California Department of Public Health

Vital Records

STATE OF CALIFORNIA

DEPARTMENT OF PUBLIC HEALTH

Vital Records
MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
To obtain additional copies of the Handbook for a minimal charge, please contact
California Department of Public Health – Vital Records (CDPH-VR) at:

California Department of Public Health

Vital Records – M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410

(916) 445-8494
TABLE OF CONTENTS
Birth Registration Handbook – Table of Contents

INTRODUCTION ...................................................................................... i

BIRTH ................................................................................................... 101

OTHER TYPES OF BIRTH REGISTRATION ................................... 201

BIRTH AMENDMENTS ...................................................................... 801

CERTIFIED COPIES ............................................................................ 901

ACCESS .............................................................................................. 1001

VERIFICATION OF RECORDS ....................................................... 1101

FEES .................................................................................................... 1201

APPENDIX A: VITAL STATISTICS FORMS ............................... 1301

APPENDIX B: OCCUPATION TABLE .......................................... 1401

APPENDIX C: BUSINESS/INDUSTRY TABLE ............................ 1501

APPENDIX D: OUT-OF-HOSPITAL BIRTH REGISTRATION ... 1601

INDEX
INTRODUCTION
 INTRODUCTION

The Vital Records System – Birth, Fetal Death and Death

Overview The California Vital Records System includes the collection, registration,
maintenance, amendment, and certification of vital records (birth, fetal
death, and death events). The Director of the California Department of
Public Health (CDPH), by law, is the State Registrar and is responsible for
directing and supervising the registration of vital records in California.
These functions are performed by CDPH-VR. Under CDPH-VR’s
supervision, each local registrar registers and transmits the original records
for events occurring in the Local Registration District (LRD) to CDPH-VR
for filing and indexing. CDPH-VR transmits statistical data from vital
records to the National Center for Health Statistics (NCHS). At the state
level, statistical reports are prepared for public health use by state and local
health departments, other government agencies, and various private and
voluntary organizations.

REFERENCE: Health and Safety Code Sections 102175 through 102249

In this section Information contained in this section includes:

Subsection Title See Page

The History of Vital Records iii

The Purpose of the Vital Records System vii

The Role of the State Registrar ix

The Role of the Local Registrar xi

The Role of the National Center for Health Statistics xiii

Procedures to Follow When A County Health xvi

Officer Leaves
Cross-Matching Birth and Death Certificates xviii

January 1, 2016 i
 INTRODUCTION

Use this page for notes.

January 1, 2016 ii
 INTRODUCTION

The History of Vital Records

Overview The history of vital records dates back to 1858 when California began its
first centralized system for registering birth and death records. Shortly
thereafter, in 1860, the State’s registration function was legislatively
repealed. Subsequent legislation in 1869 reestablished the State’s vital
records system.

Chronology of The following is a chronology of events describing the evolution of the vital
events records system and the significant statutory changes which occurred.

Year Type of Event

1858 The first statutory provision for the recording of births and deaths
in California was the Registration Act of 1858. It authorized the
Governor to appoint a State Registrar of Vital Statistics whose
duties were to prepare and furnish to county recorders suitable
forms and books for the registration of births and deaths and to file
duplicate records received from county recorders. This law was
repealed in 1860.

1869- A State Board of Health was created in 1869, but no specific

1872 provisions were made for the general preservation of vital statistics
until 1872, when the Political Code placed this responsibility with
the Secretary of the State Board of Health. Under this code,
county recorders were designated local registrars of births and
deaths. The recorder kept a Register of Births and a Register of
Deaths with an index to each. Quarterly, each recorder sent a
certified abstract of each register to the Secretary of the State
Board of Health.

1883 Boards of Health in incorporated cities of over 100,000 population

were required to keep a record of all births and deaths occurring in
the city and to file a copy of the ledger with the county recorder.

1905 The first complete registration of births and deaths in the State was
provided for in 1905 when the Legislature established the Bureau
of Vital Statistics. Certificates of Registry of Birth were deposited
by persons attending births with the county recorder or with the
health officer in cities having freeholders’ charters. The local
registrars were required to keep a Register of Births and to deliver
the original birth certificates each month to the State Registrar.

Continued on next page

January 1, 2016 iii

 INTRODUCTION

1905 The State was also divided into primary registration districts for
cont. the registration of deaths. Local registrars for death registration
were county recorders, city clerks in cities or incorporated towns,
and health officers in cities having freeholders’ charters. Funeral
directors filed the death certificates with local registrars, who kept
a copy and sent the original certificates to the State Registrar.

1915 The State was divided into primary registration districts for the
registration of births, just as it had been divided in 1905 for deaths.
Those officials who had been death registrars were assigned the
additional responsibility for birth registration.

1931 The duties of local registrars within a city were transferred to city
health officers or to county health officers. Two years later, the
county health officers in counties having a countywide health
department were designated local registrars for all territory in the
county not included within city primary registration districts.

1939 The Health and Safety Code was established and contained a
codification of all previous statutes concerning vital statistics.

1943 Major legislation was enacted with an administrative procedure for

the delayed registration of previously unregistered births.

1947 Legislation enacted the requirement that the health officer be the
local registrar of births and deaths as a prerequisite for approval as
a full-time local health department.

1951 Further refinements included that the record on file in the county
recorder’s office was not to include the medical and health data
section of birth certificates and certificates were to be transmitted
to the Office of State Registrar on a weekly basis.

Continued on next page

January 1, 2016 iv
 INTRODUCTION

1956 A provision was enacted requiring that the footprints of the child
and the fingerprints of the mother be imprinted on the reverse side
of the birth certificate. (Repealed in 1958.)

1957 Division 9 and related sections in Division 7 of the Health and

Safety Code were entirely rewritten and reorganized.

1965 Procedures were simplified for the certifier to amend medical and
health data on birth and death certificates.

1978 Legislation established each item on the birth certificate in law and
established the health and medical information on the certificate as
confidential.

1995 Division 9 and related sections of the Health and Safety Code
were reorganized. This section is now referred to as Division 102.

1995 Legislation required that if the parents are not married to each
other, the father’s name shall not be listed on the birth certificate
unless the father and mother sign a voluntary declaration of
paternity.

2003 Several pieces of legislation regarding vital events were enacted,

including adding the question whether the decedent was pregnant
to the death certificate. Other legislation addressed mass fatalities;
implementation of an electronic death registration system; and
notification to the Division of Labor Statistics and Research of all
work-related deaths.

July Identity theft legislation was implemented requiring specific

2003 individuals to sign a sworn statement under penalty of perjury that
they were authorized to receive a certified copy of a birth or death
certificate. If the request for the certified copy is mailed, the
sworn statement must also be notarized. Individuals not
authorized under the law to receive an authorized certified copy
may receive a copy marked “Informational, Not A Valid
Document to Establish Identity.”

Continued on next page

January 1, 2016 v
 INTRODUCTION

2004 Legislation was implemented allowing the acceptance of faxed

notarized statements sworn under penalty of perjury in order to
receive a certified copy. The new legislation also allowed any
agent or employee of a funeral establishment to order certified
copies of death certificates on behalf of an authorized individual.
Additional legislation required that amendments to death
certificates of a peace officer killed in the line of duty be
processed no later than 10 days after acceptance of filing.

2005 Assembly Bill (AB) 1278 (Chapter 430, Statutes of 2005) was
signed into law. AB 1278 primarily addressed changes to the birth
and fetal death certificate. However, this bill also changed the
implementation dates of two provisions previously signed into law
under Senate Bill (SB) 247 (Chapter 914, Statutes of 2002).

2007 SB 162 (Chapter 241, Statutes of 2006), California Public Health

Act of 2006, establishes the California Department of Public
Health, to be headed by the State Public Health Officer appointed
by the Governor. It also renames the California Department of
Health Services to the California Department of Health Care
Services.

2010 The State Office of Vital Records changed its name to California
Department of Public Health-Vital Records (CDPH-VR).

2013 AB 1403 (Chapter 510, Statutes of 2013) and SB 274 (Chapter

564, Statutes of 2013) allows for a child to have more than two
parents. Based on these two pieces of legislation, California
created the birth certificate (VS 10M) to allow for more than two
parents to be listed. The VS 10M is only created based on receipt
of a court order received by CDPH-VR.

2014 AB 1951 (Chapter 334, Statutes of 2014) addresses changes to the

birth certificate to identify each parent’s relationship to the child.
The revised birth certificate goes into effect January 1, 2016,
allowing each parent to select their relationship to the child. The
choices are mother, father, or parent. The parent may also elect to
leave the relationship box blank.

Current Original birth, fetal death, and death certificates are registered and
transmitted by the local registrar to CDPH-VR, where they are
indexed and filed as permanent records.

January 1, 2016 vi
 INTRODUCTION

The Purpose of the Vital Records System

Overview The vital records system was initially established to record births, fetal
deaths, and deaths occurring in California. In addition to documenting these
vital events, the statistical data derived from these records was used to
develop a health status profile for the State. The purpose of the vital records
system became twofold: 1) to establish a permanent record that is legally
recognized as prima facie evidence of the facts stated therein, and 2) to
provide a means for studying the statistical data for health evaluation and
planning purposes.

Uses of vital Vital records are certificates that have been registered for each birth, fetal
records death, and death by the local registrar of the county in which the event
occurred. Upon registration by the local registrar, the certificate becomes
the State’s legal record of that event and is prima facie evidence in all
courts. Certified copies of the original records are made available to serve
the personal needs of individuals.

