The Child Birth Certificate Texas form is an essential document used to officially record the birth of your child in Texas. This form collects vital information that will create your child's birth certificate, a legal document proving their age, citizenship, and parentage. Completing this form accurately is crucial, as it will serve your child throughout their life.
To ensure your child's information is properly recorded, please fill out the form by clicking the button below.
In Texas, the Child Birth Certificate form is a crucial document that serves as the foundation for establishing a child's identity and legal status. This form is not just a piece of paper; it plays a significant role in proving age, citizenship, and parentage, which are essential for various aspects of life, including enrolling in school, applying for a Social Security number, and obtaining medical services. The form collects vital information about the child, including the time and place of birth, as well as details about the mother and father. It also addresses the mother’s health and marital status, which can influence how parental information is recorded. To ensure accuracy, parents are encouraged to fill out the form carefully, as any errors can lead to complications and costly corrections later on. Texas law emphasizes the protection of personal information, safeguarding against unauthorized access to the data contained in birth certificates. Understanding the importance of this form and the information it requires can help parents navigate the process more smoothly, ensuring that their child's identity is officially recognized from the very start.
Mother’s Worksheet for Child’s Birth Certificate
FOR HOSPITAL USE ONLY:
MOTHER MR# _____________________________
NEWBORN MR# ________________________________
MEDICAID # _______________________________
DELIVERING DR ________________________________
RM # ____________
The information you provide on this worksheet is used to create your child’s birth certificate. The birth certificate is a legal document used to prove your child’s age, citizenship and parentage. Your child will use the birth certificate throughout his/her life. The State of Texas safeguards against the unauthorized release of identifying information from birth certificates to protect the confidentiality of parents and their child.
Please PRINT your responses carefully and accurately as errors are difficult and expensive to correct.
CHILD’S PLACE OF BIRTH
Name of Hospital or Location
Address
State
County
City
Zip Code
CHILD’S INFORMATION
Time of Birth
Date of Birth
Plurality (please circle one)
Am / Pm
Single / Twin / Triplets / Quadruplets / Quintuplets
Birth Order (please circle one)
Number of Infants Born Alive at this Birth? (please circle one)
First / Second / Third / Fourth / Fifth
One / Two / Three / Four / Five
MOTHER’S CURRENT LEGAL NAME
First Name
Middle Name
Last Name
Suffix
CHILD’S LEGAL NAME
VS-109.1 REV 2/2005
MOTHER’S RESIDENCE ADDRESS
Residence Address
Apartment Number
State/Foreign Country
City/Town/Location
Zip Code / Extension
Inside City Limits?
□ Yes
□ No
MOTHER’S MAILING ADDRESS
(If same as residence address, LEAVE THIS SECTION BLANK)
Mailing Address
MOTHER’S INFORMATION
Place of Birth (State/Foreign Country/Territory)
Social Security
Apply for Baby’s Social Security?
Did Mother Give up Rights to the Child?
Date Rights Given Up?
□ Yes □ No
Occupation
Type of Business
Mother’s Education
□8th grade or less
□9th – 12th grade, no diploma
□High School graduate or GED completed
□Some College credit, but no degree
□Associate degree (e.g., AA, AS)
□Bachelor’s degree (e.g., BA, AB, BS)
□Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)
□Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
Is Mother of Hispanic Origin?
□No, not Spanish / Hispanic / Latina
□Yes, Mexican, Mexican American, Chicana
□Yes, Puerto Rican
□Yes, Cuban
□Yes, other Spanish / Hispanic / Latina
Specify______________
What is Mother’s Race?
□ White
□ Vietnamese
□ Black/African American
□ Other Asian________
□ American Indian/Alaska Native
□ Native Hawaiian
(Name of the enrolled or principal tribe)
□ Guamanian or
Chamorro
□
□ Samoan
Asian Indian
□ Chinese
□ Other Pacific Islander
□ Filipino
Specify
□ Japanese
□ Other
□ Korean
□ Unknown
MOTHER’S HEALTH INFORMATION
Did you receive WIC for this Birth?
Height
Weight Before Pregnancy
Weight At Delivery
How many cigarettes did you smoke before and during pregnancy?
Three Months Before Cigs/Day: ____
Packs/Day: ___
First Three Months
Cigs/Day: ____
Second Three Months Cigs/Day: ____
Third Trimester
MOTHER’S MARITAL STATUS (Please read carefully)
If you are married, your husband may be listed as the father on the birth certificate, or the information may be left blank.
If you are not married, the father’s name may be listed on the birth certificate only if both parents complete an Acknowledgment of Paternity.
