Pre-Admission & Birth Certificate Information Booklet

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1 Pre-Admission & Birth Certificate Information Booklet 1

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5 Dr name: Maternity Pre Admission Form (972) Must be returned by your 26 th week Date of last Menstrual Period: Due Date: Patient Name: (Last) (First) (MI) Maiden Name: Street Address: Apt# (City) (State) (Zip code) Telephone Number: SSN for Patient Employer of Patient Marital Status: S M W D Sep DOB: Age: Race: Religious Preference (Optional): Occupation: Address of Employer:(Street) (City) (State) (Zip code) Telephone number: Spouses Name/Guarantor Name (Last) (First) (MI) Social Security Number: Street Address: (If different from patient) Employer of Spouse/Guarantor: Spouse/Guarantors DOB: Occupation: Telephone: Address of Employer:(Street) (City) (State) (Zip code) Telephone number: Nearest Relative or Friend (Not living with Patient) Relationship: Street Address: Apt# (City) (State) (Zip code) Telephone number: Insurance (Primary):Company Name,Address,City State & Zip Telephone number: Name of Policy Holder: Group Number: Policy or Certification Number: Insurance (Secondary):Company Name,Address,City State & Zip Telephone number: Name of Policy Holder: Group Number: Policy or Certification Number: Please include a copy of your identification along with the front and back of your current Insurance card or cards Thanks!!! This form is NOT a part of the permanent medical record. 3

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7 Women ssm Parent Education Classes Medical City Hospital Preparation for Childbirth is a class for first-time parent s that covers all aspects of childbirth. Includes a Tour. Lamaze Class is a class to be taken in addition to the Preparation for Childbirth class if you are interested in the instruction and practice of breathing and relaxation techniques for labor. Refresher Class is an abbreviated version of Preparation for Childbirth for parents who have delivered before. Includes a Tour. Cesarean Section Class is a class that i specifically for those who are delivering by cesarean. Sibling Class is a class that teaches How to be a good brother or sister. Daddy Boot Camp is a class in which veteran fathers orient rookie dads. Breastfeeding Class is a class of instruction in breastfeeding. It includes benefits, techniques, troubleshooting problems. Grandparent Class is a class for new or to-be grand parents. Hospital Tours may be scheduled by calling Please note that Hospital tours are included with each of the above classes. For a more detailed description of classes, further information and on-line registration visit our website at select Women s, then select Parent Educaton. To view ALL classes offered please see our web site. Questions? Contact Parent Education at

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9 What is cord blood? Cord blood is the blood that remains in the placenta after a baby is bom. Cord blood has been found to be a rich source of stem cells and is currently being used as an alternative to bone marrow in treating a number of life threatening diseases. Because these cells are normally discarded after birth, this is the ultimate recycling project. Why do we need the Texas Cord Blood Bank? Our Mission To develop and maintain a statewide resource for potentially life-saving cord blood to treat children and adults. Sadly, this potentially life-saving option is not available to everyone due to the high costs associated with the testing, processing and storage of umbilical cord blood cells. The Texas Cord Blood Bank (TCBB) allows families the opportunity to donate their infant s cord blood, regardless of socioeconomic status, to ensure that all patients needing a bone marrow/stem cell transplant are offered this opportunity. More than 70% of children and adults requiring a bone marrow transplant do not have an immunematched sibling who could be a donor. In their case, the only option is to find an unrelated donor through the national bone marrow and cord blood registries. Because immune types are specific to ethnic groups, it is important to collect cord blood units from donors of all backgrounds, especially Hispan-ics, African Americans, and Native Americans. For more information please call (210) or visit our website: 7

