2. Parent’s Worksheet for Child’s Birth Certificate

   Now that you have welcomed your baby to the world there is one more thing you must do. It is time for you to provide information, so that your child's birth certificate can be created. Please read and complete the attached "Worksheet for Child's Birth Certificate" to ensure a birth certificate is created for your child.

   Please complete the information below and verify that all fields are completed correctly as this information will be used to create the birth certificate for your child. Remember, the birth certificate will be used by your child throughout their life for legal purposes to prove their age, citizenship, and parentage. Therefore, it is very important that the information provided is correct. Please review the information to avoid any errors on the birth certificate.

   Please review the information to avoid any errors on the birth certificate.

4. Case ID Number

5. (For Office Use Only)

7. Child's Tab

9. First Name*
10. Middle Name*
11. Last Name*
13. Suffix (e.g. Jr, III) *
14. Date of Birth*
    Date of Birth
15. Time of Birth*
16. AM/PM/Military/Unknown*

    1. AM
    2. PM
    3. Military
    4. Unknown
18. Sex/Gender*
19. Request Social Security Card*

    1. Yes, parent wants a card issued
    2. No, parent does not want a card issued

21. Mother's Tab

23. Mother/Parent Current Name

25. First Name*
26. Middle Name*
27. Last Name*

29. Mother/Parent Name Before First Marriage

31. First Name*
32. Middle Name*
33. Last Name*

35. Mother/Parent Birthplace

37. Date of Birth*
    Date of Birth
38. Social Security Number*
39. Birthplace State*
40. Birthplace County
42. Mother's Email Address*
43. Mother's Phone Number*

45. Mother/Parent Address

47. Current Residence

49. Street Number and Name*
50. Apartment Number
52. Zip Code*
53. City/Town*
54. County*
55. State*
57. Inside City Limits?*

    1. Yes
    2. No
    3. Unknown

59. Mailing Address

61. If mailing address is different than residence address, complete the section below.

63. Street Number and Name
64. Apartment Number
66. Zip Code
67. City/Town
68. County
69. State

71. Mother/Parent Attributes

73. Education

    1. 8th grade or less
    2. 9th-12th grade, no diploma
    3. High School graduate or GED completed
    4. Some college credit but no degree
    5. Associate degree (e.g. AA, AS)
    6. Bachelor's degree (e.g. BA, AB, BS)
    7. Master's degree (e.g. MA, MS, etc.)
    8. Doctorate or Professional degree (e.g. PhD, EdD, MD, DDS, JD, etc.)
    9. Unknown
75. Which one or more of the following is your race? (Select all that apply)

    1. Black or African American
    2. American Indian or Alaska Native (specify)
    3. American Indian-Eastern Band of Cherokee Indian
    4. Asian Indian
    5. Chinese
    6. Filipino
    7. Japanese
    8. Korean
    9. Native Hawaiian

    1. Guamanian or Chamorro
    2. White
    3. Vietnamese
    4. Other Asian (specify)
    5. Samoan
    6. Other Pacific Islander (specify)
    7. Other (specify)
    8. Unknown
76. If Other, specify
78. If American Indian or Alaska Native, specify
80. If American Indian-Eastern Band of Cherokee Indian, select

    1. Eastern Band of Cherokee
    2. Coharie
    3. Lumbee
    4. Haiwa-Saponi
    5. Sappony
    6. Meherrin
    7. Occaneechi Band of Saponi Nation Waccamaw-Siouan
    8. Other, please specify
81. If Other, specify
83. If other Asian, specify
84. If other Pacific Islander, specify
86. Hispanic Origin (Select all that apply)

    1. Not Spanish/Hispanic/Latino
    2. Mexican, Mexican American, Chicano
    3. Puerto Rican
    4. Cuban
    5. Other Spanish/Hispanic/Latino (specify):
    6. Unknown
87. If Other, specify

89. Mother/Parent Health Tab

91. Did Mother get WIC food for herself during this pregnancy?

    1. Yes
    2. No
    3. Unknown
92. Height (feet/inches)
94. Mother Pre-pregnancy Weight (pounds)
95. Mother Weight at Delivery (pounds)

99. Cigarette smoking per day before and/or during pregnancy

101. Tobacco use during this pregnancy?

     1. Yes
     2. No
     3. Unknown
103. Three months before pregnancy

     Indicate number of packs or cigarettes

104. First three months of pregnancy

     Indicate number of packs or cigarettes

106. Second three months of pregnancy

     Indicate number of packs or cigarettes

107. Last trimester of pregnancy

     Indicate number of packs or cigarettes

109. Marital Status Tab

111. Marital Information

113. Mother ever married?*

     1. Never married
     2. Divorced
     3. Preempitve Court Order
     4. Separated

     1. Currently married
     2. Married b ut refusing husband's information
     3. Widowed

     If divorced, separated, or widowed, please provide the date. 

