NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES NC VITAL RECORDS CERTIFICATE OF LIVE BIRTH Registration District No. Local No. BIRTH NO. CHILD 1. CHILD'S NAME (First, Middle, Last, Suffix) 2. DATE OF BIRTH (Month, Day, Year) 3. TIME OF BIRTH 4. SEX

5. FACILITY NAME (If not institution, give street and number) 6. CITY, TOWN, OR LOCATION OF BIRTH 7. COUNTY OF BIRTH

FATHER 8a. FATHER'S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 8b. DATE OF BIRTH (Month, Day, Year) 8c. BIRTHPLACE (State, Territory, or Foreign Country)

MOTHER 9a. MOTHER'S CURRENT LEGAL NAME (First, Middle, Last, Suffix) 9b. DATE OF BIRTH (Month, Day, Year)

9c. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) 9d. BIRTHPLACE (State, Territory, or Foreign Country)

10a. RESIDENCE OF MOTHER - STATE 10b. COUNTY 10c. CITY, TOWN, OR LOCATION

10d. STREET AND NUMBER 10e. ZIP CODE 10f. INSIDE CITY LIMITS? Yes No 11. MOTHER'S MAILING ADDRESS: Same as residence, or: State: City, Town, or Location:

Street and Number: Zip Code: CERTIFIER 12. CERTIFIER'S NAME: 13. DATE CERTIFIED 14. DATE REC'D BY LOCAL REGISTRAR ------TITLE: MD DO HOSPITAL ADMIN. CNM/CM OTHER MIDWIFE ------/------/------/------/------ MM DD YYYY MM DD YYYY OTHER (Specify) ------

15. DATE NAME ADDED ------/------/------16. DATE AMENDED ------/------/------MM DD YYYY MM DD YYYY

NEWBORN 17. BIRTHWEIGHT (grams preferred, specify unit) 18. PLURALITY - Single, Twin, Triplet, etc. 19. IF NOT SINGLE BIRTH - Born First, Second, Third, etc. ------ grams lb/oz (Specify) ------(Specify) ------RACE 20. FATHER'S RACE (Check one or more races to indicate what the father considers himself to be) White Asian Indian Vietnamese Samoan Black or African American Chinese Other Asian Other Pacific Islander American Indian or Alaska Native Filipino (Specify) ------(Specify) ------(Name of the enrolled or principal tribe) Japanese Native Hawaiian Other ------ Korean Guamanian or Chamorro (Specify) ------21. MOTHER'S RACE (Check one or more races to indicate what the mother considers herself to be) White Asian Indian Vietnamese Samoan Black or African American Chinese Other Asian Other Pacific Islander American Indian or Alaska Native Filipino (Specify) ------(Specify) ------(Name of the enrolled or principal tribe) Japanese Native Hawaiian Other ------ Korean Guamanian or Chamorro (Specify) ------

