Current through Register Vol. 50, No. 11, November 20, 2024
Section V-12303 - Certificate of Live Birth Preparation (PHS 19)A. Section-"This Child" 1. Last Name (Item 1A) a. Enter the child's last, first, and middle names as required R.S. 40:34.b. Enter the full name of the childe exactly as given by the parent(s).c. Generation indicator's such as Jr. and II shall be entered immediately following the surname.d. In the child is legitimate, the surname of the child shall be the surname of the husband of the mother if he was married to the mother of the child at the time of conception and the birth of the child or had not been legally divorced from the mother of the child for more than 300 days prior to the birth of the child, or, if both the mother and husband agree, the surname of the child may be the maiden name of the mother or a combination of the surname of the husband and the maiden name of the mother . Surnames which are combinations of the parents' names may be hyphenated or unhyphenated.e. If the child is illegitimate, the surname of the child shall be that of the mother's maiden name, unless both the mother and biological father of the child consent to the use of the biological father's surname for the child, or, if both the mother and father agree, the surname of the biological father and the maiden name of the mother. In either case, the signature of the natural father shall be required on the original certificate of live birth in the space provided for the signature of the parent or other informant, and an authentic act of acknowledgement of paternity shall be executed by the father. The acknowledgement of paternity shall be executed after the birth of the child.f. The original or certified copy of the authentic act of acknowledgement of paternity shall accompany the certificate of live birth to the local registrar. The act shall be executed by the father and shall be counter-signed by the mother in presence of two witnesses. The acknowledgement document shall include the name of the mother of the child, the date of birth of the child, the place of birth of the child, the full name of the child as agreed by the parents, the full name of the father of the child, the city and state of birth of the father of the child, and the date of birth of the father.g. If the parents do not have a given name selected for the child, leave the item blank. Never enter "baby girl," or "infant boy." Certified copies of the birth certificate shall not be issued until the given name has been added to the certificate except as provide under §123012. Date of Birth (Item 2A-Month, Day, and Year) a. Enter the exact month, day, and year the child was born.b. The names of the months may be entered in full or the following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and Dec. Always enter the complete spelling not to be used to indicate months in this date field.c. consider a birth at midnight to have occurred at the end of the day rather than the beginning of the next day.3. Hour of Birth (Item 2B) a. Enter the hour of birth indicating a.m. or p.m. If the institution is on 24-hour or military time, the hour of birth may be so expressed. The a.m./p.m. indicator may be omitted for military time for 1300 hours and later. Any other omission of the indicator will result in the certificate being returned to the preparer for completion.4. Sex (item 3) a. Enter male or female. Do not abbreviate or use other symbols. In instances where sex is not readily determines, either sex of the child bases on the predominant indicator. If sex cannot be determined after verification with medical records, mother of the child, informants, or other sources, make no entry. Attach a note to the certificate stating the reason for omission.b. Certified copies shall not be issued while Item 3 is blank except as provided under §123015. Plurality (Item 4A Specify Single, Twin, etc.). Enter the appropriate term.6. Order (Item 4B Specify Order). If not a single birth, enter "first born," "second," etc. If not applicable, enter "not applicable" or leave blank.7. Birth Weight (Item 5). Enter the weight as shown in the hospital record, in either grams or pounds and ounces. Do not convert from one measure to the other. Specify the type of measure used (grams or pounds and ounces). Only the following standard abbreviations may be use: pounds=lbs., ounces=ozs., grams=gms.B. Section "Place of Birth" 1. Place of Birth 9Item 6A-City, Town or Location). Enter the full name of the city, town, village, or location where the birth occurred. For births occurring on a moving conveyance, enter the city, town, village, or location where the child was first removed from the conveyance.2. Parish of Birth (Item 6B) a. Enter the name of the parish where the birth occurred. For births occurring on a moving conveyance, enter the parish where the child was first removed from the conveyance.b. If the birth occurred on a moving conveyance in the United States and the child was first removed from