115. Date divorced, separated, or widowed
     Date divorced, separated, or widowed
117. Was mother married at conception, birth or anytime between conception and birth?

     1. Yes, spouse is legal parent
     2. Yes, but spouse is not legal parent
     3. Mother refusing father information

     1. No
     2. Unknown

119. Affidavit of Parentage (AOP)

121. If the parents are not married, do you and the baby's father intend to complete an AOP in which he acknowledges that he is the natural father and accepts legal responsibility for the child? Both parents must be in agreement and present to complete the AOP form. If you are not married, and an affidavit of parentage is not completed, information about the father cannot be included on the birth certificate (the father will not be listed on the child's birth certificate)

123. Select one

     1. Yes, I would like to complete an Affidavit of Parentage (AOP) form.
     2. No, I do not choose to complete an Affidavit of Parentage form and understand the father will not appear on the birth certificate.

125. Father/Parent Tab

127. Father/Parent Name and Birthplace

129. First Name*
130. Middle Name*
131. Last Name*
133. Suffix (Jr., III)*
134. Date of Birth*
     Date of Birth
135. Social Security Number*
137. Birthplace State*
138. Birthplace Country*

140. Residence Address

142. Same as mother's residence address?

     1. Yes
     2. No
144. Street Number and Name
145. Apartment Number
147. Zip Code
148. City/Town
149. State
151. County
152. Inside City Limits

     1. Yes
     2. No

     1. Unknown

154. If mailing address is different than residence address, complete the section below.

156. Street Number and Name
157. Apartment Number
159. Zip Code
160. City/Town
161. State
163. County

165. Father/Parent Attributes

167. Education

     1. 8th grade or less
     2. 9th-12th grade, no diploma
     3. High School graduae or GED completed
     4. Some college credit but no degree
     5. Associate degree (e.g. AA, AS)
     6. Bachelor's degree (e.g. BA, AB, BS)
     7. Master's degree (e.g. MA, MS, etc.)
     8. Doctorate or Professional degree (e.g. PhD, EdD, MD, DDS, JD, etc.)
     9. Unknown
169. Which one or more of the following is your race? (Select all that apply)

     1. Black or African American
     2. American Indian or Alaska Native (specify)
     3. American Indian-Eastern Band of Cherokee Indian (specify)
     4. Asian Indian
     5. Chinese
     6. Filipino
     7. Japanese
     8. Korean
     9. Native Hawaiian

     1. Guamanian or Chamorro
     2. White
     3. Vietnamese
     4. Other Asian (specify)
     5. Samoan
     6. Other Pacific Islander (specify)
     7. Other (specify)
     8. Unknown
170. If Other, specify
172. If American Indian or Alaska Native, specify
174. If American Indian-Eastern Band of Cherokee Indian, specify

     1. Eastern Band of Cherokee
     2. Coharie
     3. Lumbee
     4. Haiwa-Saponi
     5. Sappony
     6. Meherrin
     7. Occaneechi Band of Saponi Nation Waccamaw-Siouan
     8. Other (specify)
175. If Other, specify
177. If Other Asian, specify
178. If Other Pacific Islander, specify
180. Hispanic Origin (select all that apply)

     1. Not Spanish/Hispanic/Latino
     2. Mexican, Mexican American, Chicano
     3. Puerto Rican
     4. Cuban
     5. Other (specify)
181. If Other, specify

183. Informant's Tab

185. Relationship of informant (individual providing the information on the application) to baby?

     1. Mother
     2. Father
     3. Other (specify)
186. If Other, specify

188. Informant Name

190. First Name
191. Middle Name
192. Last Name

194. Facility Information Tab

196. Place of Birth

198. Type of Birth

     1. Home - Planned
     2. Home - Unplanned
     3. Home - Unknown if planned
     4. Unknown
199. Type of Facility*

     1. Home/Residence
     2. Other (specify)
200. If Other, specify
202. Street Number and Name*
203. Apartment Number
205. Zip Code*
206. City/Town*
207. State*
209. County*

211. Prenatal

213. Principal source of payment for this delivery

     1. Private Insurance (Blue Cross/Blue Shield, Aetna, etc.)
     2. Medicaid
     3. Self-Pay
     4. Other (specify)
     5. Unknown
214. If Other, specify
216. Date of last menses*
     Date of last menses
218. Did Mother receive prenatal care?*