22. MOTHER MARRIED? (At birth, conception, or any time between) Yes No 23. SOCIAL SECURITY NUMBER REQUESTED FOR CHILD? Yes IF NO, HAS PATERNITY ACKNOWLEDGMENT BEEN SIGNED IN THE HOSPITAL? Yes No No INFORMATION FOR MEDICAL AND HEALTH USE ONLY FATHER 24. FATHER'S SOCIAL SECURITY NUMBER: 26. FATHER'S EDUCATION (Check the box that 30. PLACE WHERE BIRTH OCCURRED (Check one) best describes the highest degree or level of Hospital ------—------—------school completed at the time of delivery) Freestanding birthing center Home Birth: 25. FATHER OF HISPANIC ORIGIN? (Check the 8th grade or less Planned to deliver at Home? Yes No box that best describes whether the father is 9th - 12th grade, no diploma Clinic/Doctor's office Spanish/Hispanic/Latino. Check the "No" box if High school graduate or GED completed Other (Specify) father is not Spanish/Hispanic/Latino) Some college credit but no degree ------ No, not Spanish/Hispanic/Latino Associate degree (e.g., AA, AS) Yes, Mexican, Mexican American, Chicano Bachelor's degree (e.g., BA, AB, BS) 31. FACILITY ID. (NPI) Yes, Puerto Rican Master's degree (e.g., MA, MS, MEng, MEd, Yes, Cuban MSW, MBA) Yes, other Spanish/Hispanic/Latino Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) (Specify) ------32. ATTENDANT'S NAME, TITLE, AND NPI NAME:------29. MOTHER'S EDUCATION (Check the box that MOTHER 27. MOTHER'S SOCIAL SECURITY NUMBER: NPI: ------best describes the highest degree or level of TITLE: MD DO CNM/CM — — school completed at the time of delivery) OTHER MIDWIFE ------ 8th grade or less OTHER (Specify) 28. MOTHER OF HISPANIC ORIGIN? (Check the 9th - 12th grade, no diploma ------box that best describes whether the mother is High school graduate or GED completed Spanish/Hispanic/Latina. Check the "No" box if Some college credit but no degree 33. MOTHER TRANSFERRED FOR MATERNAL MEDICAL mother is not Spanish/Hispanic/Latina) Associate degree (e.g., AA, AS) OR FETAL INDICATIONS FOR DELIVERY? Yes No No, not Spanish/Hispanic/Latina Bachelor's degree (e.g., BA, AB, BS) Yes, Mexican, Mexican American, Chicana Master's degree (e.g., MA, MS, MEng, MEd, IF YES, ENTER NAME OF FACILITY MOTHER Yes, Puerto Rican MSW, MBA) TRANSFERRED FROM: Yes, Cuban Doctorate (e.g., PhD, EdD) or Professional Yes, other Spanish/Hispanic/Latina degree (e.g., MD, DDS, DVM, LLB, JD) ------(Specify) ------MOTHER 34a. DATE OF FIRST PRENATAL CARE VISIT 34b. DATE OF LAST PRENATAL CARE VISIT 35. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY ------/------/------No Prenatal Care ------/------/------(If none, enter "0".) MM DD YYYY MM DD YYYY 36. MOTHER'S HEIGHT 37. MOTHER'S PREPREGNANCY 38. MOTHER'S WEIGHT AT DELIVERY 39. DID MOTHER GET WIC FOOD FOR ------(feet/inches) WEIGHT ------(pounds) ------(pounds) HERSELF DURING THIS PREGNANCY? Yes No 40. NUMBER OF PREVIOUS 41. NUMBER OF OTHER 42. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY 43. PRINCIPAL SOURCE OF LIVE BIRTHS (Do not include PREGNANCY OUTCOMES For each time period, enter either the number of cigarettes or the PAYMENT FOR THIS this child) (spontaneous or induced number of packs of cigarettes smoked. IF NONE, ENTER "0". DELIVERY losses or ectopic pregnancies) Average number of cigarettes or packs of cigarettes smoked per day. # of cigarettes # of packs Private Insurance 40a. Now Living 40b. Now Dead 41a. Other Outcomes Three months before pregnancy _____ OR ______ Medicaid First three months of pregnancy _____ OR ______ Self-Pay Number ------Number ------Number ------Second three months of pregnancy _____ OR ______ Other None None None Third trimester of pregnancy _____ OR ______(Specify) ------40c. DATE OF LAST LIVE BIRTH 41b. DATE OF LAST OTHER 44. DATE LAST NORMAL MENSES BEGAN 45. MOTHER'S MEDICAL RECORD NUMBER PREGNANCY OUTCOME ------/------/------/------/------MM YYYY MM YYYY MM DD YYYY MEDICAL 46. RISK FACTORS IN THIS PREGNANCY 48. OBSTETRIC PROCEDURES (Check all that apply) 51. METHOD OF DELIVERY (Check all that apply) Cervical cerclage AND Tocolysis A. Was delivery with forceps attempted but unsuccessful? Diabetes HEALTH