Birth records are used to:

 prove age, parentage, and citizenship

 secure passports

 apply for Social Security benefits and other legal needs

 obtain veteran’s benefits

 register to vote

 apply for a driver’s license

 apply for employment

 apply for social benefits

Continued on next page

January 1, 2016 vii

 INTRODUCTION

Death records are used to:

 apply for insurance benefits

 settle pension claims

 verify transfer of title of real and personal property

REFERENCE: Health and Safety Code Section 103550

Uses of vital Vital records data provides valuable health and research data. In general,
record data statistical data from vital records are used to:

 provide health authorities with a means of studying health problems and

evaluating health programs

 provide information from the records to government, education and

research organizations for such uses as population estimation and
planning and evaluating health activities such as maternal, child and
adolescent health programs

 provide information to individuals for various purposes

January 1, 2016 viii

 INTRODUCTION

The Role of the State Registrar

Overview The State Registrar administers the California Vital Records System under
the provisions of the Health and Safety Code. CDPH-VR, under the
direction of the State Registrar, is charged with statewide responsibility for
implementing and maintaining a uniform system for registration and a
permanent central registry for all birth, fetal death, and death records
(approximately 1 million events are registered annually). An important
function of CDPH-VR is to issue certified copies of certificates to
individuals or organizations that request them.

REFERENCE: Health and Safety Code Sections 102175 through 102249

CDPH-VR CDPH-VR inspects each record for completeness and accuracy of

functions information where possible and for promptness of filing, queries for missing
or inconsistent information, numbers the records, prepares indices,
processes the records, and stores the documents for permanent reference and
safekeeping. Statistical information from these records is then transmitted
to NCHS.

CDPH-VR performs the following functions:

 administers the vital records statutes and supervises the 61 LRDs

 prescribes and furnishes all forms used for registration

 prepares and issues all county letters of instruction, policies, and

guidelines as required to maintain statewide uniformity

 examines certificates received from the local registrars for acceptability

before filing and indexing

 maintains a permanent public record of each event which has occurred

in California since 1905

 prepares, maintains, and monitors computer files of birth, fetal death,

and death for data quality

 provides certified copies of vital records

Continued on next page

January 1, 2016 ix
 INTRODUCTION

 advises and instructs local registrars through consultation, regional

workshops, annual site visits, and conferences

 maintains cooperative working relationships with organizations

interested in vital records data, such as the California Conference of
Local Health Officers, California Coroners Association, California
Association of Clerks and Election Officials, County Recorders’
Association of California, California Funeral Directors Association,
Social Security Administration (SSA), Center for Disease Control and
Prevention, and NCHS

January 1, 2016 x
 INTRODUCTION

The Role of the Local Registrar

Overview The Local Registrar registers certificates of birth, fetal death, and death
events occurring in the LRD and transmits the original certificates, on a
weekly basis, to CDPH-VR.

By law, the health officer of any approved health department is the local
registrar for that LRD. The health officer or an interim health officer must
be a graduate of a medical school and be eligible for a license to practice
medicine and surgery in the State of California. In other cases, the State
Registrar appoints a local registrar of birth and deaths.

REFERENCE: Health and Safety Code Sections 102275 through 102395

and 101000 through 101010

Local registrar The local registrar performs the following functions:

functions
 reviews certificates for each birth, fetal death, and death occurring in the
jurisdiction for accuracy and completeness prior to registration

 monitors hospitals to ensure timely registration of birth certificates (see

sample letter on page xv if hospital births are not registered timely)

 prepares copies of the original certificates for the county recorder before
transmitting the original certificates to CDPH-VR

 issues certified copies of records

 provides assistance to persons who wish to amend records

 meets annually with physicians, key hospital staff, funeral directors,

coroners, and interment authorities and provides training to promote
prompt, complete, and accurate vital record registration

 maintains a cooperative working relationship with the county recorder to

ensure prompt exchange of information and assistance when necessary

January 1, 2016 xi
 INTRODUCTION

Chief deputy The chief deputy registrar is appointed by the local health officer to direct
registrar and supervise the overall registration of births, fetal deaths, and deaths in
the local registration district. This appointee may perform all of the duties
of the local registrar in the name and place of the principal.

NOTE:
 The designation of a chief deputy registrar shall be done by
written appointment.

 CDPH-VR shall be officially notified by letter of any chief

deputy registrar or deputy appointment.

 Funeral directors and funerary business-related persons shall not

be appointed as deputy registrars; such appointments are
considered a conflict of interest.

Subregistrars Most districts will not require a subregistrar. However, in some counties,
geography and travel time may dictate the need. As with the chief deputy
registrar, a subregistrar may perform all of the duties of the local registrar in
the name and place of the principal. However, controls must be in place to
assure that processing by a subregistrar meets the same high standards
established by the local registrar’s office and by CDPH-VR.

When a subregistrar is appointed, this person shall:

 be a health department employee living and/or working in the remote

part of the district where the subregistrar’s office is located

 receive the same supervision as other vital records staff

 receive training on the duties and legal obligations of birth, fetal death
and death registration

NOTE:

 CDPH-VR shall be officially notified in writing of any

subregistrar appointments.

 Funeral directors or any funerary business-related persons shall

not be appointed as subregistrars; as such appointments would be
considered a conflict of interest.

January 1, 2016 xii

 INTRODUCTION

The Role of the National Center for Health Statistics (NCHS)

Overview The NCHS in the Public Health Services of the U.S. Department of Health
and Human Services is vested with the authority for administering vital
statistics information at the national level. When birth, fetal death, and
death certificates are permanently filed in the state registrar offices,
statistical data from the individual records are sent to NCHS. From these
data, monthly, annual, and special statistical reports are prepared for the
nation and the states for use by federal agencies and others interested in
vital statistics data.

History It has been only during the last century that anything approaching adequate
data on births, fetal deaths, and deaths has been available on a nationwide
basis. Prior to 1900, only ten states and the District of Columbia could
supply data sufficiently complete and accurate to be used for national
compilation. In other states, reliable data could be obtained only from some
of the larger cities. Statistics on birth and death were based primarily on
census figures and were for the most part untrustworthy, especially with
respect to the recording of the causes of death.

Chronology of The following table is a chronology of events describing how the national
events collection of birth, fetal death, and death data on a nationwide basis began.

Year Type of Event

1900 The Bureau of the Census abandoned its efforts to secure mortality
information from its own records and concentrated on developing
uniform data from the original death records filed in the various
state health departments. Since each state had its own method of
registering deaths, the first step was to draft uniform practices and
laws and to prepare a recommended standard death certificate. This
standard form was adopted, either in whole or in part, by 18 states
and the District of Columbia and in 71 major cities located in the
other states. Those states which could demonstrate fairly complete
registration were constituted an official death registration area, and
the data collected formed the basis for the mortality reporting for
the nation.

1915 The Bureau of the Census established a birth registration area to

compliment the death registration area.

Continued on next page

January 1, 2016 xiii

 INTRODUCTION

1920 Thirty-four states and the District of Columbia were providing

uniform death statistics on a statewide basis. Twenty-four states
and the District of Columbia were providing statewide data on birth
registration.

1930 By this time only one state was not participating in the death
registration area and only two states were not participating in the
birth registration area.

1933 All states and the District of Columbia were participating in the
birth and death registration.

NCHS functions NCHS works closely with the state registrar offices, confers with them on
ways to improve methods of operation, and supplies pamphlets and other
literature for their use. NCHS also undertakes joint projects with various
states to check what problems may still exist in securing prompt, complete,
and accurate registration on all births and deaths occurring within a given
area.

NCHS performs the following functions:

 promotes uniform model vital records registration laws and participates

with states through various associations, committees, and conferences
on vital records registration issues

 prepares national vital statistics reports on birth, fetal death, and death

 prepares statistical information for the nation and the states for use by
federal agencies and others interested in vital statistics data

 provides consultation in conjunction with the National Association for

Public Health Statistics and Information System (NAPHSIS) upon
request to the states on matters concerning vital statistics

January 1, 2016 xiv

 INTRODUCTION

Sample letter Below is a sample letter for local registrars to use if hospital births are not
submitted registered timely.

Name of Hospital Administrator

Name of Hospital
Address
City, State, Zip Code

Dear (Name of Hospital Administrator):

This letter is to bring to your attention the problem of late registration of births which occur
in your facility. State law specifies that births be registered within ten days from the date
of birth.

“Each live birth shall be registered with the local registrar of births and
deaths for the district in which the birth occurred within 10 days
following the date of the event.” (Health and Safety Code
Section 102400.)

State law further specifies that the hospital administrator, or their designee, is responsible
for registering all hospital births within the time period specified above.

“For live births which occur in a hospital, the administrator of the

hospital or a representative designated by the administrator in writing
may sign the birth certificate certifying the fact of birth instead of the
attending physician and surgeon, certified nurse midwife, or principal
attendant is not available to sign the certificate; and shall be responsible
for registering the certificate with the local registrar within the time
specified in Section 102400.” (Health and Safety Code Section 102405.)

I am quite concerned about the time between a child’s birth and registration of the
certificate at the (Name of Local Registration District) by your facility. The Vital Statistics
Registration Section of the (Name of Local Registration District) performed an analysis of
certificates received for registration during (time period). Of the _______________
certificates received from your facility, __________ (_________%) were not filed within
ten days. This delay is also a great inconvenience and source of frustration to parents, since
they cannot receive a certified copy of their child’s birth certificate unless it has been
registered.

I appreciate your immediate attention to this important matter, and look forward to
receiving birth certificates from your facility within the time frame specified by law.

If you have any questions, please contact me at (_____) _____-_________.

cc: California Department of Public Health

Licensing and Certification Division
District Administrator
(local district office)

California Department of Public Health

Vital Records – M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410

January 1, 2016 xv
 INTRODUCTION

Procedures to Follow When A County Health Officer Leaves

Overview On occasion, a county health department will be faced with the departure of
their health officer (local registrar). With exception of a few State-appointed
local registrars, the county health officer is appointed by the county board of
supervisors or the appropriate administrative authority.

The following procedures must be implemented by the county and local

health departments to ensure that proper registration and certification of vital
records continues without disruption.

No vital records may be registered or certified by the departing health officer

after their final day occupying the office.