the conveyance in this state, complete a birth certificate showing each place of birth as this state.c. If the birth occurred on a moving conveyance in international waters, international airspace, or in a foreign country or its airspace, and the child was first removed from the conveyance in this state, complete a birth certificate in this state, but enter the actual place of birth insofar as can be determined.3. Place of Birth (Item 6C-Specifiy). Enter the place where the birth occurred. A "birthing" center located in and operated by a hospital is considered part of the hospital and should be reported as occurring in the hospital. Freestanding birthing centers include those facilities that are operated independently from hospitals (autonomously). The "clinic/doctor's office" category includes other non-hospital out-patient facilities where births occasionally occur.4. Name of Hospital or institution (Item 6D) a. If the birth occurred in a hospital or institution, enter the full name of the facility where the birth occurred.b. If the birth occurred at home, enter the full name of the facility to or on arrival at a facility where the birth occurred.c. If the birth occurred at home, enter the house number and street name of the place where birth occurred.d. If the birth occurred at some place other than those described above, enter the number and street name of the location.e. If the birth occurred on a moving conveyance that was not en route to a facility, enter as the place of birth the address where the child was first removed from the conveyance.5. Place of Birth Inside City Limits (Item 6E). Specify "yes" or "no."C. Section-"Usual Residence of Mother." 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, parish, 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 the purpose of 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 college is not considered temporary and should be entered on the certificate as the mother's place of residence. The address entered in 7A is the address used to query the mother if there is a need to contact her shortly after the birth. 1. Usual Residence of Mother (Item 7A). Enter the full name of the city, town, or location where the mother usually resides.2. Parish (Item 7B). Enter the full name of the parish (county) of usually residence of the mother.3. State (Item 7D). Enter the full name or standard abbreviation of the state in which the mother lives. This may direr from the state in her mailing address. If the mother is not U.S. resident, enter the name of the country and the name of the nearest unit of government that is the equivalent of a state.4. Zip (Item 7D). Enter the Zip Code of the usual residence of the mother.5. Street Address (Item 7E)a. Enter the number and street name of the place where the mother lives. Although a post office box alone is not acceptable, a post office box may be entered in parentheses at the end of the street address.b. If this location has no number and street name, enter the rural route number or a description of the place that will aid in identifying the precise location.6. Is Residence in Inside City Limits (Item 7F). Enter "yes" or "no."D. Section "Father of Child" 1. Father's Last Name (Item 8A) a. In general, if the child was: i. born to a mother who was married at the time of birth, enter the name of her husband;ii. conceived in wedlock, but born after a divorce was granted or after the husband died, type or print the name of the mother's deceased or divorced husband;iii. conceived and born out of wedlock to a divorced, widowed, or never-married mother, make no entry regarding the father's name and omit items 8B, 8C, 8D, and 8E.b. If the mother is unmarried and was not married at any time during the past 300 days, the child may be acknowledged at the time of birth by the biological father. If the acknowledgement is in proper from, the biological father's name may be entered in Item 1A on the birth certificate and items 8A, 8B, 8C, 8D, and 8E may be completed.c. The surname of the father and the child are usually the same. When they are different, carefully review this information for compliance with state law and with the parent(s) to ensure that there is no mistake.2. First Name (Item 8B). If the surname of the father was entered in 8A, enter the second name of the father. If the father does not have a second name, leave the space blank.4. City and State of Birth (Item 8D) a. If the surname of the father was entered in 8A, enter the city and state of birth.b. If the father was born in the United States, enter the name of the state.c. If the father was born in a foreign country or a U.S. territory, enter the name of the country or territory.d. If the father was born in the United States, but he state is unknown, enter "U.S.-Unknown."e. If the father was born in a foreign country, but the country in unknown, enter "Foreign-Unknown."f. If no information is available regarding place of birth, enter "unknown." Do not leave this item blank.5. Date of Birth (item 8E). a. If the surname of the father was entered in 8A, enter the exact month, day, and year the father was born.b. