationship of prenatal care to the health of the

child at birth. The number of women receiving delayed care or no care is of considerable

interest to public health officials because inadequate care may be harmful to both the mother

and fetus.

DATE OF LAST NORMAL MENSES BEGIN

Enter the start date of the mother’s last normal menses prior to the start of this pregnancy.

The date must be entered in the following format. MM/DD/YYYY.

This item, in conjunction with the date of birth, is used to determine length of gestation. A

record with a plausible date that the Last Normal Menses began provides a cross check with

length of gestation based on ultrasound or other techniques.

SOURCE OF PRENATAL CARE

Mark the appropriate box(es) to indicate all sources of prenatal care during this pregnancy. If

the “Other” box is marked, enter the other source of prenatal care.

PREGNANCY HISTORY

LIVE BIRTHS NOW LIVING

Enter the number of children born alive to this mother who are still living; do not include this

child. If this child is the mother’s first, or if all previous live-born children have died, marks

“None.”

LIVE BIRTHS NOW DEAD

Enter the number of children born alive to this mother who are no longer living; do not

include this child. If this child is the mother’s first, mark “None.”

DATE OF LAST LIVE BIRTH

If applicable, enter the date of the last live birth for this mother. The date must be entered in

the following format. MM/YYYY.

If this certificate is for the second birth of a twin set, enter the date of birth for the first baby

of the set, if it was born alive. Similarly for triplets or other multiple births, enter the date of

birth of the previous live birth of the set. If all previously born members of a multiple set

were born dead, enter the date of the mother’s last delivery that resulted in live birth. If this

certificate is for the second birth of a twin set and the first was born dead, enter the delivery

date of that fetus. Similarly, for other multiple births, if any previous member of the set was

born dead, enter the delivery date of that fetus.

Note: These items are used to determine total birth and live birth order, which are important

in studying trends in childbearing and child spacing. They are also useful in studying health

problems associated with birth order (for example, first births to older women) and

determining the relationship of birth order to infant and prenatal mortality.

NUMBER OF OTHER PREGNANCY OUTCOMES

Enter the number of other pregnancy outcomes for this mother. This includes prenatal death

and abortion

DATE OF LAST OTHER PREGNANCY OUTCOME

Enter the date of the last other pregnancy outcome for this mother.

The date entered must be in the following format: MM/YYYY. Example: 02/2005.

RISK FACTORS IN THIS PREGNANCY

Check all that apply. If none applies, check ‘none of the above’

INFECTIONS

INFECTIONS PRESENT AND/OR TREATED DURING THE PREGNANCY

Check all that apply.

HIV TEST DONE PRENATALLY:

Select from the list.

HIV TEST DONE AT DELIVERY

Select from the list.

OBSTETRIC PROCEDURES

Check all that apply.

ONSET OF LABOR

Check all that apply.

2.7 MEDICAL 2 – (TAB 7)

CHARACTERISTICS OF LABOR & DELIVERY

Check all thatapply.

METHOD OF DELIVERY

This information is used to relate method of delivery with birth outcome, to monitor

changing trends in obstetric practice and to determine which groups of women are most

likely to have cesarean delivery. Information in this item can be used to monitor delivery

trends in Texas and across the United States.

WAS DELIVERY WITH FORCEPS ATTEMPTED BUT UNSUCCESSFUL?

Select from the list.

WAS THE DELIVERY WITH VACUUM EXTRACTION ATTEMPTED BUT

UNSUCCESSFUL?

Select from the list.

FETAL PRESENTATION AT BIRTH

Select from the list.

If ‘Other’ is selected, enter clarifying information in the field.

FINAL ROUTE AND METHOD OF DELIVERY

Select from the list.

IF CESAREAN, WAS A TRIAL OF LABOR ATTEMPTED?

This field will only enable if the answer to the previous question is ‘Yes’. Select from the list.

MATERNAL MORBIDITY

Check all that apply.