Yes No Prepregnancy (Diagnosis prior to this pregnancy) External cephalic version: INFORMA- Gestational (Diagnosis in this pregnancy) TION Successful B. Was delivery with vacuum extraction attempted but Hypertension Failed unsuccessful? Prepregnancy (Chronic) Yes No Gestational (PIH, preeclampsia) None of the above Eclampsia C. Fetal presentation at birth 49. ONSET OF LABOR (Check all that apply) Cephalic Previous preterm birth Premature Rupture of Membranes Breech Other previous poor pregnancy outcome (Includes (prolonged, >12 hrs.) Other perinatal death, small-for-gestational age/ Precipitous Labor (<3 hrs.) intrauterine growth restricted birth) Prolonged Labor (> 20 hrs.) D. Final route and method of delivery (Check one) None of the above Vaginal/Spontaneous Pregnancy resulted from infertility treatment--If yes, Vaginal/Forceps check all that apply: 50. CHARACTERISTICS OF LABOR AND DELIVERY Vaginal/Vacuum Fertility-enhancing drugs, Artificial insemination (Check all that apply) Cesarean or Intrauterine insemination Induction of labor If cesarean, was a trial of labor attempted? Assisted reproductive technology (e.g., in vitro Augmentation of labor Yes fertilization (IVF), gamete intrafallopian transfer Non-vertex presentation No (GIFT) Steroids (glucocorticoids) for fetal lung maturation Mother had a previous cesarean delivery received by the mother prior to delivery 52. MATERNAL MORBIDITY (Check all that apply) If yes, how many ------Antibiotics received by the mother during labor (Complications associated with labor and delivery) Clinical chorioamnionitis diagnosed during labor Maternal transfusion None of the above or maternal temperature > 38°C (100.4°F) Third or fourth degree perineal laceration Moderate/heavy meconium staining of the amniotic Ruptured uterus 47. INFECTIONS PRESENT AND/OR TREATED DURING fluid Unplanned hysterectomy THIS PREGNANCY (Check all that apply) Fetal intolerance of labor such that one or more of Admission to intensive care unit Gonorrhea the following actions was taken: in-utero Unplanned operating room procedure following Syphilis resuscitative measures, further fetal assessment, delivery Chlamydia or operative delivery None of the above Hepatitis B Epidural or spinal anesthesia during labor Hepatitis C None of the above None of the above Was mother tested for HBsAG? Yes No If tested, include test date ------/------/------MM DD YYYY and test results: Positive Negative NEWBORN INFORMATION NEWBORN 53. NEWBORN MEDICAL RECORD NUMBER: 57. ABNORMAL CONDITIONS OF THE NEWBORN 58. CONGENITAL ANOMALIES OF THE NEWBORN (Check all that apply) (Check all that apply) Assisted ventilation required immediately following Anencephaly 54. OBSTETRIC ESTIMATE OF GESTATION: delivery Meningomyelocele/Spina bifida ------(completed weeks) Assisted ventilation required for more than six hours Cyanotic congenital heart disease NICU admission Congenital diaphragmatic hernia 55. APGAR SCORE: Newborn given surfactant replacement therapy Omphalocele Score at 5 minutes: ------ Antibiotics received by the newborn for suspected Gastroschisis If 5 minute score is less than 6, neonatal sepsis Limb reduction defect (excluding congenital Score at 10 minutes: ------ Seizure or serious neurologic dysfunction amputation and dwarfing syndromes) 56. INFANT VACCINATION Significant birth injury (skeletal fracture(s), Cleft Lip with or without Cleft Palate Infant vaccinated with Hepatitis B vaccine? peripheral nerve injury, and/or soft tissue/solid Cleft Palate alone Yes No organ hemorrhage which requires intervention) Down Syndrome If yes, include vaccination date None of the above Karyotype confirmed ------/------/------Karyotype pending MM DD YYYY Suspected chromosomal disorder Karyotype confirmed Karyotype pending Hypospadias None of the anomalies listed above

59. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? Yes No 60. IS INFANT LIVING AT TIME OF REPORT? 61. IS THE INFANT BEING IF YES, NAME OF FACILITY INFANT TRANSFERRED TO: Yes No BREASTFED AT DISCHARGE? ------Infant transferred, status unknown Yes No