10 To participate in donating your baby s cord blood to the Texas Cord Blood Bank you simply have to consent. There is no cost to you, everything that is needed for the collection will be provided for you at the hospital, when you deliver. A sample of maternal blood will be needed and this may be done at the same time your other lab work is drawn-again, at no additional cost to you. The collection process takes place following the birth of your baby, after the cord has been clamped and cut. Traditionally the placenta, cord and blood are thrown away following the delivery. By taking a few extra steps, we can collect this blood which is a natural by- product of birth and a non-controversial source of stem cells. If the collection meets the standards, the stem cells will be processed and stored for future use by seriously ill children and adults. Benefits of cord blood: * There is no risk to the baby or the mother. * Since cord blood immune cells are less mature, they are more easily accepted by the patient when used in transplantation. As a result, patients with a less than perfect immune match can now be treated. * There are fewer immune complications after transplantation. * Since cord blood is banked and ready to use, it is immediately available when a patient needs it. The day following delivery, if the sample has been determined to be adequate, the RN coordinator will come to visit with you to obtain a second consent and a thorough medical, social, and family history. Every attempt will be made to do this at a time that is convenient for you. By donating what is usually discarded, your baby s first gift will be to help the life of someone whose life is threatened by serious illness. How can YOU make a difference? There are a few public unrelated banks in the United States; each represents an ethnic mix unique to their geographic area. TCBB is focused on the needs of Texans. TCBB is prepared to collect, prcess and store unrelated cord blood. The cost incurred by the TCBB to collect, process, test and store one unit of cord blood is over $1,500. If you would like to make a contribution to theis program, please send your donation to the Texas Cord Blood Bank. 8

11 Texas Cord Blood Bank 6211 IH 10 West San Antonio, Texas (210) (800) Fax: (210) Visit our website: 9

12 ****IMPORTANT INFORMATION **** Congratulations on the birth of your child. You must fill out the worksheet that is attached for your child s birth certificate. (The last 5 sheets) Read the Instructions on the top of the Worksheet that is attached Fill it out completely DO NOT leave any blanks Double Check your Information ***The information that you put on this worksheet is the information that is going to be on YOUR baby s Birth Certificate. *****If you are not married to the biological father and you want his name to appear on the birth certificate, the state of Texas require s that an Acknowledgment of Paternity must be completed and signed by both parents. (Please read the following 3 pages) ***************ATTENTION..WEEKEND BIRTHS****************** (Friday & Saturday Births) You will be required to come see me on the Monday following your child s birth for the following Items: Immtrac Form Verification of Birth Facts If an Acknowledgement of Paternity is needed, both you and the father will be required to come. (please bring picture id s) **If I do not hear anything from you by 2:00 pm on Monday, I will file the birth certificate without a fathers name. I am located on the 7th Floor North Building D between 7:00 am to 2:00 pm (Monday thru Friday) My phone number is: Thank you, Carmen Ybarra, Birth Registrar MCD01404 (Rev. 02/10) 10

13 Voluntary Acknowledgment of Paternity If you are not married to the father of your child but you want him listed as the legal father on the birth certificate, here is information you will need to know: Both parents must sign a document called an Acknowledgment of Paternity (AOP). When the Acknowledgment of Paternity is filed with the Vital Statistics Unit (VSU), the biological father becomes the legal father. Identification must be provided to complete an AOP. The Acknowledgment of Paternity can be signed: Before your baby is born; When your baby is born; or Anytime afterwards. To sign the AOP before your baby s birth, both you and the biological father must go to a certified entity listed below. When the AOP is completed, the certified entity will fax it to VSU. Please bring your copy of the AOP to the hospital when you have your baby. If an AOP was not completed when the baby was born, both parents may go at anytime afterwards to a certified entity listed below to complete an AOP. The Acknowledgment of Paternity can be signed and completed at: Attorney General Child Support Offices Local Registrar (County Clerk s Office) Local City Vital Statistics Offices To find a certified entity near you, you may call (866) Important Information If you are married to someone other than the father of the child, your husband must complete the Denial of Paternity section on the Acknowledgment of Paternity form. If you were divorced within 300 days before your child s birth and a court order does not exclude your ex-husband as the father of the child, your ex-husband must sign the Denial of Paternity. If the Denial of Paternity is needed and not completed, you cannot proceed with the AOP. You may contact a child support office or private attorney for assistance. Form 1608 Revised: 09/

