:
New York City Department of Health
And Mental Hygiene
Bureau of Vital Statistics
April 2021
125 Worth St.
New York, NY 10013
Dear New Mother/Parent (Person Giving Birth),
The New York City Department of Health and Mental Hygiene (NYC Health
Department) issues your child’s birth certificate. A birth certificate is the
permanent legal record of your child’s birth and is used as proof of your
child’s age, citizenship and parentage. The information you provide is
required by law. Unless you complete this form correctly, we cannot create
an accurate birth certificate for your child.
Information about your education, race, smoking, height and weight before
pregnancy are collected for public health purposes. Additional questions
labeled “QI” (Quality Improvement) are requested by the New York State
(NYS) Department of Health to learn more about the quality of prenatal care
New Yorkers are receiving. NYC and NYS laws protect against the unlawful
release of birth certificate information to ensure the confidentiality of you
and your child.
• It is extremely important that you provide complete and accurate
information to questions on this worksheet. Please print all information
clearly.
• The worksheet must be completed in English. If you are not able to
complete it in English by yourself, or if you have any questions, please
call the hospital Birth Registrar at __________________________.
• The worksheet must be completed and returned to the Birth Registrar
within 24 hours of the birth of your child.
For Facility Birth Registration Tracking Purposes
Mother/Parent Worksheet - Data Collected for Registration of Newborn Birth Certificate
Mother/Parent’s
Medical Record
Number:
Mother/Parent’s Name:
Child’s Medical
Record Number:
Child’s Date
of Birth
Number delivered this pregnancy
If more than one, birth order of this child
VR-203 (Rev. 4/21)
Country
Months lived in U.S.
9. Where were you born?
City State (if not in United States (U.S.), please indicate country)
10. If you were born outside of the U.S., how long
have you lived in the U.S.?
____ ____
VR-203 (Rev. 4/21)
Please print all names exactly as you would like them to appear on the birth certificate.
To change this information in the future, you will be required to submit a correction application to the Health Department.
Child
If more than one child delivered, birth order of this child: _____
Child’s FIRST Name Child’s MIDDLE Name(s) Child’s LAST Name Suffix
(Jr., III, etc.)
1. What will be your
child’s legal name?
2. Do you want a Social Security number (SSN) and card for your child?
M Yes M No
As long as you have provided the legal first and last name of your newborn child above, you may request an SSN for your child. The Health Department will send the
request to the Social Security Administration at the time the certificate is filed. If you do not request this now, you will need to contact Social Security directly to obtain
an SSN for your child. The hospital, birth facility and Health Department will not be responsible for making the request on your behalf.
If yes, the card will be mailed to Mother/Parent’s
Mailing Address by the Social Security Administration.
Mother/Parent (Person Giving Birth)
Mother/Parent’s First Name Mother/Parent’s Middle Name Mother/Parent’s Legal Last Name Suffix
3. What is your current
legal name?
M My maiden name is my current legal name
4. What is your maiden name?
Name prior to first marriage
Mother/Parent’s First Name Mother/Parent’s Middle Name Mother/Parent’s Legal Last Name Suffix
Current
Age
Sex M Female
Date of Mother/
Parent’s
Birth
5-7. What is your date of birth, current age and sex?
M Male
“X” means a gender that is not exclusively male or female
(that is, a non-binary gender identity)
____ ____ / ____ ____ / ____ ____ ____ ____
M X
Month Day Year
Mother/Parent’s SSN M I do not have an SSN
8. What is your Social Security Number?
Father/Parent’s SSN will be requested in the Father/Parent’s
information section, if applicable.
Providing parents’ SSNs is required by Federal Law, 42 USC 405(c) (Section 205c
of the Social Security Act). The numbers will be made available to the NYS Office
of Temporary and Disability Assistance to assist with child support enforcement
activities and to the Internal Revenue Service (IRS) through the Social Security
Administration for the purpose of determining Earned Income Tax Credit compliance.
____ ____ ____ – ____ ____ – ____ ____ ____ ____
Your signature below indicates that the information regarding the Social Security number on this form is correct.
Mother/Parent’s Signature
Date
__ __ / __ __ / __ __ __ __
Month Day Year
Mother/Parent’s Birthplace
OR
If less than one year:
Years lived in U.S.
___ ___ ___ ___
Mother/Parent’s Address
11. Where do you usually live?
Where is your household physically located?
If not in U.S., please indicate address, city and country.
12. What is your mailing address?
This is where the birth certificate will be mailed.
The first copy of the birth certificate is free.
13. What are your telephone numbers?
Street Address (do not enter a PO Box or In Care of (c/o)) Apt. Number
City State ZIP Code Country
If NYC, County (borough)
M New York (Manhattan)
M Bronx
M Kings (Brooklyn)
M Queens
M Richmond (Staten Island)
Do you live within the city limits specified above? M Yes M No Outside NYC (Specify County): _____________________________________
M Same as my usual residence above
M No mailing address (If no mailing address, certificate will NOT be mailed; you will need to pick it up at the Health Department.)