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and Dec. Enter the complete spelling for the months of May, June, and July.E. Section-"Mother of Child" 1. Mother's Maiden Name (Item 9A). Type of print the last name of the mother as given at birth or adoption, not a name acquired by marriage.2. First Name (Item 9B). Enter the first name of the mother.3. Second Name (Item 9C). Enter the second name of the mother. If the mother has no second name, leave the item blank.4. City and State of Birth (Item 9D) a. Enter the city and state of birth.b. If the mother was born in the United State, enter the name of the state.c. If the mother was born in a foreign country of a U.S, territory, enter the name of the country or territory.d. If the mother was born in the Unites State, but he state is unknown, enter "U.S.Unknown."e. If the mother was born in a foreign country, but the country is unknown, enter "Foreign-Unknown."f. If no information is available regarding place of birth, enter "Unknown." Do not leave this item blank.5. Date of Birth (Item 9E) a. Enter the exact month, day, and year that the mother was born.b. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and Dec. Enter the complete spelling of May, June and July.F. Section "Informant's Certification" 1. Name of Informant (Item 10) a. Obtain the signature of the informant. The signature shall be limited to the space provided. A person other than the mother or the father whose signature appears in this area shall check "other."b. If the informant fails to sign, send a certified letter return receipt requested to the last known address of the mother requesting that she sign the certificate. If the mother fails to comply with the request within a reasonable period of time, transmit the unsigned certificate to the local registrar along with a copy of the letter and the "return receipt." The state registrar of vial records may, at his discretion, withhold issuance of certified copes of unsigned certificates.c. If the mother is un married and an authentic act of acknowledgement has been executed by the father, the father shall sign the birth certificate as the informant in accordance with R.S. 40:34 (B)(1)(iv). Additionally, the mother shall initial item 10.2. Date of Certification (Item 11). Enter in numeral form (e.g. 10/10/89 or 10-10-90 for October 10, 1989) the month day and year of the signature in Item 10.3. Address of Informant (Item 12A). Enter the street address, rural route or otherwise indicate the residence of the person whose signature appears in the Item 10 above or the individual whose name has been entered as the informant. If the address is the same as the address information provided for the mother in items 7A-E, the entry in this item may be limited to the SIP code. If the information is an employee at the hospital or clinic where the delivery occurred, the address of that facility may be entered.4. Relation ship to Child (Item 12B). Enter the relationship of the person whose signature appears in Item 10 to the child whose name appears in Item 1A. If there is no relationship, enter "none."G. Section- "Attendant" 1. Signature and Address of Attendant (item 13) a. The person signing attests to the fact that he attended the birth and that the child was born alive at the place and time and on the date stated.b. Obtain the signature of the physician or other person in attendance at the birth. Rubber stamps or other facsimile signatures are not permitted. The signature shall be in permanent, black ink and shall be confined to the space provided.c. Signatures which overflow to adjoining blocks obscure other important information and interfere with any efforts to machine read birth data at a later date. Birth documents which contain such signatures may be returned to the hospital or other preparer to be properly prepared.d. For births occurring in institutions, the administrator of the institution or his designee shall sign if the physician or other person in attendance is unable or unwilling to certify within 72 hours after the birth. In such instances the name of the physician or other person in attendance is unable or unwilling to certify within 72 hours after the birth. In such instances the name of the physician or other person who actually attended the delivery shall be typed or printed and the administrator or designee shall sign in black ink. For births occurring outside an institution, the midwife or other person managing the birth shall complete this item.e. In all instances, check the appropriate box to identify the actual attendant's title. M.D.=doctor of medicine, D.O.=doctor of osteopathy, C.N.M.=certified nurse midwife. Lay midwives should be identified as "Other Midwife." If "Other (Specify)" is checked, type the title of the attendant on the line provided.2. Date of Signature (Item 14). Enter the date in numeral form separated by slashes or dashes, or in alphabetic form.H. Section-"Registrar's Certification." These items are to be completed only by the state registrar or his designee. 