14 Reconocimiento de Paternidad Voluntario Si no está casada con el papá del niño pero desea ponerlo como el papá legal en el acta de nacimiento, necesita saber la siguiente información: Ambos padres deben firmar el documento llamado Reconocimiento de Paternidad (AOP). Cuando el Reconocimiento de Paternidad es presentado ante la Unidad de Estadísticas Vitales (VSU), el papá biológico se convierte en el papá legal. Debe mostrar su identificación para completar un AOP. El Reconocimiento de Paternidad puede ser firmado: antes del nacimiento de su bebé; al nacer su bebé; o a cualquier momento después del nacimiento de su bebé; Para firmar el Reconocimiento de Paternidad antes del nacimiento de su bebé, ambos la mamá y el papá biológico deben ir a una de las entidades certificadas mencionadas aquí abajo. Al completar el Reconocimiento de Paternidad, la entidad certificada enviará un fax a la Unidad de Estadísticas Vitales. Por favor traiga una copia del Reconocimiento de Paternidad al hospital cuando nazca su bebé. Si no completó un Reconocimiento de Paternidad al nacer su bebé, ambos padres pueden ir posteriormente en cualquier momento a una de las entidades certificadas mencionadas abajo para completar el Reconocimiento de Paternidad. El Reconocimiento de Paternidad puede ser firmado y completado en: Procurador General de Oficinas de Manutención de Menores Secretario local (Oficina del Secretario del Condado) Oficinas locales de la ciudad de Estadísticas Vitales Para encontrar una entidad certificada en su área, puede llamar (866) Información Importante Si está casada y su esposo no es el papá del niño, su esposo debe llenar la sección Negación de Paternidad, que se encuentra en el Reconocimiento de Paternidad. Si se divorció dentro de 300 días antes del nacimiento de su hijo y una orden judicial no excluye a su ex marido como el padre del niño, su ex marido tiene que firmar la Negación de la Paternidad. Si la Negación de Paternidad es necesaria pero no la han llenado; no puede proceder con el Reconocimiento de Paternidad. Usted todavía puede establecer la paternidad si solicita los servicios de una oficina de manutención de niños o consultando a un abogado privado. 12 Form 1608 Actualizado: 09/2011

15 This is a legal document. If you are not sure that the man named in this Acknowledgment is the biological father of the child, you should NOT sign this document. You may want to get a genetic test. The biological father who signs this Acknowledgment becomes the legal father of the child when this document is filed with the Department of State Health Services, Texas Vital Statistics Signing this legal document gives you certain rights and responsibilities. Signing this document is voluntary. You should consult an attorney if you have any concerns about signing this document. This document requires an Entity Code completed in the lower right corner by an individual certified by the Office of the Attorney General to administer Acknowledgments of Paternity. Benefits, Right, and Responsibilities of Paternity Establishing parentage makes it easier for a child to receive benefits such as social security, military and veteran s benefits, health care coverage and life insurance, as well as inheritance. This Acknowledgment has the same effect as a court order establishing paternity. Both parents have parental right and duties as provided by state law. Either parent has the right to seek primary custody of the child. A parent not living with the child may have the right to visit and maintain a relationship with the child, either as both parents agree or as ordered by a court. By signing this Acknowledgment, you may be ordered to pay child support and medical support. This document may be completed before the birth of the child, at the time of birth, or at any time after the birth of the child prior to any court hearing in a proceeding involving the child. If this document is signed before the birth of the child, it is binding for any child born no later than 300 days after the signature date on this document. When this Acknowledgment is properly filed with Texas Vital Statistics, it creates a parent-child relationship between the man and child. Establishment of paternity is required for a father s name to be entered on a birth certificate. Child Support services can be obtained through the Office of the Attorney General, Child Support Division or by hiring an attorney. Denial of Paternity If a child s mother is married to a man other than the biological father at the time of birth or within 300 days of the ending of a marriage (by a finalized divorce,) the (ex) husband is presumed to be the legal father. To complete this document for a child that has a presumed father, the presumed father must deny paternity by completing the Denial of Paternity section. The mother must agree that the presumed father is not the biological father by also signing the denial section. The acknowledgment section must also be completed by the biological father and mother, or the denial will not be accepted. Upon the filing of this document, the presumed father is legally determined not to be the father of the child. His legal duty to support the child is removed. Likewise, his legal right of custody or visitation with the child is terminated. Change of Mind If any party to this document changes his/her mind about acknowledging or denying paternity, he/she may file a Rescission of Acknowledgment of Paternity (VS-158) to rescind this document. The Rescission of Acknowledgment of Paternity must be filed within sixty (60) days after this legal document is filed with Texas Vital Statistics or before the date a proceeding related to the child is initiated, whichever occurs first. After sixty (60) days, or the date a proceeding for the child was initiated, a lawsuit is required to challenge this document. Fraud, duress, or material mistake of fact in signing this form must be proven during the lawsuit. If a Party is a Minor Minors are authorized to complete the Acknowledgment of Paternity without parental consent. Minors are allowed to rescind or challenge this document in the same procedures as persons eighteen (18) or older. All parties must receive oral notice of the above information before completing this Acknowledgment. You can receive oral notice of the information by calling and selecting option 1, Notice of Rights and Responsibilities of a Parent. September 2011 If you have questions, you may call the Paternity Opportunity Program at