Notify the Notify the board of supervisors or the appointing authority of the health
appointing officer’s departure prior to the actual departure date whenever possible.
authority
Once the health officer leaves, the board of supervisors or the appointing
authority must appoint a new health officer or an acting health officer before
any birth, fetal death, or death certificates may be registered, or any certified
copies may be issued. Or else, the duties of the health officer may be
temporarily discharged by a chief deputy, assistant or deputy next in
authority.

REFERENCE: Government Code Section 24105

Notify 1. Please notify the Birth and Marriage Registration Section (BMRS) at
BMRS (916) 445-8494 as soon as you learn the health officer is leaving.
2. Submit formal written notification of the health officer’s effective date of
departure.
3. Submit the name of the newly appointed health officer or acting health
officer and the effective date that the new health officer or acting health
officer may begin registering and certifying vital records to:

California Department of Public Health

Vital Records – M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410
Attn: Chief, Vital Records

4. If an acting health officer is replaced by the new health officer follow

Steps 1, 2 & 3 listed above.

Continued on next page

January 1, 2016 xvi

 INTRODUCTION

Procedures to Follow When A County Health Officer Leaves,

Continued

Signing the When an acting health officer is officially appointed, they as the acting health
certificates officer must sign the birth, death, and fetal death certificates submitted for
registration. A facsimile stamp with the new appointee’s name may be used
provided the signature or initials of the chief deputy registrar are entered after
the stamped name.

When a new health officer is officially appointed, they must sign the birth,
death, and fetal death certificates submitted for registration as such. As usual,
a facsimile stamp with the new health officer’s name may be used provided
the signature or initials of the chief deputy registrar are entered after the
stamped name.

If the facsimile stamp is not ordered in a timely manner, all certificates will
need to be signed individually.

Issuing certified When issuing certified copies of vital records, the acting or newly appointed
copies health officer must sign as such on the banknote paper. If the prior health
officer’s signature is preprinted on the banknote paper, it may still be used,
but the acting or newly appointed health officer must co-sign each document.
As an alternative to destroying the current banknote paper supply, CDPH-VR
suggests that the above procedure be followed until the supply is depleted or a
new supply with the new signature is printed. CDPH-VR will accept
documents processed in this fashion. However, you may wish to consult your
county counsel before implementing it.
As usual, a facsimile stamp may be used when issuing certified copies.

NOTE: These procedures may also be used when a Recorder leaves office.

Questions The above procedures have been developed to assist counties and local health
departments in planning for an efficient and timely transition should the
health officer depart.
If you have any questions regarding registration, please contact BMRS at
(916) 445-8494.
If you have any questions regarding certified copies, please contact the
Quality Assurance and Intelligence Reform Section (QAIR) at
(916) 552-8116.

January 1, 2016 xvii

 INTRODUCTION

Cross-Matching Birth and Death Certificates

Overview CDPH-VR began cross-matching birth and death records for California
events on January 1, 1978. However, due to a change in the mainframe and
system limitations, crossmatch ended in 2010. CDPH-VR hopes to resume in
2016. When CDPH-VR receives information on a death, a search for a birth
certificate is conducted based on the personal information reported on the
death certificate. If a birth certificate is located, the birth certificate and index
are marked deceased.

Cross-match CDPH-VR will notify the local registrar and county recorder when a cross-
list match is made. The cross-match list will be sent to each local county office.

Local registrar/ Upon notification by the State Registrar that a person is deceased, the local
county recorder registrar and county recorder are responsible for ensuring that the birth
responsibilities certificate copy is stamped “DECEASED.” The stamp should be at least one-
half inch high in boldface style and should be placed in the Place of Birth area
on the birth certificate.

The birth index should also be marked that the record is for a deceased
person. If room permits, also indicate the date of death and death certificate
file number.

If the local registrar has information that the child listed on a newly created
birth certificate is deceased, and the certificate has not yet been forwarded to
CDPH-VR, the local registrar should enter the date of death in field 15A and
stamp the original certificate “DECEASED.”

REFERENCE: Health and Safety Code Section 102245

Certified copies All certified copies of birth certificates for individuals that are deceased must
display the legend “DECEASED.”

If an applicant requests a certified copy of a deceased person’s birth

certificate and states it is their own record, provide the certified copy to the
applicant marking the record “DECEASED.” Then, provide a copy of the
application for a certified copy to CDPH- VR for further investigation.

REFERENCE: Health and Safety Code Section 103540

January 1, 2016 xviii

 INTRODUCTION

Use this page for notes.

January 1, 2016 xix

BIRTH
 BIRTH
The Certificate of Live Birth (VS 10D)
Overview Each live birth, which occurs within California, must be registered with the
local registrar for the district in which the birth occurred within 10 days
following the date of the birth. Birth certificates submitted for registration
beyond the 10 day mandate may be accepted by the local registrar, but they
must be properly registered within one year of the date of birth. Certificates
are acceptable for registration if received prior to the child’s first birthday.

REFERENCE: Health and Safety Code Section 102400

Live birth means the complete expulsion or extraction from its mother of a
product of conception (irrespective of the duration of pregnancy) which
after such separation, breathes or shows any other evidence of life such as
the beating of the heart, pulsation of the umbilical cord, or definite
movement of voluntary muscles, whether or not the umbilical cord has been
cut or the placenta is attached.

REFERENCE: California Code of Regulations 915

In this section Information contained in this section includes:

Subsection Title See Page

Requirements for Completing the Birth Certificate 103

Responsibilities of the Hospital Administrator 105

Public Information on the Certificate 109

(Items 1-17)
Confidential Information for Public Health Use 144
(Items 18-33)
State Registrar Items 190

Numbering the Birth Certificate 194

January 1, 2016 101

 BIRTH
Use this page for notes.

January 1, 2016 102

 BIRTH
Requirements for Completing the Birth Certificate
Overview All physicians, informants, and other persons having knowledge of the
facts, shall supply upon the prescribed forms any information they possess
regarding any live birth. The certificate form shall be completed in
accordance with the requirements set forth in the Health and Safety Code.

If the parents refuse to cooperate in the filing of the birth certificate, the
hospital administrator should still prepare a VS 10D for the child. If
necessary, information to prepare the birth certificate may be obtained from
the medical records file.

REFERENCE: Health and Safety Code Sections 102135 and 102425

English only The form is to be completed using the 26 alphabetical characters of the
English language.

REFERENCE: California State Constitution, Article 3, Section 6 and

Health and Safety Code Section 8

Appropriate Punctuation is a standardized mark or sign used in punctuating sentences or

punctuation phrases.

Examples of appropriate punctuation for vital records:

 hyphen such as “Smith-Jones”

 apostrophe as in “O’Hare”

 period as used with “Jr.”

 comma such as “Smith, Jr.”

Unacceptable Unacceptable entries:

entries
 pictographs – a picture, e.g., 

 ideograms – a picture or symbol that represents a thing or an idea, but

not a particular word or phrase for it, e.g., ⇑

 diacritical marks – any of various marks added to a letter to indicate its

pronunciation or to distinguish it in some way, e.g., è, ñ, ē, ç

January 1, 2016 103

 BIRTH

Signatures Signatures should be the usual or customary signature.

A signature made with a mark (X) is acceptable; however, it must be

identified with the statement “his/her mark” followed by the signature of the
person who witnessed the signing, and the word “witness,” after their
signature.

Example: X his mark Judy Jones witness

NOTE:
Signatures, which extend into other fields making entries illegible,
will cause the certificate to be rejected.

Use black ink The birth certificate must be completed legibly in durable black ink.

REFERENCE: Health and Safety Code Section 102125

Complete all The VS 10D must be completed as follows:

items
 All items must be completed or the reason for their omission
satisfactorily explained.

 The race, occupation, education, and social security numbers may be

withheld if the parents refuse to provide the information.

REFERENCE: Health and Safety Code Sections 102125 and 102425

No alterations No erasures, whiteout, or alterations of any kind are allowed on the form.

REFERENCE: Health and Safety Code Section 102140

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Responsibilities of the Hospital Administrator and
State-Licensed Alternative Birth Center Administrator
Overview The following information applies to both the hospital administrator and the
state-licensed alternative birth center administrator. For convenience, both
types of administrators will be referred to as hospital administrator.

The hospital administrator is responsible for preparing a VS 10D for each

birth that occurs in their facility. This responsibility includes obtaining the
personal data, preparing the certificate, securing the required signatures, and
registering the certificate with the local registrar within ten days of the birth.

In addition to the above responsibilities, the hospital administrator must

implement procedures to facilitate efficiency in the preparation and signing
of birth certificates to ensure timely registration. The hospital administrator
is also responsible for implementing security procedures to restrict access to
blank and completed birth certificates to authorized staff only.

REFERENCE: Health and Safety Code Section 102405

Required forms Hospital staff must use the following forms to collect the required
information as necessary for preparation of the birth certificate.

Form Number Use

Certificate of Live VS 10D To record births
Birth

Race Identification VS 10D (Back) To collect parents self-identified

Work Sheet race information

Medical Data VS 10A To enter appropriate medical codes

Supplemental onto the birth certificate
Work Sheet
Newborn No form number To obtain parents’ consent to
Automatic request their child’s social security
Number number through the birth
Assignment registration process
(NANA)
Declaration of CS 909 To allow a parent’s name (Items
Paternity 6A-6C) to be listed on the birth
certificate if the parents are not
married to each other

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Completing the Upon completion of the required forms, hospital staff must:
birth certificate
 prepare a correct and legible birth certificate with all items completed

 provide the certificate to the parent(s)/informant(s) for review and

signature

 obtain the certifier/attendant’s signature in Item 13A

NOTE:
The parent/informant shall only be asked to sign the birth certificate
after both the public portion and the confidential medical and social
information items have been entered on the form.