CHILDS HEALTH INFORMATION

BIRTH WEIGHT

Enter the infant’s birth weight, in either grams or pounds and ounces. Do not convert from

one measure to the other. Weight in grams should be entered to the left of the printed

“Grams:” Weight in pounds and ounces should be entered to the left of the printed “Pounds,

Ozs.”

Do not enter fractions. Round fractional ounces to the nearest ounce; round fractional grams

to the nearest gram.

This is the single most important characteristic associated with infant mortality. It is also

related to prenatal care, socioeconomic status, marital status, and other factors surrounding

the birth. Consequently, it is used with other information to plan for and evaluate the

effectiveness of health care.

OBSTETRIC ESTIMATE OF GESTATION (WEEKS)

Please enter the obstetric estimate of the infant’s gestation.

If the obstetric estimate of gestation is not known, enter one question mark (?) in the space.

Do not complete this item based on the infant’s date of birth and the mother’s date of LMP.

CALCULATED GESTATION (WEEKS)

The Calculated Gestation (Weeks) will be automatically calculated from the date entered in

the Date of Birth field and the date entered in the Date Last Normal Menses Began field.

CHILD’S SEX

If sex and name are inconsistent, verify both entries. If sex cannot be determined after

verification with medical records, mother of child, or other sources, select “Not Yet

Determined”

This item aids in identification of the infant. It is also used for measuring sex differentials in

health related characteristics and for making population estimates and projections.

APGAR SCORE

At 5 minutes / At 10 minutes

Enter the infant’s Apgar score at 5 minutes, and if the score at 5 minutes is less than 6, enter

the infant’s Apgar score at 10 minutes.

If the infant’s Apgar score is not known or was not taken at 5 minutes or 10 minutes, enter

“unknown.”

If Apgar score is not taken at 5 minutes or 10 minutes, select “Not Taken”.

WAS INFANT TRANSFERRED WITHIN 24 HOURS DELIVERY?

ABNORMAL CONDITIONS OF THE NEW BORN

Mark each abnormal condition associated with the newborn infant. If more than one

abnormal condition exists, mark each condition.

This item cannot be left blank.

This information should be obtained from the infant’s physician or the medical records .

ASSISTED VENTILATION REQUIRED IMMEDIATELY FOLLOWING DELIVERY

(LESS THAN 30 MINUTES):

It is a mechanical method of assisting respiration for newborns with a respiratory failure. In

this case, the ventilation assistance lasts for less than 30 minutes.

Synonym to be included in this item: Intubated with 02 less than 30 minutes

ASSISTED VENTILATION REQUIRED FOR MORE THAN SIX HOURS:

Newborn placed on assisted ventilation for 30 minutes or longer.

Synonym to be included in this item: Intubated with O2 30 minutes or more.

NICU ADMISSION:

Check if baby was admitted into the NIC unit.

NEWBORN GIVEN SURFACTANT REPLACEMENT THERAPY:

Check if this item applies.

ANTIBIOTICS RECEIVED BY THE NEWBORN FOR SUSPECTED NEONATAL

SEPSIS:

Sepsis: A systemic infection diagnosed in the newborn. ICD-9 code 771.8

SEIZURE OR SERIOUS NEUROLOGICAL DYSFUNCTION:

Seizures: A seizure of any etiology. Frequent and serious neonatal problem, usually focal,

migratory clonic jerks of extremities, alternating hemiseizures, or primitive subcortical

seizures. A sudden, brief attack of altered consciousness, motor activity, sensory phenomena,

or inappropriate behavior. ICD 9 code 779.0

SIGNIFICANT BIRTH INJURY (SKELETAL FRACTURE(S), PERIPHERAL NERVE

INJURY, AND/OR SOFT TISSUE/ SOLID ORGAN HEMORRHAGE WHICH

REQUIRES INTERVENTION):

Check if applies.