     1. Yes
     2. No
219. Date of first visit
     Date of first visit
220. Date of last visit
     Date of last visit
221. Total number of visits*
223. Total Number of Previous Live Births
224. Live births now living*
225. Now dead*
226. Date of last live birth*
     Date of last live birth
228. Total number of other pregnancy outcomes (spontaneous or induced terminations)
229. Number of Other Pregnancy Outcomes*
230. Date of Last Other Pregnancy Outcome*
     Date of Last Other Pregnancy Outcome

232. Pregnancy Factors

234. Risk factors for this pregnancy (Check all that apply)

     1. Diabetes - Gestational (Diagnosis in this pregnancy)
     2. Diabetes - Prepregnancy (Diagnosis prior to this pregnancy)
     3. Hypertension - Prepregnancy (Chronic)
     4. Hypertension - Gestational (PIH, preeclampsia)
     5. Hypertension - Eclampsia
     6. Previous preterm birth
     7. Other Previous Poor Pregnancy Outcome (Includes: Perinatal Death, Small For Gestational Age/Intrauterine Growth Restricted Birth)
     8. Pregnancy resulted from infertility treatment - fertility enhancing drugs, artificial insemination or intrauterine insemination
     9. Pregnancy resulted from infertility treatement - assisted reproductive technology (e.g. in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT)
     10. Mother had a previous cesarean delivery (specify how many)
     11. None of the above
     12. Unknown
236. If mother has had cesarean delivery, how many?
238. Infections tested
239. Was mother tested for HBsAG?*

     1. Yes
     2. No
240. If yes, results are

     1. Positive
     2. Negative
     3. Pending
241. If yes, test date
     If yes, test date
243. Infections present and/or treated during this pregnancy (Check all that apply)

     1. Gonorrhea
     2. Syphilis
     3. Chlamydia

     1. Hepatitis B
     2. Hepatitis C
     3. None of those listed
245. Obstetric procedures (Check all that apply)

     1. Cervical cerclage
     2. Tocolysis
     3. External cephalic version - successful

     1. External cephalic version - failed
     2. None listed

247. Labor Tab

249. Onset of labor (check all that apply)

     1. Premature rupture of the membranes (Prolonged, >= 12 hours)
     2. Precipitous labor (<3 hours)
     3. Prolonged labor (>=20 hours)
     4. None of the above
     5. Unknown
251. Characteristics of Labor and Delivery (Check all that apply)

     1. Induction of labor
     2. Augmentation of labor
     3. Non-vertex presentation
     4. Steroids (glucosteroids) for fetal lung maturation received by the mother prior to delivery
     5. Antibiotics received by the mother during labor
     6. Clinical chorioamnionities diagnosed during labor or maternal temperature >=38C (100.4F)
     7. Moderate/heavy meconium staining of the amniotic fluid
     8. Fetal intolerance of labor such that one or more of the following actions was taken: in-utero resuscitative measures, further fetal assessment, or operative delivery
     9. Epidural or spinal anesthesia during labor
     10. None of the above
     11. Unknown

253. Delivery Tab

255. Method of Delivery
256. Was delivery with forceps attempted but unsuccessful?

     1. Yes
     2. No
     3. Unknown
257. Was delivery with vacuum extraction attempted but unsuccessful?

     1. Yes
     2. No
     3. Unknown
258. Fetal presentation at birth

     1. Cephalic
     2. Breech
     3. Other
260. Final route and method of delivery

     1. Vaginal/Spontaneous
     2. Vaginal/Forceps
     3. Vaginal/Vacuum
     4. Cesarean
261. If cesarean, was a trial of labor attempted?

     1. Yes
     2. No
     3. Not applicable
     4. Unknown
263. Maternal Morbidity (Check all that apply)

     1. Maternal transfusion
     2. Third or fourth degree perineal laceration
     3. Ruptured uterus
     4. Unplanned hysterectomy
     5. Admission to intensive care unit
     6. Unplanned operating room procedure following delivery
     7. None of the above
     8. Unknown
265. Mother transferred for maternal medical or fetal indication prior to delivery

     1. Yes
     2. No
     3. Unknown
266. Transfer Facility
268. Infant transferred within 24 hours*

     1. Yes
     2. No
269. Transfer Facility

271. Newborn Tab

273. Infant Birthweight (Pounds, Ounces)*
274. Grams
276. APGAR Score 5 minutes*
277. APGAR Score 10 minutes
279. Plurality