REFERENCE: Health and Safety Code Section 102425(15)(d)

Registering the Birth certificates must be registered with the local registrar within 10 days
birth certificate of the event.

The Declaration of Paternity forms must be batched separately and

forwarded to:

California Department of Child Support Services – Paternity Opportunity

Program (POP) Unit
P.O. Box 419070 (your agency’s three digit code)
Rancho Cordova, CA 95741-9070

NOTE:
The ten-day registration period is calculated by excluding the date of
birth and counting each day thereafter until the tenth day is reached.
If the tenth day falls on a holiday, the 11th day after the date of birth
becomes the due date for timely registration. Sunday is considered a
holiday.

REFERENCE: Health and Safety Code Section 102400 and Government

Code Section 6700

After the birth After the certificate is registered by the local registrar, corrections or
certificate is additions to the certificate must be made by applying an amendment. If the
registered correction is a hospital error, the hospital may assist the parents in applying
the amendment. See the Amendment Section for additional instructions.

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Security for The security procedures for storage of blank birth certificates include:
blank certificates
 providing locked file cabinets or locked file rooms for storage of blank
birth certificates

 limiting access to blank and completed birth certificates to authorized

staff only

 maintaining a daily supply of blank birth certificates in a locked office

cabinet

 ensuring that the supply is locked at all times

 using an inventory log to monitor and reconcile the number of birth

certificates prepared with the number of certificates taken from storage
at the end of each day

 returning blank certificates to storage noting the number being returned

on the log and initial

 marking “VOID” on any certificate that needs to be destroyed

 noting the number of voids on the control log

 destroying all voids by shredding them in the presence of two

individuals

Questions If you have any questions regarding registration, please contact BMRS at
(916) 445-8494.
If you have any questions regarding certified copies, please contact QAIR
at (916) 552-8116.

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Use this page for notes.

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Public Information on the Certificate (Items 1-17)

Description The Public Information Section of the VS 10D contains Items 1 through 17.
The collection of this information is required by statute.

REFERENCE: Health and Safety Code Section 102425

In this section The VS 10D is divided into several sections identified by labels in bold
print on the left side of the form. The Public Information Section includes
the following subsections:

Subsection Title Includes Items Numbered See Page

This Child 1A through 4B 112

Place of Birth 5A through 5D 118

Name of Parent 6A through 8 121

Name of Parent 9A through 11 127

(person giving birth)
Informant Certification 12A through 12C 135

Certification of Birth 13A through 14 139

Local Registrar 15A through 17 143

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Use this page for notes.

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This Child
Description Information collected in this section establishes the facts of the birth of the
child.

The parent(s) specify the name(s), including the last name, for their child
that will be entered on the birth certificate. After the certificate is
registered, the name(s) can only be changed by court order.

REFERENCE: Health and Safety Code Sections 102425 and 103400

In this section Information collected in this section includes:

Item Item Title See Page

Number
1A Name of Child – First 112

1B Middle 112

1C Last 112

2 Sex 113

3A This Birth, Single, Twin, etc. 113

3B If Multiple, This Child 1st, 2nd, etc. 114

4A Date of Birth – MM/DD/CCYY 114

4B Hour – (24-hour Clock Time) 115

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1A, 1B &1C Enter the names in each field exactly as provided by the parent(s):
Name of child
 1A First

 1B Middle

 1C Child’s Last

NOTE:
 The form must be completed using the 26 alphabetical characters
of the English language with appropriate punctuation, if
necessary.

 No pictographs (), ideograms (), diacritical marks (è, ñ, ē, ç),

or extraneous entries are allowed.

 Only one line of information is allowed in each field.

 Multiple names in a field may not be stacked.

 Do not leave any of these items blank. Enter a dash if necessary.

What to do if… The table below provides additional instructions for completing Items 1A
through 1C.

If… Then…
no name is given or parents cannot enter a dash (“-“) in each item. Do not
agree on the name enter Baby Boy or Baby Girl – unless
that is name given by the parents.
the certificate is registered without the local registrar must upon receipt of
a name the certificate prepare and send a
Supplemental Name Report (VS 107)
to the parents to add the name(s). See
the Amendment Section for additional
instructions.

REFERENCE: Health and Safety

Code Section 103325
additional space is necessary for enter as many characters that fit in the
entering long or multiple names space. Complete an Affidavit to Amend
a Record (VS 24) to add the remaining
names. See the Amendment Section
for additional instructions.
the child’s name is a hyphenated check for obvious errors in spelling
name consisting of both the and make sure the parents approve the
parents’ names order.
Continued on next page
January 1, 2016 112
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the child’s last name is not the check for spelling errors and verify
same as parents’ names with parents.
Roman numerals are used enter as requested by the parents.
the parent(s) decide to change the an Application for Amendment of Birth
child’s name, and the certificate Record to Reflect Court Order Change
has already been registered of Name (VS 23) will be required. See
the Amendment Section for additional
instructions.

NOTE:
Parents should be advised that they are not required to name the
child; however, if they decide to wait, the certificate will become a
two-page document with the name listed on page two of the
document.

2 Verify the sex of the child against the name given in Item 1A, and enter
Sex Male or Female as appropriate.

Acceptable Acceptable entries also include:

entries
 M

 F

 dash if unknown or undetermined

3A Specify the birth as Single, Twin, Triplet, Quadruplet, etc., even if all
This birth single, infants of the conception were not delivered alive.
twin, etc.

What to do if… The table below provides additional instructions for completing Item 3A.

If the child is… Then…

a twin, but the sibling was not enter Twin in Item 3A.
delivered alive
is a single birth enter Single.

of a multiple birth verify and enter the appropriate

plurality for each sibling.

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of a multiple birth where other do not count those fetuses.

fetuses were “reabsorbed” (not
delivered) or were expulsed or
extracted

3B For multiple births, specify the birth order of the child.

If multiple, this
child 1st, 2nd, etc.

What to do if… The table below provides additional instructions for completing Item 3B.

If the child is… Then enter…

a single birth a dash.

of a multiple birth the birth order of the child such as:

1st, 2nd, 3rd, etc.
a second twin and the first twin 2nd in Item 3B, and the date the first
was not born alive twin died in Item 27F (Date of Last
Other Termination).
a second twin and the first twin 2nd in Item 3B, do not record the date
was terminated by an induced of the termination in Item 27F (Date of
abortion Last Other Termination) because
induced abortions are not reported in
Items 27D through 27F.

4A Enter the child’s date of birth in numeric format.

Date of birth
Do not use dashes to separate the month, day, and year. Do not leave
blank.

Example Format: MM/DD/CCYY

Example: 01/15/2016

NOTE:
If the date of birth indicates that the child is already one year old at
the time of registration, a Delayed Registration of Birth (VS 85)
must be filed with CDPH-VR. See instructions for the VS 85 in the
Other Types of Birth Registration Section.

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4B Enter the 24-hour military clock time when the child was born.
Hour
Do not enter seconds, colons, other punctuation, or use dashes.

For unattended births, enter the birth parent’s best estimated time of birth.
“Unknown” is an acceptable entry only if the birth parent is unable to
reasonably estimate the time of birth.

Example 4:16 p.m. is entered as 1616.

24-Hour Clock Please refer to the time conversion table below.

TIME CONVERSION TO 24-HOUR CLOCK

Regular 24-Hour Regular 24-Hour

Clock Clock Clock Clock

12:00 a.m. 0000 12:00 noon 1200

1:00 0100 1:00 p.m. 1300
2:00 0200 2:00 1400
3:00 0300 3:00 1500
4:00 0400 4:00 1600
5:00 0500 5:00 1700
6:00 a.m. 0600 6:00 p.m. 1800
7:00 0700 7:00 1900
8:00 0800 8:00 2000
9:00 0900 9:00 2100
10:00 1000 10:00 2200
11:00 1100 11:00 2300
11:59 2359

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Use this page for notes.

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Place of Birth
Description Information collected in this section must accurately identify the place of
birth. The place of birth and the physical/residence address of the person
giving birth are used together in planning and evaluating prenatal care
services and obstetrical programs.

For births that occur in a hospital, the name of the hospital or facility is
entered on the certificate. A birthing center located in and/or operated by a
hospital is considered part of the hospital.

If the birth occurs on the way to the hospital or shortly before arrival,
hospitals are encouraged to register the birth as a courtesy for the parents.
To register a “courtesy” birth certificate in the Automated Vital Statistics
System (AVSS), the password to use is “HOME.” This will open up field
5A to enter the exact place of birth.

For births that occur outside of the hospital, please refer to the Other Types
of Birth Registration Section.

In this section Information collected under the “Place of Birth” heading includes:

Item Item Title See Page

Number
5A Place of Birth – Name of Hospital or 118
Facility
5B Street Address – Street and Number, or 118
Location
5C City 119

5D County 119

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5A Enter the name of the hospital or place where the birth occurred.
Place of birth

What to do if… The table below provides additional instructions for completing Item 5A.

If the birth occurred in a… Then enter…

hospital the hospital name.
place other than a hospital a description such as: residence, auto,
doctor’s office, clinic, etc.
prison, mental hospital, shelter for a dash. Complete Items 5B through
unwed/battered persons 5D with the address of the facility.
bus, car, train, or ambulance bus, car, train, or ambulance as
appropriate and indicate the nearest
cross streets or position on highway,
e.g., Intersection 4th and Main or X
miles east of Metro City on U.S. 105.
Complete Items 5B and 5C.
airplane airplane en route to…, and specify
latitude and longitude in Item 5B.
Enter the name of the city where the
airport is located in Item 5C and the
county having jurisdiction over that
city in Item 5D.
ship at sea ship en route to…, and specify latitude
and longitude in Item 5B. Enter the
port of call (city) in Item 5C and the
county having jurisdiction over that
city in Item 5D.