NONE OF THE ABOVE:

If it is Abnormal Conditions of the New Born is not known enter “None of the above”

Note: Information on abnormal conditions of the newborn helps measure the extent infants

experience medical problems and can be used to plan for their health care needs. This item

also provides a source of information on abnormal outcome in addition to congenital

anomalies or infant death. These data allow researchers to estimate the number of high-risk

infants who may benefit from special medical services.

CONGENITAL ANOMALIES

Mark each anomaly of the child. Do not include birth injuries. The checklist of anomalies is

grouped according to major body systems. If there are no congenital anomalies of the child,

select “None of the Above.” This item must be completed. This information should be

obtained from the mother’s and infant’s physician or the medical records (obstetric and

pediatric).

ANENCEPHALY

Partial or complete absence of the brain and skull. Also called anencephalus, acrania, or

absent brain. Babies with craniorachischisis (anencephaly with contiguous spine defect)

should also be included in this category.

MENINGOMYELOCELE/SPINA BIFIDA

Spina bifida refers to herniation of the meninges and/or spinal cord tissue through a bony

defect of spine closure. Meningomyelocele refers to herniation of meninges and spinal cord

tissue. Babies with meningocele (herniation of meninges without spinal cord tissue) should

also be included in the category. Both open and closed (covered with skin) lesions should be

included. Spina bifida occulta (a midline bony spinal defect without protrusion of the spinal

cord or meninges) should not be included in this category.

CYANOTIC CONGENITAL HEART DISEASE

Congenital heart defects that cause cyanosis. This includes, but is not limited to, to

transposition of the great arteries (vessels), teratology of Fallot, pulmonary or pulmonic

valvular atresia, tricuspid atresia, truncus arteriosus, total/partial anomalous pulmonary

venous return with or without obstruction.

CONGENITAL DIAPHRAGMATIC HERNIA

Defect in the formation of the diaphragm allowing herniation of abdominal organs into the

thoracic cavity.

OMPHALOCELE

A defect in the anterior abdominal wall, accompanied by herniation of some abdominal

organs through a widened umbilical ring into the umbilical stalk. The defect is covered by a

membrane, (different from gastroschisis, see below), although this sac may rupture. Also

called exomphalos. Umbilical hernia (completely covered by skin) should not be included in

this category.

GASTROSCHISIS

An abnormality of the anterior abdominal wall, lateral to the umbilicus, resulting in

herniation of the abdominal contents directly into the amniotic cavity. Differentiated from

omphalocele by the location of the defect and absence of a protective membrane.

LIMB REDUCTION DEFECT (EXCLUDING CONGENITAL AMPUTATION AND

DWARFING SYNDROMES)

Complete or partial absence of a portion of an extremity secondary to failure to develop.

CLEFT LIP WITH OR WITHOUT CLEFT PALATE

Cleft lip with or without cleft palate refers to incomplete losure of the lip. Cleft lip may be

unilateral, bilateral or median; all should be included in this category.

CLEFT PALATE ALONE

Cleft palate refers to incomplete fusion of the palatal shelves. This may be limited to the soft

palate or may also extend into the hard palate. Cleft palate in the presence of cleft lip should

be included in the “Cleft Lip with or without cleft Palate” category, rather than here.

DOWN SYNDROME:

Trisomy 21

Karotype (select from list)

Confirmed, Pending or Unknown.

SUSPECTED CHROMOSOMAL DISORDER

Includes any constellation of congenital malformations resulting from or compatible with

known syndromes caused by detectable defects in chromosome structure.

Karotype (select from list) Confirmed,

Pending or Unknown.

HYPOSPADIAS:

Incomplete closure of the male urethra resulting in the urethral meatus opening on the ventral

surface of the penis. Includes first degree – on the glans ventral to the tip, second degree – in

the coronal sulcus, and third degree – on the penile shaft.

NONE OF THE ABOVE

Indicates no congenital anomalies were identified by the time of the birth certificate

completion.

Note: Information on congenital anomalies is used to identify health problems that require

medical care and to monitor the incidence of the stated conditions. It is also used to study

unusual clusters of selected anomalies, to track trends among different segments of the

population, and to relate the prevalence of anomalies to other characteristics of the mother,

infant, and the environment.