If mailing address is In Care of (c/o), please indicate here:
In Care of (another person or organization/agency)
Street Address (PO Box is not permitted in a NYC mailing address) Apt. Number
City State ZIP Code Country
Day
Evening
( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___ Ext. _____________
( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___
M Yes M No
20. Did you participate in WIC during this pregnancy?
(Special supplemental nutrition for Woman, Infants and Children.)
Height Pre-Pregnancy Weight
21. What is your height?
____ ____ Feet ____ ____ Inches ____ ____ ____ pounds
22. What was your pre-pregnancy weight?
M No M Yes If yes, what was the average number of cigarettes per day or packs per day you smoked during the following times?
23. Did you smoke cigarettes in the three months
Please answer below. Enter 0 if none during any of these periods
before or during this pregnancy?
Time Period Number of Cigarettes per day OR Number of Packs per day
Three months before your pregnancy ___ ___ _____
First three months of your pregnancy ___ ___ _____
Second three months of your pregnancy ___ ___ _____
Third three months of your pregnancy ___ ___ _____
24. Did you use alcohol during this pregnancy?
M Yes M No
25a. Did you work with a doula (a trained birth
M Yes M No M Do Not Know
assistant) during this pregnancy?
25b. What was the doula’s name and organization (if applicable)?
Name (first, last): ___________________________ Organization:__________________________ M Do Not Know
25c. Was the doula present during your labor and/or delivery? Check (8) all that apply M Yes, the doula provided support in-person
M Yes, the doula provided support virtually (for example, over the phone, Zoom, FaceTime)
M No
M No - Skip to Question 27
26. (QI) did you receive
M Yes - If yes, please answer the following: During any of your prenatal care visits, did a doctor, nurse or other health care worker talk with you about any of the things listed below?
prenatal care (medical
a) How smoking during pregnancy could affect your baby? M Yes M No
e) Birth control methods to use after your pregnancy? M Yes M No
care for this pregnancy)
b) How drinking alcohol during your pregnancy could affect your baby? M Yes M No
f) What to do if your labor starts early? M Yes M No
before admission for
c) How using illegal drugs could affect your baby? M Yes M No
g) How to keep from getting HIV (the virus that causes AIDS)? M Yes M No
d) How long to wait before having another baby? M Yes M No
h) Physical abuse to women by their husbands or partners? M Yes M No
this delivery?
27. (QI) How many times per week during your current pregnancy did
you exercise for 30 minutes or more, aside from your usual activities?
____ ____ Times per week
28. (QI) Did you have any problems with your gums at any time during pregnancy (for example, swollen or bleeding gums)? M Yes M No
29. (QI) During your pregnancy, would you say that you were:
M Not depressed at all M A little depressed M Modately depressed
M Very depressed and did not receive help M Very depressed and did receive help
Check (8) one box only
M You wanted to be pregnant sooner
30. (QI) Thinking back to just before you were pregnant, how did
M You wanted to be pregnant later
you feel about becoming pregnant?
Check (8) one box only
M You wanted to be pregnant then
M You didn’t want to be pregnant then or at any time in the future
Mother/Parent’s Attributes
14. Education: What is the highest level of school that you
completed at the time of your baby’s delivery?
Check (8) one box only
15. Were you employed during the pregnancy?
16. What is your current/most recent occupation/job?
17. What industry did you perform this occupation/job?
Do not give the name of the business but write what type of business it is.
18. What is your ancestry?
Check (8) one box and specify what you most consider yourself to be.
19. What is your race?
Race is defined by U.S. Census. Hispanic/Latino is not a race according
to the U.S. Census. For Hispanic ancestry, please use Question 18.
Check (8) all that apply and specify where indicated.
M 8th grade or less; none
M Associate degree (for example, AA, AS)
M 9th-12th grade, no diploma
M Bachelor’s degree for example, BA, AB, BS)
M High school graduate or GED
M Master’s degree (for example,. MA, MS, MEng, MEd, MSW, MBA)
M Some college credit, but no degree
M Doctorate (for example, PhD, EdD) or Professional degree
(for example, MD, DDS, DVM, LLB, JD)
M Yes M No
Occupation (For example: cashier, bank teller, nurse, attorney, etc.)
Industry (For example: restaurant, banking, health care, legal, etc.)