NOTE:
The birth of a child at sea or on any moving public conveyance such
as a bus, ambulance, train, ship, or airplane is required to be reported
to the local registrar having jurisdiction over the place of the first
stop or first port of call.

5B Enter the full street or rural address of the place of birth.

Street address -
Street and
number, or
location

Unacceptable Unacceptable entries include general delivery and post office box numbers.
entries

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5C Enter the name of the city or town where the birth occurred.
City
NOTE:
In rare instances when the birth took place in a remote rural area and
there is no city or town for the place of birth, enter the name of the
closest city or town within the county of birth, preceded by the word
“Rural,” e.g., Rural Metro City.

5D Enter the name of the California county where the birth occurred.
County

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Use this page for notes.

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Name of Parent (Items 6A-6C)

Description The information collected in this section pertains to the parent of the child
not giving birth.

If the parents are married to each other or in a state-registered domestic

partnership (SRDP), the second parents’ name may be listed in Items 6A-
6C.

If the person giving birth is in an SRDP,* this parents’ name may be listed
in (Items 6A-6C). For more information on procedures for SRDPs, please
see “Name of Parent” section, page 122.

If the person giving birth is not married or in an SRDP, the second parents’
name shall not be listed in Items 6A-6C unless both are biological parents
and both sign a voluntary Declaration of Paternity (CS 909).

The name entered on the certificate in Items 6A-6C and 9A-9C must be the
parent’s legal name by birth, adoption, court-ordered name change, or
naturalization. Also known as (AKA) must not be entered on the certificate,
but may be added by amendment.

REFERENCE: Health and Safety Code Sections 102425(a)(4)(C) and

102425.1; Family Code Section 297.5(a); Government Code Section 14771

In this section Information collected under the “Name of Parent” heading includes:

Item Item Title See Page

Number
6A Name of Parent – First 122

6B Middle 122
6C Last – Birth Name 122

6D Relationship check boxes 122

7 Birthplace (State/Foreign Country) 125

8 Date of Birth 126

* The California Domestic Partner Rights and Responsibilities Act applies to partners who are
members of the same sex, and to partners who are of opposite sexes when one or both of the
partners are over 62 years of age. Other criteria for Domestic Partners is contained in Family
Code Section 297.

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Registering a As of January 1, 2005, equal consideration must be given to birth parents

birth for with state-registered domestic partners.
SRDPs*
The person giving birth should be asked if they are in a SRDP or married.
If they reply yes, then they should be asked if they want to add the second
parent’s name to the birth certificate in Items 6A-6C.

If the person replies they are not in a SRDP or married, then they should be
asked if they and the biological parent would like to sign a voluntary
CS 909 to add this parent’s name in Items 6A-6C.

It is the responsibility of the person giving birth to state if they qualify as

state-registered domestic partners.

6A, 6B & 6C Enter the legal name of the parent not giving birth as it appears on their
Name of Parent birth record, adoption, court-ordered name change, or naturalization papers
(Parent Not as follows:
Giving Birth)  6A First –Insert the first name in 6A First

 6B Middle

 6C Last – Birth Name

Definition Birth name is the parent’s name prior to any marriages.

Unacceptable Unacceptable entries:

entries
 unknown

 withheld

 item is blank

 artificial insemination
NOTE:
 The form is completed using the 26 alphabetical characters of the
English language with appropriate punctuation, if necessary.
 Roman numerals are acceptable in Item 6C.
 No pictographs (), ideograms (), diacritical marks (è, ñ, ē, ç),
or extraneous entries are allowed.
 Only one line of information is allowed in each field.
 Multiple names in one field may not be stacked.

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6D Check the appropriate relationship box or leave blank as appropriate:

Check boxes to
identify the □ Mother
parent’s □ Father
relationship to □ Parent
the child

NOTE:
An informant signing the birth certificate must have personally consulted
with the parent(s) prior to selecting a relationship. If a parent is not
available for consultation, then no box should be selected. These boxes are
optional and may be completed using an X, check mark, or be completely
shaded in. No more than one box may be marked for each parent.
REFERENCE: Health and Safety Code Section 102425.1

* The California Domestic Partner Rights and Responsibilities Act applies to

partners who are members of the same sex, and to partners who are of
opposite sexes when one or both of the partners are over 62 years of age.
Other criteria for Domestic Partners is contained in Family Code Section 297.
Continued on next page

January 1, 2016 123

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What to do if… The table below provides additional instructions for completing Items 6A
through 6C.

If… Then enter…

the parents are either: a dash in Items 6A through 6C.

 not married

 not in an SRDP

 not completing a voluntary CS 909

the person giving birth - listed in Items 9A- a dash in Items 6A through 6C.
9C does not know who the other parent is
the person giving birth - listed in Items 9A- a dash in Items 6A through 6C.
9C refuses to provide the other parent’s
name
this parent has no middle name a dash in Item 6B.
this parent has only one name the name in Item 6C with a dash
in Items 6A and 6B. This is
based on guidance from SSA
and NCHS for indexing
purposes.
additional space is needed for the name to as many characters that fit in the
fit space and complete a VS 24.
See the Amendment Section for
additional instructions.
this parent wishes to list an AKA parent’s legal birth name in
Items 6A through 6C and the
AKA’s on a VS 24.
this parent is deceased, but the parents their full name.
were married
this parent is deceased and was not married a dash.
to or in an SRDP with the other parent*

* The surviving parent will be required to obtain an Adjudication of Facts

of Parentage in order to add the deceased parents’ name.

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7 Enter the two-letter abbreviation of the state of birth of the parent. Spell out
Birthplace United States (U.S.) territories and foreign countries; abbreviations may be
(State/Foreign used if a U.S. territory or foreign country name will not fit in Item 7.
Country)
STANDARD STATE ABBREVIATIONS
State State
Alabama……………………….. AL North Dakota……………………. ND
Alaska….………………………. AK Ohio……………………………... OH
Arizona………………………… AZ Oklahoma……………………….. OK
Arkansas……………………….. AR Oregon…………………………... OR
California………………………. CA Pennsylvania…………………….. PA
Colorado……………………….. CO Rhode Island…………………….. RI
Connecticut……………………. CT South Carolina…………………... SC
Delaware………………………. DE South Dakota……………………. SD
District of Columbia…………… DC Tennessee……………………….. TN
Florida…………………………. FL Texas……………………………. TX
Georgia………………………… GA Utah……………………………… UT
Hawaii…………………………. HI Vermont…………………………. VT
Idaho…………………….…….. ID Virginia………………………….. VA
Illinois…………………………. IL Washington……………………… WA
Indiana…………………………. IN West Virginia……………………. WV
Iowa……………………………. IA Wisconsin……………………….. WI
Kansas…………………………. KS Wyoming……………...………… WY
Kentucky………………………. KY
Louisiana………………………. LA
Maine…………………………... ME
Maryland………………………. MD
Massachusetts………………….. MA
Michigan………………………. MI
Minnesota……………………… MN
Mississippi……………………... MS
Missouri………………………... MO
Montana………………………... MT
Nebraska……………………….. NE
Nevada…………………………. NV
New Hampshire………………... NH
New Jersey…………………….. NJ
New Mexico…………………… NM
New York……………………… NY
North Carolina…………………. NC

Continued on next page

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What to do if… The table below provides additional instructions for completing Item 7.

If the parent is… Then enter…

known to have been born in a Foreign-Unk.
foreign country, but the country is
unknown
known to have been born on the Foreign-Unk.
high seas
known to have been born in the US-Unk.
U.S. but the state is unknown
unknown or the information is a dash.
refused
not identified in Items 6A-6C the state of birth.
(contains dashes), but the state of
birth is known
deceased the place if known or a dash.

8 Enter the date of birth of the parent in numeric format.

Date of birth

Example Format: MM/DD/CCYY

Example: 12/16/1985

What to do if… The table below provides additional instructions for completing Item 8.

If… Then enter…

the day is unknown month and year only, e.g., 01/--/1985.

the month and day are unknown year only, e.g., --/--/1985.

the information is unavailable or is a dash.

refused
the parent is not identified in Items date of birth.
6A-6C (contains dashes), but the
date of birth is known
the parent is deceased the date if known or a dash.

NOTE:
Do not enter the age of the parent. Do not use dashes to separate
month, day, and year. Do not leave blank.
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Name of Parent (Person Giving Birth) (Items 9A-9C)

Description The information collected in this section pertains to the person giving birth.

If the parents are married to each other or in an SRDP, the second parents’
name may be listed in Items 6A-6C.

For more information on procedures for SRDPs, please see “Name of

Parent” section, page 122.

If the person giving birth is not married or in an SRDP, the second parents’
name shall not be listed in Items 6A-6C unless both are biological parents
and both sign a voluntary CS 909.

The name entered on the certificate in Items 6A-6C and 9A-9C must be the
parents’ legal name by birth, adoption, court-ordered name change, or
naturalization. AKA’s must not be entered on the certificate, but may be
added by amendment.

REFERENCE: Health and Safety Code Section 102425(a)(4)(C);

Family Code Section 297.5(a); Government Code Sections 14771

In this section Information collected under the “Name of Parent” heading includes:

Item Item Title See Page

Number
9A Name of Parent - First 128

9B Middle 128

9C Last - Birth Name 128

9D Relationship check boxes 129

10 Birthplace – State/Foreign Country 131

11 Date of Birth 132

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9A, 9B & 9C Enter the legal name of the parent giving birth legal name as it appears on
Name of Parent their birth record, adoption, court-ordered name change, or naturalization
(Person Giving papers.
Birth)
 9A First

 9B Middle

 9C Last (Birth Name)

Definition Birth name is the parent’s name prior to any marriages.

Unacceptable Unacceptable entries:

entries
 unknown

 withheld

 item is blank

NOTE:
 The form is completed using the 26 alphabetical characters of the
English language with appropriate punctuation, if necessary.

 Roman numerals are acceptable in Item 6C.