IMMTRAC CONSENT

ImmTrac is the Texas immunization registry developed by the Texas Department of State

Health Services (DSHS). ImmTrac is a free, confidential registry designed to consolidate

immunization records from multiple providers and store a child’s immunization information

electronically in one secure central system. ImmTrac offers physicians and other healthcare

providers and authorized users an easy online access to a child’s immunization history. The

Registry is part of a DSHS initiative to increase vaccination coverage for children across

Texas.

With written parental consent, the ImmTrac Registry receives vaccination information for a

child from private and public healthcare providers across the state, including input from the

Vital Statistics Section of DSHS, Women, Infant and Children (WIC) clinics, Medicaid, the

Texas-Wide Integrated Client Encounter System (TWICES), and health plans. Upon

registration with ImmTrac, immunization information is available to schools, licensed

childcare facilities, local health departments, public health districts, payors, and state

agencies having legal custody of a child. Parents may request their child's ImmTrac record

from their physician or their local health department.

Please indicate the parent’s choice regarding consent for ImmTrac participation. The birth

registrar will be required to affirm that this information accurately reflects the parent’s

choice.

If the parent has not yet been offered the option to consent for ImmTrac participation you

may skip this section and answer later this section must be completed for legal release of the

birth registration in TxEVER.

More information on the ImmTrac program can be found at

www.dshs.state.tx.us/immunize/immtrac

2.8 CERTIFIER – (TAB 8)

ATTENDANT / CERTIFIER

ATTENDANT

Select an attendant from the list. If the attendant is not on the list, the Attendant’s Name and

Mailing Address may be entered via “On the Fly’ (AOF) process.

Type the full name and address of the person who delivered the baby (that is, the person who

was with the mother when the baby emerged from the birth canal- regardless of who cut the

umbilical cord). Enter the street and number, city or town, state and zip code.

ER physicians are considered to be the attending physician when an infant is delivered en

route to the facility if no other attendant can be identified or located for signature.

In the case of a foundling, the ER physician, the Chief of Staff Services, the Hospital

Administrator or, as a last resort, the case Social Worker may be shown on the record as

attendant. The record should be completed in so far as is possible.

A single line may be drawn through the word “attendant.” If the mother was alone when the

baby was born, she should be listed as the attendant.

However, she must file the birth certificate as a non-institutional birth and present the

documents required for such a filing to the local registrar in the registration district where the

birth occurred [See Non-Institutional Births for more instruction]. No record may be

accepted for filing without the attendant’s name and address being completed. The mailing

address is used for inquiries to correct or complete items on the record and for follow back

studies to obtain additional information about the birth.

IS CERTIFIER SAME AS ATTENDANT?

If yes is selected, the remaining fields will populate under attendant information.

CERTIFIER INFORMATION

Select a certifier from the list. If a certifier is not on the list, the certifier may be entered via

“On the fly’ (AOF) process. This person will be electronically certifying the record in

TxEVER.

DATE CERTIFIED

This will pre-populate with the date the record is electronically certified by the certifier.

PRINCIPAL SOURCE OF PAYMENT FOR THIS DELIVERY

Select the principal payment source from the list, or select “other” from the list and enter the

source in the “other” specify field.

MOTHER MEDICAID/CHIP NAME

If the mother is enrolled in CHIP enter that name in the Medicaid/CHIP name.

If it is not known if she is enrolled in CHIP, but mother is enrolled in Medicaid enter

mother’s Medicaid name in the Medicaid/CHIP name.

MOTHER MEDICAID/CHIP NUMBER

Use the mother's CHIP Perinatal ID number or Enrollment Confirmation Letter number to

enter the into Medicaid/CHIP number field.

If CHIP Perinatal number is not known, enter the mother's Emergency Medicaid ID number,

if known.