1. Date of Acceptance by Local Registrar (Item 15A.) a. Enter the exact month, day, and year of acceptance.b. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and (e.g. Dec. 1, 1989). Enter the complete names of the month for May, June, and July.2. Signature of the Local Registrar (Item 15B.) a. This item is signed by the local or state registrar when the certificate is filed.b. The signature documents the fact that the certificate has been accepted by and filed with the registrar. If another person signs for the local registrar, that person shall write the registrar's name per his/her initials.3. Date Filed by State Registrar (Item 15C.) a. Enter date accepted in the Vital Records Registry.b. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and (e.g. Dec. 1, 1989). Enter the complete names of the month for May, June, and July.I. Section-"Social Security Number (Item 16)1. Place a "x" in the "yes" or "no" block and sign. When this item is left blank, "no" will be assumed. Only a parents signature will be accepted in Item 16. When the "yes" block is checked and the item is properly signed, information may be released to the Social Security Administration to facilitate assigning a Social Security Number to the child.2. Signatures which overflow to adjoining blocks obscure other important information and interfere with efforts to machine read birth date at a later date. Birth documents which contain such signatures may be returned to the hospital or other preparer to be properly prepared.J. Section-"Origin, Race, and Education" 1. Hispanic Origin (Items 17A. and 17B.) a. If the parents are not of Hispanic origin, indicate "no." If unknown, indicate "unknown." If a parent or both parents are Hispanic origin, specify.b. "Hispanic" refers to those people whose origins are from Spain, Mexico, or the Spanish-speaking countries of Central or South America. Origin can be viewed as the ancestry, nationality, lineage, or country in which the person or his or her ancestors were born before their arrival in the United States.c. There is no set rule as to how many generations are to be taken into account in determining Hispanic origin. A person may report Hispanic origin based on the country of origin of a parent, grandparent, or some far-removed ancestor. The response should reflect what the person considers himself or herself to be and is not based on percentages of ancestry. Although the prompts include the major Hispanic groups of Cuban, Mexican, and Puerto Rican, other Hispanic groups should also be identified in the space provided.d. If a person indicates that he or she is a multiple Hispanic origin, enter the origins as reported (for example, Mexican-Puerto Rican).e. If a person indicates that he or she is Mexican-American or Cuban-American, enter the Hispanic origin as stated.f. 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 independently.2. Race (Items 18A. and 18B.) a. Enter the race of the mother and of the father as obtained from the parent(s) or other informant. This item shall be completed for the mother on all certificates but for the father only if a father's name appears in item 8A. The entry in this item shall reflect the response of the informant.b. For Asians and Pacific Islanders, enter the national origin of the mother and father, such as Chinese, Japanese, Korean, Filipino, or Hawaiian.c. If the informant indicates that the mother and/or father is of "mixed race," enter both races or ancestries.3. Ages of Parents (Items 19A. and 19B.) a. Enter the ages in years of the mother and the father at the date of birth of the child.4. Education of Parents (Items 20A. 20B.) a. Elementary/Secondary (0-12) - College (1-4 or 5+)b. Enter the highest number of years of regular schooling completed by the mother and father in either the space for elementary/secondary school or the space for college. An entry should be made in only one of the spaces. The other space should be left blank. Report only those years of school that were completed. A person who enrolls in college but does not complete one full year should not be identified with any college education in this item.K. Medical/Social History. Items 21 through 35 collect a medical/social history of the mother and the child. The information is collected for statistical analysis and public health planning. Upon acceptance of the Certificate of Live Birth, the medical/social history shall be key-punched and the original medical history portion shall be severed from the remainder of the document and be destroyed. 1. Live Births Now Living (Item 21A.). Enter the number of children born live to the mother who were living at the time of the birth. Specify zero, "0", if none.2. Live Births Now Dead (Item 21B.). Enter the number of children born live to this mother who were dead at the time of this birth. Specify zero, "0", if none.3. Date of Last Live Birth (Item 21C.) a. Enter the date (month and year) of birth of the last live-born child of the mother.b. 