If you are or have been married to someone other than the biological father of this child, or have been married to someone other than the biological father within 300 days before this child’s birth, the Acknowledgment of Paternity must also include a Denial of Paternity from your husband or former husband to allow the biological father’s information to be listed on the birth certificate.
□ Yes, Currently Married
□ Yes, Never Married
□ Yes, Divorced
□ Yes, Widowed
□Yes, Married – (no paternity information on birth certificate)
Have you been married to someone other than the biological father in the 300 days before the child’s birth? □ Yes □ No
Do you want to complete an Acknowledgement of Paternity? □ Yes
MOTHER’S NAME PRIOR TO HER FIRST MARRIAGE
FATHER’S INFORMATION (Biological father)
Legal First Name
Father’s Education
Is Father of Hispanic Origin?
□No, not Spanish / Hispanic / Latino
□Yes, Mexican, Mexican American, Chicano
□Yes, other Spanish / Hispanic / Latino
What is Father’s Race?
□ Other Asian
□ Asian Indian
Has Paternity – Genetic Testing Been Done?
State/Foreign Country/Territory
PRESUMED FATHER’S INFORMATION (Complete ONLY if applicable)
Zip Code Extension
MOTHER’S MEDICAID INFORMATION (Complete ONLY if applicable)
Mother’s Medicaid Name
Mother’s Medicaid Number
IMMTRAC REGISTRY
Do you consent for your baby’s immunization information to be included in the statewide Immunization Registry and to share the immunization information with registered providers? □ Yes □ No
Congratulations on the birth of your new Little Texan!
Texas Vital Statistics would like to take this opportunity to answer some most commonly asked questions about birth certificates in Texas. . .
“How do I get a copy of my baby’s birth certificate?”
You can request and purchase a certified copy of your child’s birth certificate from the local registrar’s office located in the city or county where the birth occurred, or from the Texas Vital Statistic office located in Austin, Texas.
A CERTIFIED BIRTH CERTIFICATE is a permanent legal document filed in the State of Texas that establishes your child’s identity and is used to apply for medical or government services, passports, school admission, etc.
“When will I receive my baby’s social security card?”
If you answered “Yes” to the question, “Apply for baby’s social security number?”, the birth information will be forwarded to the Social Security Administration as soon as the Texas Vital Statistic office receives the data from the hospital. The Social Security Administration then requires 2-3 weeks to process the information. A social security card will be mailed to the mother’s mailing address as provided in this worksheet. The entire process usually takes 4-6 weeks to complete.
“When will I receive my baby’s Medicaid number?”
If you provided an answer for the questions “Mother’s Medicaid Name?” and “Mother’s Medicaid Number?”, the birth information will be forwarded to the Medicaid office as soon as the Texas Vital Statistic office receives the data from the hospital. Medicaid then requires 2-3 weeks to process the information. An Infant Medicaid card will be mailed to the mother’s mailing address as provided in this worksheet. The entire process usually takes 4-6 weeks to complete.
Medical Data Worksheet for Child’s Birth Certificate
This form to be completed by hospital staff. This data will be used to populate the medical data portion of the birth certificate for the newborn. The medical data is required to be reported within five days of the birth. [HSC §192.003]
PATIENT REFERRENCE:
MOTHER MR# _________________________________________
NEWBORN MR# ___________________________________________
MOTHER’S NAME ______________________________________
NEWBORN NAME _________________________________________
MEDICAID# ___________________________________________
DOB ____________________________________________________
DELIVERING DR _______________________________________
DATE AOP SENT__________________________________________
MOTHER TRANSFERRED _______________________________
SOURCE OF PAYMENT FOR DELIVERY ______________________
□ Born at Facility
□ Born En Route
□ Foundling
□ Home Birth
Prenatal Care □ Yes □ No □ Unknown
Date of First Visit ____/____/______
Date of Last Visit ____/____/______
Total Number of Prenatal Visits for this Pregnancy: ________
Date Last Normal Menses Began ___/___/_____
Pregnancy History
Live births now living (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____
Live births now dead (Do not include this birth. For multiple deliveries, do not include the 1st born in the set if completing this worksheet for that child. If none enter “0”.): _____
Date of last live birth: ____/______
MM YYYY
Number of other pregnancy outcomes (Include fetal losses of any gestational age. If this was a multiple delivery, include all fetal losses delivered before this infant in the pregnancy.