 No pictographs (), ideograms (), diacritical marks (è, ñ, ē, ç),

or extraneous entries are allowed.

 Only one line of information is allowed in each field.

 Multiple names in one field shall not be stacked.

 The birth certificate shall not be registered without the name of

the person giving birth. If the information is refused, check the
medical file for information. If no information is available, enter
a dash in field 9A and 9B. Enter UNK in field 9C.

Continued on next page

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Registering a As of January 1, 2005, equal consideration must be given to birth parents

birth for with state-registered domestic partners.
SRDPs*
The person giving birth should be asked if they are in an SRDP or
married. If they reply yes, then they should be asked if they want to add
the second parent’s name to the birth certificate in Items 6A-6C.

If the person replies they are not married, then they should be asked if
they and the biological parent would like to sign a voluntary CS 909 to
add the second parent’s name in Items 6A-6C.
It is the responsibility of the person giving birth to state if they qualify as
state-registered domestic partners.

9D Check the relationship box or leave blank as appropriate:

Check boxes
to identify the □ Mother
parent’s □ Father
relationship □ Parent
to the child NOTE:
An informant signing the birth certificate must have personally
consulted with the parent(s) prior to selecting a relationship. If a parent
is not available for consultation, then no box should be selected for
them. These boxes are optional and may be completed using an X,
check mark, or be completely shaded in. No more than one box may be
marked for each parent.
REFERENCE: Health and Safety Code Section 102425.1

* The California Domestic Partner Rights and Responsibilities Act applies to partners who
are members of the same sex, and to partners who are of opposite sexes when one or both
of the partners are over 62 years of age. Other criteria for Domestic Partners is contained
in Family Code Section 297.

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What to do if… The table below provides additional instructions for completing Items 9A
through 9C.

If… Then…
the person giving birth has no enter a dash in Item 9B.
middle name
additional space is needed for the enter as many characters that fit in the
names to fit on one line space and complete a VS 24. See the
Amendment Section for additional
instructions.
the person giving birth wishes to complete a VS 24 to add the name(s).
list an AKA
the person giving birth has only enter the name in Item 9C and dashes
one known name in Items 9A and 9B. This is based on
guidance from SSA and NCHS for
indexing purposes.
this is a surrogate pregnancy or refer to Other Types of Birth
foundling Registration Section.

the information is refused obtain information from the medical

file and enter in fields 9A-9C.
the information is unknown enter a dash in fields 9A and 9B and
Unk in field 9C.

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10 Enter the two-letter abbreviation for the person giving birth’s U.S. state of
Birthplace birth. Spell out U.S. territories and foreign countries; abbreviations may be
(State/Foreign used if a U.S. territory or foreign country name will not fit in Item 10.
Country)
STANDARD STATE ABBREVIATIONS
State State
Alabama……………………….. AL North Dakota……………………. ND
Alaska….………………………. AK Ohio……………………………... OH
Arizona………………………… AZ Oklahoma……………………….. OK
Arkansas……………………….. AR Oregon…………………………... OR
California………………………. CA Pennsylvania…………………….. PA
Colorado……………………….. CO Rhode Island…………………….. RI
Connecticut……………………. CT South Carolina…………………... SC
Delaware………………………. DE South Dakota……………………. SD
District of Columbia…………… DC Tennessee……………………….. TN
Florida…………………………. FL Texas……………………………. TX
Georgia………………………… GA Utah……………………………… UT
Hawaii…………………………. HI Vermont…………………………. VT
Idaho…………………….…….. ID Virginia………………………….. VA
Illinois…………………………. IL Washington……………………… WA
Indiana…………………………. IN West Virginia……………………. WV
Iowa……………………………. IA Wisconsin……………………….. WI
Kansas…………………………. KS Wyoming……………...………… WY
Kentucky………………………. KY
Louisiana………………………. LA
Maine…………………………... ME
Maryland………………………. MD
Massachusetts………………….. MA
Michigan………………………. MI
Minnesota……………………… MN
Mississippi……………………... MS
Missouri………………………... MO
Montana………………………... MT
Nebraska……………………….. NE
Nevada…………………………. NV
New Hampshire………………... NH
New Jersey…………………….. NJ
New Mexico…………………… NM
New York……………………… NY
North Carolina…………………. NC

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What to do if… The table below provides additional instructions for completing Item 10.

If… Then enter…

the person giving birth was born in Foreign-Unk.
a foreign country, but the country
is unknown
the person giving birth was born on Foreign-Unk.
the high seas
the person giving birth was born in U.S.-Unk.
the U.S. but the state is unknown
information is refused Unk

11 Enter the person giving birth’s date of birth in numeric format.

Date of birth

Example Format: MM/DD/CCYY

Example: 12/17/1985

What to do if… The table below provides additional instructions for completing Item 11.

If… Then enter…

the day is unknown month and year only, e.g., 11/--/1985.

the month and day are unknown year only, e.g., --/--/1985.

the year is unknown, or if no a dash.

information is available

NOTE:
Do not enter the age of the person giving birth. Do not use dashes
to separate month, day, and year. Do not leave blank.

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Use this page for notes.

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Informant Certification
Description The review of the completed birth certificate by the parent or other
informant prior to signing is required by law and is an aid in improving
accuracy of the certificate.

Under no circumstance shall a parent or other informant sign a blank or

incomplete certificate.

REFERENCE: Health and Safety Code Section 102425(f)

In this section Information collected under the “Informant Certification” heading includes:

Item Item Title See Page

Number
12A Parent or Other Informant – Signature 135

12B Relationship to Child 136

12C Date Signed 137

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12A Instruct either parent or the informant (usually the parent) to verify that the
Parent or other certificate is correct and to sign their usual and customary signature in
informant Item 12A.

REFERENCE: Health and Safety Code Section 102425(a)(7)

Definition Informant refers to any person who has knowledge of the facts of the birth,
e.g., a parent, medical clerk, grandparent, friend, relative, etc.

NOTE:
 Do not leave this item blank.

 Signatures which extend into other fields making entries illegible

will cause the certificate to be rejected.

 The signatures in Items 12A and Item 13A should not be the
same person unless one of the parents attended the birth and the
other parent died.

Unacceptable It is unacceptable to enter “unavailable for signature” in 12A.”

entries

What to do if… The table below provides additional instructions for completing Item 12A.

If… Then…
the parent’s signature differs verify the information with the parents.
significantly from the legal
names in Items 6A-6C or 9A-9C
neither parent is capable of a person with knowledge of the facts of
signing birth must review the information and
sign the certificate, e.g., medical clerk,
grandparent, etc.

Continued on next page

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If… Then…
both parents wish to sign the both may sign their names beside each
certificate other, but must be contained in the space
allotted.
a signature is made with a mark, it must be followed by an indication of
e.g., X “his/her mark” and the signature of the
person who witnessed the signing, and
the word “witness.”

12B Enter the relationship to the child of the parent or other informant on the
Relationship to certificate.
child
The relationship should be listed according to the informant’s preference.

Note: Birth Clerks should not enter the word “parent” prior to asking the
parent or informant how they want the relationship listed. For example, a
birth parent may prefer the word mother, parent, etc.

Acceptable Examples of acceptable entries include:

entries
 mother  neighbor
 father  certified nurse midwife
 parent  guardian
 parents *  medical records clerk
 grandparent  ambulance attendant
 father/mother  social worker
 mother/father  friend

* an entry of parents (plural) should only be entered if both parents sign the
certificate.

Continued on next page

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Unacceptable None or Unknown are unacceptable entries.

entries

12C Instruct the person certifying the information to enter the date they reviewed
Date signed and signed the certificate.

Example Format: MM/DD/CCYY

Example: 01/16/2016

NOTE:
 Certificates with handwritten dates in this field that are not in the
above format may be accepted.

 Do not leave blank.

NOTE The signatures in Items 12A and 13A (Parent or Other Informant and
Attendant/Certifier) should not be the same person. There may be some
exceptions when the signatures are the same, e.g., one of the parents
attended the birth and the other parent died. In this case, both the attendant
and the parent would be the same. However, such exceptions are expected
to be rare; and, therefore, as a general rule, the signatures should be
different.

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Certification of Birth
Description This section is completed by the person in attendance at the birth or the
designated hospital representative who can certify the fact of birth. Under
no circumstance shall a physician or other certifier sign a blank or
incomplete certificate.

REFERENCE: Health and Safety Code Section 102425(a)(8)

In this section Information collected under the “Certification of Birth” heading includes:

Item Item Title See Page

Number
13A Attendant/Certifier – Signature and Degree or 139
Title
13B License Number 139

13C Date Signed 140

13D Typed Name, Title and Mailing Address of 141

Attendant
14 Typed Name and Title of Certifier if Other than 141
Attendant

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13A Instruct the attendant or certifier to sign the completed certificate. Enter
Attendant/ their degree, if appropriate.
Certifier
signature and
degree or title

Definitions Attendant refers to the physician, certified nurse, physician’s assistant, or

other person who was in attendance at the birth.

Certifier refers to the hospital administrator, designated representative, or

other person who is certifying the fact of birth.

REFERENCE: Health and Safety Code Section 102405

NOTE:
 Only one signature is allowed.

 Signatures which extend into other fields making entries

illegible, will cause the certificate to be rejected.

 Physician signature stamps may not be used in lieu of an ink

signature.

What to do if… The table below provides additional instructions for completing Item 13A.

If… Then…
the person giving birth delivered enter “unattended.”
alone
a child attended the birth the child may sign the certificate.
the attendant such as a midwife or enter “unavailable.”
paramedic is unavailable

13B Enter the California license number if a licensed physician, certified nurse
License number midwife, paramedic, or other licensed person attended the birth. If there
was no attendant or certifier, enter a dash.

Continued on next page

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What to do if… The table below provides additional instructions for completing Item 13B.