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 is was born alive. Similarly, for triplets or other multiple births, enter the date of 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 a live birth.c. Enter "-," "Not applicable," or "None" if the mother has not had a previous live birth. Do not leave this item blank.d. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and (e.g. Dec. 1, 1989). Enter the complete names of the month for May, June, and July.4. Other Terminations (Items 21D. and 21E.) a. Enter the number of fetuses that were delivered dead regardless of the length of gestation. Include each recognized loss of a product of conception, such as ectopic pregnancy, still-birth, and spontaneous or induced abortion.b. Check "None" if this is the first pregnancy for this mother or if all previous pregnancies resulted in live-born infants.c. Enter the date (month and year) of the last termination of pregnancy that was not a live birth regardless of the length of gestation.d. If the mother has never had such a termination, enter "-," "Not applicable," or "None." Do not leave this item blank.e. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and (e.g. Dec. 1, 1989). Enter the complete names of the month for May, June, and July.f. If this certificate is for the second birth of a twin set and the first was born dead, enter the date of delivery of that fetus. Similarly, for other multiple births, if any previous member of the set was born dead, enter the date of delivery of that fetus. If all previously born members of a multiple set were born alive, enter the date of the mother's last delivery that resulted in a fetal death.5. Mother Married? (Item 22). Enter "Yes" if the mother was married at the time of conception, at the time of birth, or at any time between conception and birth. Otherwise, enter "No." A woman is legally married even if she is separated. A person is no longer legally married when there is a signed divorce decree. If divorced or widowed, enter "no" in this space and the date of the divorce or death of the spouse in the left hand margin.6. Date Last Normal Menses Began (Item 23). Enter the actual date that the last menses began. The following abbreviations may be used: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and (e.g. Dec. 1, 1989). Enter the complete names of the month for May, June, and July.7. Month of Pregnancy Prenatal Care Began (Item 24) a. Prenatal care begins when a physician or other health professional first examines and/or counsels the pregnant woman.b. The month of pregnancy in which prenatal care began is measured from the date the last normal menses began and not from the date of conception.c. If prenatal care begins in the last month of pregnancy, enter "first" or "1." Similarly, enter "second" or "2" if prenatal care begins in the second month of pregnancy, etc. Enter "none" or "-" if the mother did not receive prenatal care. Never enter a named month. Such an entry is not responsive to the question.8. Prenatal Visits-Total Number (Item 25). Enter the number of visits made for medical supervision of the pregnancy by a physician or other health care provider during the pregnancy. If no prenatal care was received, enter "None." If Item 24 is reported as "None," this item should also be completed as "None." Do not leave this item blank.9. Clinical Estimate of Gestation (Item 26). Enter the length of gestation as estimated by the attendant. Do not compute this information from the date last normal menses began and date of birth. If the attendant has not done a clinical estimate of gestation, enter "None." Do not leave this item blank.10. Apgar Score(Item 27A. and 27B.) a. Enter the Apgar score (0 through 10) as assigned by the delivery room personnel one minute after birth in 27A.b. Enter the Apgar score (0 through 10) as assigned by the delivery room personnel five minutes after birth in 27B.11. Mother Transferred Prior to Delivery (Item 28A) a. Specify "yes" or "no." If "yes," enter name of facility transferred from.b. Indicate "no" if this is the first facility the mother was admitted to for delivery. Indicate "yes" if the mother was transferred from one facility to another facility before the child was delivered. If the mother was transferred more than once, enter the name of the last facility from which she was transferred.12. Infant Transferred (Item 28B). Indicate "no" if the infant was not transferred to another facility. Indicate "yes" if the infant was transferred from this facility to another facility after delivery. If the infant was transferred, enter the name of the facility the infant was transferred to. If the infant was transferred once, enter the name of the first facility to which the infant was transferred.13. If delivery at Home-Intentional (Item 28C.). If delivery was at home, specify "yes" or "no." If delivery was