16 Este es un documento legal. Si no está segura que el hombre a quien se nombra en el Reconocimiento de Paternidad es el papá biológico del niño, NO debe firmar este documento. Usted quizás quiera hacer una prueba genética. El papá biológico que firma el Reconocimiento de Paternidad se convierte en el papá legal del niño cuando el documento es registrado en la Unidad de Estadísticas Vitales del Departamento Estatal de Servicios de Salud. Al firmar este documento legal, se le otorgan a usted ciertos derechos y responsabilidades. Firmar este documento es voluntario. Debe consultar con un abogado si tiene cualquier inquietud sobre la firma de este documento. Este documento requiere que sea incluido un Código de Entidad en la esquina de abajo al lado derecho que debe ser puesto por una persona autorizada por la Procuraduría General para administrar el Reconocimiento de Paternidad. Beneficios, Derechos y Responsabilidades de la Paternidad Establecer el parentesco ayuda a facilitar que un niño reciba beneficios tales como seguro social, beneficios militares y de veteranos, cobertura de cuidado médico y seguro de vida, al igual que herencias. Este Reconocimiento de Paternidad tiene el mismo efecto que una orden de la corte estableciendo la paternidad. Ambos padres tienen derechos de paternidad y deberes según como dispone la ley estatal. Cualquiera de los padres (mamá o papá) tiene derecho de intentar obtener la custodia principal del niño. Un padre que no vive con el niño quizás pueda tener derecho a visitar y mantener una relación con el niño, ya sea por acuerdo de los dos padres o por orden de una corte. Al firmar este Reconocimiento de Paternidad, a usted se le puede ordenar que pague manutención de niños o manutención médica. Este documento se puede llenar antes de nacer el niño, al momento de nacer, o en cualquier momento después del nacimiento del niño previo a que se realice alguna audiencia en corte en un procedimiento que involucre al niño. Si este documento es firmado antes de nacer el niño, establece un vínculo para cualquier niño que nace dentro de un lapso de 300 días después de la fecha de la firma de este documento. Cuando este Reconocimiento de Paternidad queda debidamente registrado con la Unidad de Estadísticas Vitales de Texas, establece una relación de padre e hijo entre el hombre y el niño. Se requiere establecer la paternidad para que el nombre del papá aparezca en el acta de nacimiento. Puede obtener servicios de manutención de niños a través de la División de Manutención de Niños de la Procuraduría General o contratando a un abogado Negando la Paternidad Si la mamá de un niño está casada con un hombre que no es el papá biológico al momento de nacer o dentro de 300 días de que termine un matrimonio (por medio de un divorcio finalizado), dicho esposo o ex esposo se presume es el papá legal. Para completar este documento para un niño con un presunto papá legal, el presunto papá debe negar la paternidad llenando la sección Negación de la Paternidad. La mamá debe estar de acuerdo que el presunto papá no es el papá biológico al también firmar la sección negando la paternidad. El papá biológico y la mamá también deben llenar la sección de reconocimiento, o no será aceptada la negación de la paternidad. Al registrar este documento, se determina que el presunto papá no es el papá legal del niño. Su deber legal de proporcionar manutención al niño queda eliminado. Igualmente, su derecho legal de custodia o visitas con el niño queda eliminado. Cambio de Opinión Si una de las partes mencionadas en este documento cambia de opinión sobre el reconocimiento o el rechazo de paternidad, pueden registrar una Anulación del Reconocimiento de Paternidad (VS-158) para anular este documento. La Anulación del Reconocimiento de Paternidad debe ser registrada dentro de sesenta (60) días después que este documento legal haya sido registrado con Estadísticas Vitales de Texas o antes de haya sido realizada la primera audiencia en un procedimiento que involucre al niño, incluyendo la manutención de niños, según lo que ocurra primero. Después de sesenta (60) días, o de la fecha de la primera audiencia, se requiere una demanda para desafiar este documento. El fraude, coacción o equivocación material de hecho al firmar este formulario debe ser comprobado durante la demanda. Si Una de las Partes Es Menor de Edad Los menores de edad están autorizados para llenar el Reconocimiento de Paternidad sin permiso de sus padres. Los menores de edad pueden anular o desafiar este documento bajo los mismos procedimientos a disposición de personas de dieciocho (18) años o mayores. Todas las partes deben recibir un aviso oral de la información mencionada arriba antes de llenar el Reconocimiento de Paternidad. Usted puede recibir aviso oral de esta información llamando al y seleccionando la opción 1, Aviso de Derechos y Responsabilidades de un Padre. Si tiene preguntas, llame al Programa de Oportunidad de Paternidad al September