If none enter “0”.): _____
Date of last other pregnancy outcome: ____/______
Infections Present and/or Treated During Pregnancy
□ Gonorrhea
□ Hepatitis B
□ Syphilis
□ Hepatitis C
□ Chlamydia
□ None of the above
Source of Prenatal Care
(check all that apply)
□ None
□ Midwife
□ Hospital Clinic
□Other, Specify __________________
□ Public Health Clinic
□ Private Physician
Risk Factors in this Pregnancy (check all that apply)
Diabetes
□Prepregnancy (diagnosis prior to this pregnancy)
□Gestational (diagnosis in this pregnancy)
Hypertension
□Prepregnancy (chronic)
□Gestational (PIH, preeclampsia)
□Eclampsia
□Previous preterm birth
□Other previous poor pregnancy outcome (includes perinatal death, small-for- gestational age/intrauterine growth restricted birth)
□Pregnancy resulted from infertility treatment
□Fertility-enhancing drugs, artificial insemination or intrauterine insemination
□Assisted reproductive technology
□Mother had a previous cesarean delivery
If yes, how many?_____
□Antiretrovirals administered during pregnancy or at delivery
□None of the above
HIV Test
HIV test done Prenatally
HIV test done at Delivery
Obstetric Procedures (check all that apply)
□Cervical cerclage
□Tocolysis
External cephalic version
□Successful □ Failed
Characteristics of Labor & Delivery
□Induction of labor
□Augmentation of labor
□Non-vertex presentation
□Steroids (glucocorticoids) for fetal lung maturation received by mother prior to delivery
□Antibiotics received by mother during labor
□Chorioamnionitis or maternal temperature > = 38 degrees C or
100.4degrees F
□Moderate/heavy meconium staining of the amniotic fluid
□Fetal intolerance of labor was such that one or more of the following actions was taken: in-utero resuscitative measures, further assessments, or operative delivery
□Epidural or spinal anesthesia during labor
Maternal Morbidity – Complications associated with Labor & Delivery
□Maternal transfusion
□Third or forth degree perineal laceration
□Ruptured uterus
□Unplanned hysterectomy
□Admission to intensive care unit
□Unplanned operating room procedure following delivery
Onset of Labor (check all that apply)
□Premature Rupture of the Membranes [prolonged > =12 hours]
□Precipitous Labor [< 3 hours]
□Prolonged Labor [> = 20 hours]
Method of Delivery
Was delivery with forceps attempted but unsuccessful?
Was delivery with vacuum extraction attempted but unsuccessful?
Fetal presentation at birth
□ Other, _________________________
□ Cephalic
□ Breech
Final route and method of delivery
□ Vagina/Spontaneous
□ Vagina/Forceps □ Vagina/Vacuum
If cesarean, was a trial of labor attempted?
□ Cesarean
Child’s Health Information
Birth Weight
________ Grams, or ________LB. ________OZ.
Obstetric Estimate of Gestation (completed weeks): _________
Child’s Sex: □ Male □ Female □ Not yet determined
Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______
Abnormal Conditions of the Newborn (check all that apply)
□Assisted ventilation required immediately following delivery
□Assisted ventilation required for more than six hours
□NICU admission
□Newborn given surfactant replacement therapy
□Antibiotics received by the newborn for suspected neonatal sepsis
□Seizure or serious neurologic dysfunction
□Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or soft tissue/solid organ hemorrhage which requires intervention)
Congenital Anomalies of the Newborn (check all that apply)
Was Infant Transferred within 24 hours of Delivery?
□No □ Yes, Specify Facility _________________
Is Infant Living at Time of Report?
□Yes □ No
Is Infant Being Breastfed at Discharge?
□Anencephaly
□Meningomyelocele/Spina bifida
□Cyanotic congenital heart disease
□Congenital diaphragmatic hernia
□Omphalocele
□Gastroschisis
□Cleft palate alone
□Down syndrome
□Karyotype confirmed
□Karyotype pending
□Suspected chromosomal disorder
Hepatitis B Immunization given?
□ Hypospadias
□ Cleft lip with or without Cleft palate
Filling out the Child Birth Certificate form in Texas is an important step after the birth of your child. This form collects essential information that will be used to create your child's official birth certificate. Once completed, the information will be submitted to the appropriate state authorities to ensure your child's identity and legal status are recognized.
The Child Birth Certificate Texas form is used to gather important information needed to create your child's birth certificate. This document is essential as it serves as proof of your child's age, citizenship, and parentage. Your child will use this birth certificate throughout their life for various purposes, including applying for school and government services.
You can request a certified copy of your child's birth certificate from the local registrar's office in the city or county where the birth took place. Alternatively, you can also obtain it from the Texas Vital Statistics office located in Austin, Texas. A certified birth certificate is a permanent legal document that establishes your child's identity.