M Hispanic/Latino (For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)
Specify: _____________________________________________________________________
M Not Hispanic/Latino (For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)
Specify: _____________________________________________________________________
M White M Filipino M Native Hawaiian
M Black or African American M Japanese M Guamanian or Chamorro
M American Indian or Alaska Native M Korean M Samoan
(name of enrolled or principal tribe) M Vietnamese M Other Pacific Islander (specify)
______________________ M Other Asian (specify) ________________________
M Asian Indian ______________________ M Other (specify)
M Chinese ________________________
Mother/Parent’s Health
Quality Improvement (QI) questions 26, 27, 28, 29 and 30 are voluntary and asked for the NYS Department of Health —
all QI answers are confidential and used for public health purposes only.
VR-203 (Rev. 4/21)
31.
What is the name of your baby’s father/parent prior
Father/Parent’s First Name Father/Parent’s Middle Name(s) Father/Parent’s Last Name Suffix
(Jr., III, etc.)
to the father/parent’s first marriage (name at birth)?
Please write father/parent name exactly as you would like it to appear on the
certificate. To change this information in the future, you will be required to
submit a correction application to the Health Department.
Date of Father/
Current
Sex M Female
32-34. What is the father/parent’s date of birth,
Parent’s
Age
M Male
Birth
____ ____
current age, and sex? “X” means a gender that is not exclusively
____ ____ / ____ ____ / ____ ____ ____ ____
M X
Month Day Year
male or female (that is, a non-binary gender identity)
Father/Parent’s SSN M Father/Parent does not have an SSN
35. What is the father/parent’s Social Security number?
Providing parents’ SSNs is required by Federal Law, 42 USC 405(c) (Section 205c of the Social Security Act). The numbers will be made
____ ____ ____ – ____ ____ – ____ ____ ____ ____
available to the NYS Office of Temporary and Disability Assistance to assist with child support enforcement activities and to the Internal
Mother/Parent’s signature on previous page confirms that the above SSN is correct
Revenue Service (IRS) through the Social Security Administration for the purpose of determining Earned Income Tax Credit compliance.
If you want the name of the child’s father/parent to appear on the birth certificate, you must provide accurate
and complete information as outlined below and submit a completed form to the hospital Birth Registrar.
And
1) If married, ask the hospital what is necessary to ensure the other parent’s name appears as the legal
parent of your child on the birth certificate; or
2) If married and more than one person could be the other parent of the child, you must go to Family Court
to establish parentage; or
3) If you are not married and the child is not the subject of a surrogacy agreement, both you and the alleged
parent can sign an acknowledgment of parentage form in the presence of two unrelated witnesses; or
4) If your circumstances are not covered by the above, speak with the hospital Birth Registrar.
Father/Parent’s Information For Live Birth
To Be Completed By Mother/Parent Or Father/Parent
Father/Parent
Father/Parent’s Birthplace
36. Where was the father/parent
born?
City State (If not in U.S., please indicate country) Country
37. If the father/parent was born outside of the U.S.,
how long have they lived in the U.S.?
Years lived in U.S.
___ ___
OR
If less than one year:
Months lived in U.S.
___ ___
Father/Parent’s Attributes
38. Education: What is the highest level of school that the
father/parent completed at the time of your baby’s
delivery?
Check (8) one box only
39. What is the father/parent’s current or most recent
occupation/job?
40. In what industry did they perform this occupation/job?
Do not give the name of the business, but write what type of business it is.
41. What is the father/parent’s ancestry?
Check (8) one box only and specify what the father/parent most considers
themselves to be.
42. What is the father/parent’s race?
Race is defined by the U.S. Census. Hispanic/Latino is not a race according to
the U.S. Census. For Hispanic/Latino ancestry, please use Question 41. Check
(8) all that apply and specify where indicated.
M 8th grade or less; none
M Associate degree (for example, AA, AS)
M 9th-12th grade, no diploma
M Bachelor’s degree for example, BA, AB, BS)
M High school graduate or GED
M Master’s degree (for example,. MA, MS, MEng, MEd, MSW, MBA)
M Some college credit, but no degree
M Doctorate (for example, PhD, EdD) or Professional degree
(for example, MD, DDS, DVM, LLB, JD)
Occupation (For example: cashier, bank teller, nurse, attorney, etc.)
Industry (For example: restaurant, banking, health care, legal, etc.)
M Hispanic/Latino (For example: Mexican, Puerto Rican, Cuban, Dominican, etc.)
Specify: _____________________________________________________________________
M Not Hispanic/Latino (For example: Italian, African American, Haitian, Pakistani, Ukrainian, Nigerian, Taiwanese, etc.)
Specify: _____________________________________________________________________
M White M Filipino M Native Hawaiian
M Black or African American M Japanese M Guamanian or Chamorro
M American Indian or Alaska Native M Korean M Samoan
(name of enrolled or principal tribe) M Vietnamese M Other Pacific Islander (specify)
______________________ M Other Asian (specify) ________________________
M Asian Indian ______________________ M Other (specify)
M Chinese ________________________
VR-203 (Rev. 4/21)