17 Information about Child Support for New Parents The Attorney General of Texas Child Support Division is committed to helping parents with paternity establishment, child support and visitation. Q: Who may apply? A: Anyone who would like to establish paternity, child support and/or medical support Q: Why should I apply? A: People come to the Attorney General s Child Support offices for many reasons sometimes because parents are not together. Even parents who are together and getting along may want to consider applying for child support services. Unmarried mothers or fathers who would like the added security of DNA testing before legal fatherhood (paternity) is established, removing the possibility of legal challenges in the future Note: If you open a child support case with the Office of the Attorney General and the OAG determines that a DNA test is necessary, one will be provided with no upfront cost. Mothers or fathers who want to establish a formal financial arrangement (this protects both parents) Mothers who are married to someone other than the biological father and need help establishing paternity with the biological father Q: How do I apply? A: Applying for child support services means filling out an application with the Office of the Attorney General and providing the staff with as much information as you can about your child, yourself, and the other parent. This can be done: Online Go to the Office of the Attorney General s website at: In Person You may visit any of our offices to obtain an application. For additional information, call (800) Q: How much does it cost? A: There is no charge to apply for child support services. Effective October 1, 2011, custodial parents with full-service cases who have never received Temporary Assistance for Needy Families (TANF) will pay a $25 service fee each year that they receive at least $500 in child support collections. Fees will be deducted from child support payments. Parents who have more than one child support case will pay a fee on each case that meets the criteria. Q: Will I have to go to court? A: Many parents take care of all their child support business in the office through the Child Support Review Process (CSRP). If parents can reach an agreement about paternity establishment, child support and visitation, and/or medical support, they can sign all the necessary documents and establish an order without going to court. 15 Revised: 09/2011