If you indicated that you want to apply for your baby's social security number, the birth information will be sent to the Social Security Administration (SSA) once the Texas Vital Statistics office receives it from the hospital. The SSA typically takes 2-3 weeks to process this information. You can expect the social security card to arrive at the mailing address you provided within 4-6 weeks.
If you provided your Medicaid information on the form, the birth details will be forwarded to the Medicaid office after the Texas Vital Statistics office receives the data from the hospital. Similar to the social security card, Medicaid usually takes 2-3 weeks to process this information. An Infant Medicaid card will be mailed to the address you provided, generally within 4-6 weeks.
You will need to provide various details on the form, including:
Make sure to fill out the form carefully, as errors can be difficult and costly to correct.
If you make a mistake on the Child Birth Certificate Texas form, it can be challenging to correct. Errors may require additional paperwork and fees. Therefore, it is crucial to print your responses clearly and accurately. If you realize a mistake after submission, contact the Texas Vital Statistics office for guidance on how to proceed.
Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure every section is complete, including the child’s name, mother’s details, and place of birth.
Incorrect Dates: Entering the wrong date of birth or time of birth is a common mistake. Double-check these details to avoid complications later.
Omitting Parent Information: Not providing accurate information about both parents can result in issues. Make sure to include both parents’ names, social security numbers, and other relevant details.
Neglecting to Review: Failing to review the completed form before submission can lead to overlooked errors. Take a moment to go over the form to ensure accuracy.
When completing the Child Birth Certificate Texas form, several other documents may also be required or helpful. These documents support the birth registration process and ensure all necessary information is accurately recorded. Below is a list of common forms associated with the birth certificate process in Texas.
These forms and documents work together to facilitate the accurate registration of a birth in Texas. Ensuring all paperwork is completed correctly will help avoid delays and complications in obtaining vital records for the newborn.
The Texas Marriage Certificate serves as a legal document that confirms the union between two individuals. Similar to the Child Birth Certificate, it establishes identity and is often required for various legal and administrative purposes, such as applying for joint bank accounts or insurance. Just as the birth certificate provides proof of parentage, the marriage certificate verifies the marital status of the individuals involved. Both documents require accurate information and are safeguarded by state laws to protect personal data.
The Social Security Card is another important document that shares similarities with the Child Birth Certificate. It serves as a unique identifier for individuals within the United States and is essential for accessing government services, employment, and benefits. Just as a birth certificate is used to establish a child's identity, the Social Security Card confirms a person's eligibility for various programs. The process for obtaining both documents involves submitting personal information and may take several weeks for processing.
The Passport is a crucial document for international travel, akin to the Child Birth Certificate in terms of identity verification. A passport requires proof of citizenship, which is often established through a birth certificate. Both documents are vital for confirming one's identity and citizenship status, whether for domestic purposes or international travel. The application processes for both involve providing detailed personal information and can take time to complete.
The Driver's License is a widely recognized form of identification that, like the Child Birth Certificate, establishes identity and age. It is often required for various activities, such as driving legally or verifying identity in public spaces. Both documents are issued by state authorities and require accurate personal information. The process to obtain a driver’s license typically includes presenting a birth certificate as proof of identity.
The Adoption Certificate is similar to the Child Birth Certificate in that it establishes a legal relationship between a child and their adoptive parents. This document serves as proof of the adoption and may be required for legal matters, just as a birth certificate is used for identity verification. Both documents are crucial for establishing familial relationships and ensuring the child’s rights and benefits under the law.
The Medical Records Release Form allows parents to share their child's medical information with healthcare providers. Like the Child Birth Certificate, it requires accurate personal details to ensure the correct information is shared. Both documents are essential for managing a child's health care needs, with the birth certificate often serving as a foundational document for accessing medical services. This form ensures that parents maintain control over their child's medical history and information.
When filling out the Child Birth Certificate Texas form, it is important to ensure that the information is accurate and complete. Here are some guidelines to help you:
Following these guidelines will help ensure that the birth certificate is processed smoothly and correctly. This document is essential for your child's future identification and legal needs.
When it comes to the Texas Child Birth Certificate form, there are several misconceptions that can lead to confusion for new parents. Here’s a breakdown of ten common misunderstandings:
Understanding these misconceptions can help parents navigate the process of obtaining their child's birth certificate more smoothly. Being informed and prepared is key to avoiding potential issues down the line.
Filling out the Child Birth Certificate form in Texas is an important task that requires attention to detail. Here are key takeaways to help you navigate the process effectively:
By keeping these takeaways in mind, you can help ensure a smooth process in securing your child's birth certificate in Texas.