If… Then enter…

the license begins with A, C, or G California physician’s license number.
followed by numbers
the number has not been issued yet Applied for.

the physician is fulfilling residency Resident.

requirements
the physician is fulfilling internship Intern.
requirements
the physician is licensed in another a dash.
state
the person giving birth delivered a dash.
the child alone
the entry for Item 13A is a dash.
Unavailable
the attendant does not have a None.
California license number

NOTE:
Even if a certifier signs in Item 13A, the attendant’s license number,
if appropriate, must be entered in Item 13B.

13C The attendant or certifier is to enter the date they sign the completed birth
Date signed certificate. If no attendant or certifier, enter a dash.

Example Format: MM/DD/CCYY

Example: 01/15/2016

NOTE:
 For unattended births, or the attendant or certifier is unavailable
to sign, enter a dash.

 Certificates with handwritten dates in this field that are not in the
correct format are acceptable.

 Do not leave blank.

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13D Type the name and mailing address of the person who attended this birth.
Typed name,
title and mailing NOTE:
address of  The attendant information should be entered even if a certifier,
attendant rather than an attendant, signed Item 13A.

 If there was no attendant, enter a dash.

14 Type the name and title of the person who is certifying the fact of birth.
Typed name and
title of certifier if NOTE:
other than  This is the typed name of the hospital administrator or
attendant designated representative who is certifying the facts of birth in
absence of the attendant.

 Enter a dash if Item 13A is signed by the person identified in

Item 13D.

 Enter a dash if the person giving birth delivered alone.

 Enter a dash for out-of-hospital births.

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Local Registrar
Description Prior to registration, the local registrar shall review each birth certificate for
accuracy and completeness. If the certificate is acceptable on its face, the
local registrar shall sign and date the certificate and apply a local file
number. If it is not acceptable, e.g., missing signatures, etc., the certificate
must be returned to the hospital. Upon registration by the State, the
certificate becomes the legal record of that event and is prima facie evidence
in all courts.

After the certificate is registered, any changes (corrections or additions)

shall only be made through the amendment process. For specific
information on amendment procedures, refer to the Amendment Section.

REFERENCE: Health and Safety Code Section 102305

In this section Information collected under the “Local Registrar” heading includes:

Item Item Title See Page

Number
15A Date of Death 143

15B State File Number (State Use Only) 143

16 Local Registrar – Signature 143

17 Date Accepted for Registration 143

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15A If the newborn dies before the certificate is forwarded to CDPH-VR, enter
Date of death the date of death in numeric format.

Example Format: MM/DD/CCYY

Example: 01/17/2016

NOTE:
 This item is left blank if the child is alive when the certificate is
being registered.

 The date of death must be reported if the local registrar has

knowledge of this fact at the time of registration.

15B CDPH-VR will enter the SFN of the newborn’s death certificate, if
State File applicable.
Number (State
Use Only)

16 Enter the name of the local registrar (health officer or appointed registrar).
Local registrar
signature NOTE:
 A deputy registrar may not sign the registrar’s name.

 The entry may be handwritten, typed, or stamped.

 If typed or stamped, the signature or initials of the deputy must

be handwritten after the registrar’s name.

 To ensure all information is legible, signatures should not exceed

the box.

17 Enter the date the certificate was accepted for registration in numeric
Date accepted format. Do not leave blank.
for registration

Example Format: MM/DD/CCYY

Example: 01/18/2016

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Confidential Information for Public Health Use Only

(Items 18-33)
Description The second section of the VS 10D is labeled Confidential Information for
Public Health Use Only (Items 18-33). The information collected in this
section is used for a wide range of public health research and medical
studies, as well as for the child’s personal use. These items are designated
confidential and are not open for public inspection.

Copies of birth certificates shall not be retained in patient files. Any person
releasing the information contained in this section to unauthorized
individuals is guilty of a misdemeanor punishable by a $500 fine or six
months imprisonment for the first offense.

REFERENCE: Health and Safety Code Sections 102430 and 102475

NOTE:

Some of the confidential items are recorded on the electronic birth record,
but do not appear on the paper certificate.

In this section The confidential portion of the VS 10D is divided into several sections
identified by labels in bold print on the left side of the form. The
“Confidential Information for Public Health Use Only” section includes the
following subsections:

Subsection Title Includes Items Numbered See Page

Genetic Father 18 through 20C 148

Genetic Mother 21 through 24E and 156

(Birth Parent) electronic items

Medical Data 25A through 31 and 168

electronic items
Social Security Numbers 32 through 33 188

State Registrar Items A through F and Census 191

Tract
Numbering the Birth 194
Certificate

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Use this page for notes.

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Genetic Father
Description The information collected in this section pertains to the genetic father’s
race, ethnicity, occupation, and education. Hospital staff are required to
complete these items. If the parent(s) or other informant questions these
items, hospital staff must be able to explain the reasons for collecting the
information in order to facilitate complete and accurate reporting. See next
page on collection of race/Hispanic data. A detailed explanation need not
be volunteered if not requested.

REFERENCE: Health and Safety Code Section 102425

Definition Genetic father is the male genetic contributor to the creation of the baby
through sperm donation or sexual intercourse.

In this section Information gathered under “Genetic Father” heading includes:

Item Item Title See Page

Number
Collection of Race/Hispanic Data 147

18 Race 148

19 Is Genetic Father Hispanic, Latino or 149

Spanish?

20 Date Last Worked 150

20A Usual Occupation 151

20B Kind of Business or Industry 151

20C Education – Highest Level or Degree 152

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Collection of Race/Hispanic Data

Collection of Prior to completing Item 18 and Item 19 on the VS 10D, use a copy of the
Race & Spanish/ worksheet located on the back of the certificate to gather race and
Hispanic/Latino Spanish/Hispanic/Latino origin information. A copy of the worksheet
origin data should be provided to the parents for completion. Race and Spanish/
Hispanic/Latino origin are self-identified items. Enter the race and
Spanish/Hispanic/Latino origin information on the front of the certificate in
the appropriate fields.

Definitions for There is no set rule as to how many generations are to be taken into account
Race & Spanish/ in determining Hispanic origin or race. The response on the worksheet is to
Hispanic/Latino reflect the racial group with which the genetic father identifies and is not
based on percentages of ancestry.
Hispanic refers to 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 genetic
father or their ancestors were born before their arrival in the United States.

 A person’s origin may be reported based on their country of origin, or

on the country of origin of a parent, grandparent, or some far-removed
ancestor.
 The response is to reflect the Hispanic population group with which the
genetic father identifies, if any, and is not based on percentages of
ancestry.
 Hispanic origin or descent is not to be confused with race. A person of
Hispanic origin may be of any race.

Presenting the worksheet to the parents in a positive, pleasant manner and

How to collect assuring the informant that the information is confidential will facilitate
Race & Spanish/ collection of the requested data. The following is a suggested statement of
Hispanic/Latino explanation:
data
“The information requested will be transferred to the confidential
portion of the birth certificate and access to this portion is limited by
law. This information is extremely valuable in producing data for
various population groups. It is used to study racial variations in
childbearing, access to health care, and pregnancy outcomes, such as
infant mortality and birth weight. Race and Hispanic origin are
important variables in preparing population estimates, and in
planning, developing, and evaluating the effectiveness of health
programs.”
NOTE: In order to obtain the most accurate information, Spanish/
Hispanic/Latino origin should be determined prior to determining race.

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18 Instruct the parent or informant to check up to three races on the worksheet

Race for the genetic father’s race. Enter the data in Item 18 on the birth
certificate.

What to do if… The table below provides additional instructions for completing the work
sheet and Item 18.

If… Then…
none of the categories on the work instruct the informant to check Other
sheet apply (Specify) and specify the race in the
space provided. Enter the data in
Item 18.
more than one box is checked on enter up to three races separated by a
the worksheet slash (/) in the order specified by the
parent in Item 18. Do not stack.
Complete a VS 24 to add the
remaining data.

NOTE: AVSS will truncate entries as

appropriate.
no information is available enter Unk in Item 18.

the information is refused enter Withheld in Item 18.

NOTE:
No facetious or derogatory descriptions are allowed in Item 18.
Extraneous entries are not acceptable, e.g., human being.

Item 18 is optional. The genetic father or informant may refuse to

provide the information.

REFERENCE: Health and Safety Code Section 102425(c)

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19 Instruct the parent or informant to check one box on the worksheet to

Genetic Father specify the genetic father’s Hispanic origin or descent. Enter the data in
Hispanic, Latino Item 19.
or Spanish?

What to do if… The table below provides additional instructions for completing the
worksheet and Item 19.

If… Then…
the genetic father is not of the informant checks No – (Not
Hispanic origin or descent Hispanic). Enter No in Item 19.
the genetic father is of Hispanic the informant checks Yes and specifies
origin or descent his origin or descent. Enter the data in
Item 19.
the genetic father is of Hispanic the informant checks Yes – Other
origin or descent, but none of the Hispanic (Specify) and specifies their
categories apply origin or descent, such as: Nicaraguan,
Chilean, or Guatemalan on the work
sheet. Enter the data in Item 19.
the genetic father is of more than the informant checks Yes – Other
one Hispanic origin or descent Hispanic (Specify) and lists the multiple
Hispanic origins or descents separated
by a slash or hyphen, such as:
Nicaraguan/El Salvadoran,
Venezuelan-Colombian on the work
sheet. Enter the data in Item 19.
no information is available on the enter Unk in Item 19.
genetic father’s Hispanic origin or
descent
information is refused enter Withheld in Item 19.

NOTE:
Item 19 is optional. The genetic father or informant may refuse to
provide the information.

REFERENCE: Health and Safety Code Section 102425(c)

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20 Enter the most recent date (month and year) that the genetic father worked
Date Last in their usual occupation.
Worked

Example Format: MM/CCYY

Example: 01/2016

What to do if… The table below provides additional instructions for completing Item 20.