18 Información para los nuevos padres sobre la manutención de niños La División de la Procuraduría General de Texas para la Manutención de Niños está comprometida a ayudar a los padres a establecer la paternidad, la manutención de niños y las visitas. Nuestros servicios son gratis o de bajo costo. P: Quién puede solicitar servicios? R: Cualquier persona que desee establecer la paternidad o la manutención médica o de niños. P: Por qué debo solicitarlos? R: Las personas acuden a las oficinas de manutención de niños por muchas razones, a veces porque los padres no están juntos. Hasta los padres que están juntos y se llevan bien podrían considerar solicitar servicios de manutención de niños. Las mamás o papás solteros que quieren la seguridad adicional que brinda una prueba de ADN antes de establecer la paternidad legal, para eliminar la posibilidad de desafíos legales en el futuro. Las mamás o papás que quieren establecer un acuerdo financiero formal (esto protege a ambos padres). Las mamás que están casadas con alguien que no es el papá biológico y necesitan ayuda para establecer la paternidad del papá biológico. P: Cómo solicito servicios? R: Solicitar los servicios de manutención de niños significa llenar una solicitud ante la Procuraduría General y darle al personal toda la información posible sobre el niño, usted y el otro padre. Esto se puede hacer: En la Internet - Vaya a la página Internet de la Procuraduría General en En persona - Puede ir a cualquiera de nuestras oficinas y obtener una solicitud. Para información adicional, llame al P: Cuánto cuesta? R: Nuestros servicios son gratis. Si no se ha establecido la paternidad y los padres solicitan la prueba de ADN, la prueba inicial es gratis. P: Tendré que presentarme ante una corte? R: Muchos padres resuelven sus asuntos de manutención de niños en nuestras oficinas a través del Proceso de Revisión de Manutención de Niños (Child Support Review Process, CSRP). Si los padres pueden llegar a un acuerdo sobre el establecimiento de la paternidad, la manutención médica o de niños y las visitas, pueden firmar todos los documentos necesarios y establecer una orden sin ir a la corte. P: Qué sucede si cambio de opinión después de abrir mi caso? R: Mientras que el padre con custodia no haya recibido asistencia social del estado, simplemente puede llenar un formulario y nuestra oficina cerrará el caso Revised 11/17/09

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21 Mother s Worksheet for Child s Birth Certificate MOTHER MR# NEWBORN MR# Mothers Name 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 INFORMATION SEX OF BABY (please circle one) MALE FEMALE Time of Birth Date of Birth Plurality (please circle one) Am / Pm Single / Twin / Triplets / Quadruplets / Quintuplets MOTHER S CURRENT LEGAL NAME First Name Middle Name Last Name Suffix CHILD S LEGAL NAME First Name Middle Name Last Name Suffix MOTHER S RESIDENCE ADDRESS Residence Address Apartment Number State/Foreign Country County City/Town/Location Zip Code / Extension Inside City Limits? Yes No Mother s Date of Birth Place of Birth (State/Foreign Country/Territory) Social Security Home phone: Cell/Other phone: MOTHER S MAILING ADDRESS (If same as residence address, LEAVE THIS SECTION BLANK) Mailing Address Apartment Number State/Foreign Country City/Town/Location Zip Code / Extension Inside City Limits? Yes No MCD01404 (Rev. 08/10) MOTHER S WORKSHEET FOR CHILD S BIRTH CERTIFICATE 19

22 MOTHER S INFORMATION Apply for Baby s Social Security? Yes No Occupation: Mother s Education Did Mother Give up Rights to the Child? Yes No Type of Business: Is Mother of Hispanic Origin? What is Mother s Race? Date Rights Given Up? 8 th grade or less 9 th 12 th 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) No, not Spanish / Hispanic / Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, other Spanish / Hispanic / Latina Specify White Black/African American American Indian/Alaska Native (Name of the enrolled or principal tribe) Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Specify Other Unknown MOTHER S HEALTH INFORMATION Did you receive WIC for this Birth? Yes No 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: Packs/Day: Second Three Months Cigs/Day: Packs/Day: Third Trimester Cigs/Day: Packs/Day: 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 / / Source of Prenatal Care (check all that apply) None Midwife Hospital Clinic Public Health Clinic Private Physician Other, Specify Pregnancy History Unknown Live births now living (Do not include this birth. For multiple deliveries, do not include the 1 st 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 1 st 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: / MM YYYY MOTHER S WORKSHEET FOR CHILD S BIRTH CERTIFICATE MCD01404 (Rev. 08/10) Page 2

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