not at home, specify "not applicable" or "NA."14. Did Child Die at Facility (Item 29). Specify "yes" or "no."15. Medical Risk Factors (Item 30A). Check each of the medical risk factors that the mother experienced during this pregnancy. If the mother experienced medical risk factor(s) not identified in the list for example, other infectious diseases, AIDS, or syphilis-check "Other" and enter the risk factor on the line provided. Medical risk factors should be identified from the hospital or physician record. If there were no medical risk factors, check "None." Do not leave this item blank.16. Other Risk Factors (Item 30B.)a. Complete each question/statement. Check "Yes" for tobacco use if the mother smoked tobacco at any time during the pregnancy. Check "No" if the mother did not smoke during the entire pregnancy. Also check "No" if a non-cigarette form of tobacco was used exclusively during the pregnancy. If "Yes" is checked, specify the average number of cigarettes the mother smoked per day during her pregnancy. If, on the average, she smoked less than one cigarette per day, enter "Less than one." If "No" is checked, do not make any entry on the line requesting the average number of cigarettes per day.b. Check "Yes" for alcohol use if the mother consumed alcoholic beverages at any time during her pregnancy. Check "No" if the mother did not consume any alcoholic beverages during the entire pregnancy. If "Yes" is checked, specify the average number of drinks she consumed per week. One drink is equivalent to five ounces of wine, 12 ounces of beer, or one ounce of distilled liquor. If, on the average, she drank less than one drink per week, enter "Less than one." If "No" is checked, do not make any entry on the line requesting the average number of drinks per week.c. Enter the amount of weight gained by the mother during the pregnancy in pounds. Do not enter the total weight of the mother. If no weight was gained, enter "None." If the mother lost weight during her pregnancy, enter the amount of weight lost (for example, "Lost 10 pounds). Do not leave this item blank.d. Information for this item should be obtained from the mother's medical chart or the physician. If the medical chart is not available or does not include this information and the physician is unavailable, the informant should be asked to respond to these items.17. Obstetrical Procedures (Item 31). Check each type of procedure that was used during this pregnancy. More than one procedure may be checked. If a procedure was used that is not identified in the list, check "Other" and specify the procedure on the line provided. If no procedures were used, check "None." Do not leave this item blank. This information should be obtained from the mother's medical chart or the physician.18. Complications of Labor and/or Delivery (Item 32). Check each medical complication present during labor and/or delivery. If a complication was present that is not identified in the list, check "Other" and specify the complication on the line provided. If there were no complications, check "None." Do not leave this item blank. This information should be obtained from the mother's medical chart or the physician.19. Method of Delivery (Item 33). Check the method of delivery of the child. If more than one method was used, check all methods that apply to this delivery. Do not leave this item blank. This information should be obtained from the mother's medical chart or the physician.20. Abnormal Conditions of the Newborn (Item 34). Check each abnormal condition associated with the newborn infant. If more than one abnormal condition is present that is not identified in the list, check "Other" and specify the condition on the line provided. Do not leave this item blank. This information should be obtained from the mother's and infant's physicians or the medical records (obstetric and pediatric).21. Congenital Anomalies of Child (Item 35). Check each anomaly of the child. Do not include birth injuries. The checklist of anomalies is grouped according to major body systems. If an anomaly is present that is not identified in the list, check "Other" and specify the anomaly on the line provided. Note that each group of system-related anomalies includes an "Other" category for anomalies related to that particular system. If there is a question as to whether the anomaly is related to a specific system, enter the description of the anomaly in "Other (Specify)" at the bottom of the list. If there are no congenital anomalies of the child, check "None." Do not leave this item blank. This information should be obtained from the mother's and infant's physicians or the medical records (obstetric and pediatric).La. Admin. Code tit. 48, § V-12303
Promulgated by the Department of Health and Human Resources, Office of Preventive and Public Health Services, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, LR 15:971 (November 1989).AUTHORITY NOTE: Promulgated in accordance with R.S. 40:33, R.S. 40:49, and R.S. 40:54-56.