If neither CHIP nor Medicaid numbers are known, enter mother's name, and nine "9’s” into

the Medicaid/CHIP number field, so it appears as: 999999999

If the hospital is not participating in the auto forwarding process, hospital will have to

manually complete DHS 7484 form for those records where the mother’s Medicaid number

is used.

Hospitals do not need to complete the DHS 7484 form for these records where the CHIP

perinatal number is entered.

To participate in the automatic forwarding email h[email protected]xas.gov with your

• Facilities name;

• Medicaid provider number; and

• Your name and title.

Medicaid contact: Karen Roach @ (512) 231-5643 (check status or obtain 7484 form)

Enter the mother’s Medicaid number, if known. The number contains nine digits.

INFANT MEDICAL RECORD NUMBER

Enter the infant’s medical record number

INFANT PRIMARY CARE PHYSICIAN

Enter the infant’s primary care physician.

WAS MOTHER TRANSFERRED TO THIS FACILITY FOR DELIVERY?

Select yes, no or unknown from the list. Select NO if this is the first facility the mother was

admitted to for delivery.

Select YES if the mother was transferred from one facility to another facility before the child

was delivered.

SPECIFY FACILITY:

Enter the name of the facility from which the mother was transferred.

If the mother was transferred during labor from the care of a documented midwife, answer

YES and enter the word MIDWIFE followed by the midwife’s name.

If the mother was transferred more than once, enter the name of the last facility from which

she was transferred.

Transfer information is important in identifying high-risk deliveries and following up on

maternal and infant deaths.

2.9 INTENDED MOTHER – (TAB 9) [SURROGATE OPTION ONLY]

Note: This tab will only appear in TxEVER if the “Surrogate” function is active in the

General tab.

INTENDED MOTHER’S NAME PRIOR TO MARRIAGE

TITLE PREFERENCE:

Select from the drop down list one of these three option—as per the mother’s choice:

“Mother,” “Father,” “Parent.”

FIRST NAME:

Enter the mother’s first name.

MIDDLE NAME:

Enter the mother’s middle name. If there is no middle name leave this item blank, do not

enter NMI, NMN, etc.

LAST NAME:

Enter the mother’s last name.

SUFFIX:

Enter any suffixes following the last name.

INTENDED MOTHER

FIRST NAME:

Enter the mother’s first name.

MIDDLE NAME:

Enter the mother’s middle name. If there is no middle name leave this item blank, do not

enter NMI, NMN, etc.

LAST NAME:

Enter the mother’s last name.

SUFFIX:

Enter any suffixes following the last name.

DATE OF BIRTH

Enter the exact month, day and year that the mother was born. The date entered must be in

the following format: MM/DD/YYYY.

AGE

This field will auto-fill based on the information entered in the previous field.

STATE, TERRITORY OR FOREIGN COUNTRY OF BIRTH

Select the state, territory, or foreign country of the mother’s birth. If it is not on the list, it

may be entered via “On the Fly” (AOF) process. Enter the mother’s place of birth.

If the mother was born in the United States, enter the name of the state; if the mother was

born in a foreign country or a U.S. territory, enter the name of the country or territory.

If no information is available regarding place of birth, enter “Unknown” in this item. If the

mother was born in the United States or a U.S. Territory, but the exact state or territory is

unknown, enter “United States.”

If the mother was born in a foreign country, but the country is unknown, enter “Foreign.”

This item provides information on recent immigrant groups, such as Asian and Pacific

Islanders, and is used for tracing family histories. It is also used to compare the childbearing

characteristics of women who were born in the United States with those of foreign-born

women.

SSN

Enter the mother’s social security number. A parent may refuse to give his or her social

security number, but it is strongly recommended it be obtained if possible.

In some instances, one or both may not have social security numbers. Should they refuse to

provide their number, or not have a number, leave this field blank; do not enter “unknown.”

MOTHER’S MARITAL STATUS

The following choices are available.

• Never married – if this selection is made, focus will automatically advance to the

“Paternity Affidavit” field.