     1. Single
     2. Twin
     3. Triplet
     4. Quadruplet
     5. Quintuplet
     6. Sextuplet
     7. Septuplet
     8. Octuplet
     9. Unknown
280. Birth Order

     1. First
     2. Second
     3. Third
     4. Fourth
     5. Fifth
     6. Sixth
     7. Seventh
     8. Eighth or more
     9. Unknown
     10. Not applicable
281. If not single birth, number of infants in this delivery born alive:
282. Is infant living at time of report?*

     1. Yes
     2. No
     3. Infant transferred, status unknown
284. Did infant receive Hepatitis B vaccine?

     1. Yes
     2. No
     3. Unknown
     4. Refused
285. Date Hepatitis B vaccine given
     Date Hepatitis B vaccine given
287. Was infant immunized with Nirsevimab (RSV)?

     1. Yes
     2. No
     3. Unknown
     4. Refused
288. RSV dosage amount

     1. 50mg
     2. 100mg
     3. Unknows
     4. Not applicable
289. Date administered
     Date administered

291. Newborn Factors Tab

293. Abnormal conditions of the newborn (Check all that apply)

     1. Assisted ventilation required immediately following delivery
     2. Assisted ventilation required for more than six hours
     3. NICU Admission
     4. Newborn given surfactant replacement therapy
     5. Antibiotics received by the newborn for suspected neonatal sepsis
     6. Seizure or serious neurologic dysfunction
     7. Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)
     8. None of the above
     9. Unknown
295. Congenital Anomalies (Check all that apply)

     1. Anencephalus
     2. Meningomyelocele/Spina Bifida
     3. Cyanotic congenital heart disease
     4. Congenital diaphragmatic hernia
     5. Omphalocele
     6. Gastroschisis
     7. Limb reduction defect (excluding congenital amputation and dwarfing syndromes)
     8. Cleft lip with or without cleft palate
     9. Cleft palate alone
     10. Down Syndrome Karyotype confirmed
     11. Down Syndrome Karyotype pending
     12. Suspected other chromosomal disorder Karyotope confirmed
     13. Suspected other chromosomal disorder Karyotope pending
     14. Hypospadias
     15. None of the anomalies listed above
     16. Unknown

297. Attendant/Certifier Tab

299. Attendant at Birth

301. First Name*
302. Middle Name*
303. Last Name*
305. Suffix (Jr., III)*
307. Attendant's Title*

     1. MD
     2. DO
     3. Certified Nursing Midwife/ Certified Midwife
     4. Other Midwife
     5. Other (specify)
308. If Other, specify
310. NPI*
312. Address
314. City
315. State
316. Zip Code
318. County

320. Certifier

322. Same as attendant?

     1. Yes
     2. No
324. First Name
325. Middle Name
326. Last Name
328. Suffix (Jr., III)
330. Certifier's Title

     1. Birth Certifier
     2. MD
     3. DO
     4. Certified Nursing Midwife Certified Midwife
     5. Other Midwife
     6. Hospital Administrator
     7. Other (specify
331. If Other, specify
333. NPI
335. Address
337. City
338. State
339. Zip Code
341. County
343. Date Certified
     Date Certified

345. Required Documents

     Attach copies of the following documents to this form: 

     • Proof of residence (e.g., mail or driver’s license)
     • Mother’s valid state-issued ID
     • Father’s valid state-issued ID (if listed on the birth certificate)
     • Proof of pregnancy (ultrasound, confirmation letter, or notarized statement from a pediatrician)

     
     

347. Proof of residence (e.g., mail or driver’s license)*
349. Mother’s valid state-issued ID*
351. Father’s valid state-issued ID (if listed on the birth certificate)*
353. Proof of pregnancy (ultrasound, confirmation letter, or notarized statement from a pediatrician)*

355. Parent Signature

357. I acknowledge that I have reviewed all the information provided on this birth application and attest that the information is correct. I understand that I will be given another opportunity to review this information on the Mother's Worksheet. I understand that it is my responsibility to identify any errors and report them to the birth registrar before the birth is registered. I also understand that if an error is found after the birth certificate has been registered, I will be responsible for completing an amendment with the North Carolina State Vital Records Office and any fees associated with the birth certificate being corrected.

359. Mother/Parent Signature

     Digital Signature

360. Date
     Date
362. Father/Parent Signature (if applicable)

     Digital Signature

363. Date
     Date

365. You’ll be notified when you can pick up copies of the birth certificate at the Orange County Register of Deeds office.

Leave This Blank:


367. 1. Receive an email copy of this form.
368. Email address

     This field is not part of the form submission.

369. Submit

* indicates a required field