If … Then enter…
the genetic father is currently the current month and year.
employed
the genetic father never worked None.
or is a student
the month is unknown the year only, e.g. --/2016.

the year is unknown, or if no Unk.

information is available
the information is refused Withheld.

NOTE:
Item 20 is optional. The genetic father or informant may refuse to
provide the information.

The dates entered may be after the child’s date of birth. For
example, the child’s date of birth may be 7/31/2016 with the genetic
father’s date last worked 08/2016.

REFERENCE: Health and Safety Code Section 102425(c)

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20A Enter the genetic father’s usual occupation, which is the work they have
Usual occupation done for the longest period of time. If the genetic father is retired,
unemployed, disabled, or deceased, report their usual occupation when they
were working.

Acceptable Acceptable entries also include:

entries
 abbreviations

 unknown

 withheld

What to do if… The table below provides examples of appropriate entries for Item 20A. For
additional information on occupations, refer to Appendix B.

If the genetic father… Then specify type…

is a doctor physician, dentist, veterinarian,
chiropractor, etc.
works in data processing computer programmer, keypunch
operator, etc.
is a nurse registered nurse, nurse-midwife,
nurse’s aide, nurse practitioner, etc.
farm worker farmer, farm hand, farm supervisor,
fruit picker, migratory farm hand, etc.

NOTE:
Item 20A is optional. The genetic father or informant may refuse to
provide information.

REFERENCE: Health and Safety Code Section 102425(c)

20B Enter the genetic father’s usual kind of business or industry corresponding
Kind of business with Item 20A. The description should indicate clearly and specifically the
or industry kind of business or industry of employment.

Do not enter company name.

Continued on next page

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Acceptable Acceptable entries also include:

entries
 abbreviations

 unknown

 withheld

 never worked

What to do if… The table below provides examples of appropriate entries for Item 20B. For
additional information on business or industry, refer to Appendix C.

If the business is… Then specify…

mine copper mine, etc.

retail bookstore, card store, etc.

manufacturer fountain pen manufacturer, etc.

construction road construction, housing

construction, etc.
oil and gas industry oil field drilling, petroleum refinery,
retail gasoline station, wholesale oil
distributor, natural gas pipeline, etc.

NOTE:
Item 20B is optional. The genetic father or informant may refuse to
provide information.

REFERENCE: Health and Safety Code Section 102425(c)

20C Use the Race/Ethnicity and Education Worksheet to gather information that
Education – best describes the highest degree or level of school completed by the genetic
Highest father. Enter the education information on the birth certificate.
Level/Degree

Continued on next page

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What to do if… The table below provides additional instructions for completing Item 20C.

If the genetic father… Then…

did not complete one full year of enter 0.
formal education
completed grades, 1, 2, 3…11 enter the highest year completed.
completed 12th grade, but did not enter 12 ND.
receive a diploma
graduated from high school or enter HS Graduate or GED.
completed the GED (General
Equivalency Diploma)
earned some college credit, but did enter Some College.
not receive a degree
received an Associate degree (e.g., enter Associate.
AA, AS)
received a Bachelors degree (e.g., enter Bachelors.
BA, AB, BS)
received a Masters degree (e.g., enter Masters.
MA, MS, MEng, MEd, MSW,
MA)
received a Doctorate (e.g., PhD, enter either Doctorate or
EdD) or Professional degree (e.g., Professional.
MD, DDS, DVM, LLB, JD)
attended a specialty school such as do not include in the number of
a beauty, barber, business, or school years completed.
technical school
was educated outside of the U.S.A. identify and enter the number of years
completed or degree received
compared to U.S.A. education.
no information is available enter Unk.

information is refused enter Withheld.

NOTE:
Item 20C is optional. The genetic father or informant may refuse to
provide information.

REFERENCE: Health and Safety Code Section 102425(c)

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Genetic Mother
Description The information collected in this section pertains to the genetic mother’s
race, ethnicity, occupation, and education. If the parent(s) or other
informant questions these items, hospital staff must be able to explain the
reasons for collecting the information in order to facilitate complete and
accurate reporting. See next page on collection of race/Hispanic data. A
detailed explanation need not be volunteered if not requested.

REFERENCE: Health and Safety Code Section 102425

Definition Genetic mother is the person who produces an egg that results in an embryo.

In this section Information gathered under “Genetic Mother” heading includes:

Item Item Title See Page

Number
Collection of Race/Hispanic Data 155

21 Race 156

22 Genetic Mother Hispanic, Latina, or 157

Spanish?

23 Date Last Worked 158

23A Usual Occupation 159

23B Kind of Business or Industry 159

23C Education – Highest Level or Degree 161

24A Residence – Street and Number, or Location 162

24B County/Province 163

24C City 163

24D State/Foreign Country 163

24E Zip Code 163

Electronic Mailing Address 164

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Collection of Race/Hispanic Data

Collection of Prior to completing Item 21 and Item 22 on the VS 10D, use a copy of the
Race & Spanish/ worksheet located on the back of the certificate to gather race and
Hispanic/Latina Spanish/Hispanic/Latina origin information. A copy of the worksheet
origin data should be provided to the parents for completion. Race and Spanish/
Hispanic/Latina origin are self-identified items. Enter the race and
Spanish/Hispanic/Latina origin information on the front of the certificate in
the appropriate fields.
Definitions for There is no set rule as to how many generations are to be taken into account
Race & Spanish/ in determining race or Hispanic origin or descent. The response on the
Hispanic/Latina worksheet is to reflect the racial group with which the genetic mother
identifies and is not based on percentages of ancestry.
Hispanic refers to 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 genetic
mother or their ancestors were born before their arrival in the United States.
 A person’s origin may be reported based on their country of origin, or
on the country of origin of a parent, grandparent, or some far-removed
ancestor.
 The response is to reflect the Hispanic population group with which the
genetic mother identifies, if any, and is not based on percentages of
ancestry.
 Hispanic origin or descent is not to be confused with race. A person of
Hispanic origin may be of any race.

How to collect Presenting the worksheet to the parent in a positive, pleasant manner and
Race & Spanish/ assuring the informant that the information is confidential will facilitate
Hispanic/Latina collection of the requested data. The following is a suggested statement of
data explanation:
“The information requested will be transferred to the confidential
portion of the birth certificate and access to this portion is limited by
law. This information is extremely valuable in producing data for
various population groups. It is used to study racial variations in
childbearing, access to health care, and pregnancy outcomes, such as
infant mortality and birth weight. Race and Hispanic origin are
important variables in preparing population estimates, and in
planning, developing, and evaluating the effectiveness of health
programs.”
NOTE: In order to obtain the most accurate information, Spanish/
Hispanic/Latina origin should be determined prior to determining race.

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21 Instruct the genetic mother or informant to check up to three races on the

Race worksheet for the genetic mother’s race. Enter the data in Item 21 on the
birth certificate.

What to do if… The table below provides additional instructions for completing the work
sheet and Item 21.

If… Then…
none of the categories apply instruct the informant to check Other
(Specify) and specify the race in the
space provided. Enter the data in
Item 21.
more than one box is checked on enter up to three races separated by a
the work sheet slash (/), in the order specified by the
genetic mother in Item 21. Do not
stack. Complete a VS 24 to add the
remaining data.

NOTE: AVSS will truncate as

appropriate.
no information is available enter Unk in Item 21.

information is refused enter Withheld in Item 21.

the pregnancy involves a surrogate refer to Other Types of Birth

parent Registration Section.

NOTE:
No facetious or derogatory descriptions are allowed in Item 21.
Extraneous entries are not acceptable, e.g., human being.

Item 21 is optional. The genetic mother or informant may refuse to

provide the information.

REFERENCE: Health and Safety Code Section 102425(c)

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22 Instruct the genetic mother or informant to check one box on the worksheet
Genetic Mother to specify the genetic mother’s Hispanic origin or descent. Enter the data in
Hispanic, Latina, Item 22.
or Spanish?

What to do if… The table below provides additional information for completing the
Hispanic item on the worksheet and the birth certificate.

If… Then…
the genetic mother is not of the informant checks No – (Not
Hispanic origin or descent Hispanic). Enter No in Item 22.
the genetic mother of Hispanic the informant checks Yes and specifies
origin or descent their origin or descent. Enter the data
in Item 22.
the genetic mother of Hispanic the informant checks Yes – Other
origin or descent, but none of the Hispanic (Specify) and specifies their
categories apply origin or descent, such as: Nicaraguan,
Chilean, or Guatemalan on the work
sheet. Enter the data in Item 22.
the genetic mother of more than the informant checks Yes – Other
one Hispanic origin or descent Hispanic (Specify) and lists the multiple
Hispanic origins or descents separated
by a slash or hyphen, such as:
Nicaraguan/El Salvadoran,
Venezuelan-Colombian on the work
sheet. Enter the data in Item 22.
no information is available on the enter Unk in Item 22.
genetic mother’s Hispanic origin
or descent
information is refused enter Withheld in Item 22.

NOTE:
Item 22 is optional if the genetic mother or informant refuses to
provide the information.

REFERENCE: Health and Safety Code Section 102425(c)

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23 Enter the most recent date (month and year) that the genetic mother worked
Date Last in their usual occupation.
Worked

Example Format: MM/CCYY

Example: 01/2016

What to do if… The table below provides additional instructions for completing Item 23.

If… Then enter…

the genetic mother is currently the current month and year.
employed
the genetic mother never worked None.
or is a student
the genetic mother was a the current month and year.
homemaker prior to their delivery
the month is unknown the year only, e.g. --/2013.

the year is unknown, or if no Unk.

information is available
the information is refused Withheld.

NOTE:
Item 23 is optional. The genetic mother or informant may refuse to
provide the information.

The dates entered may be after the child’s date of birth. For
example, the child’s date of birth may be 7/31/2016 with the genetic
mother’s date last worked 08/2016.

REFERENCE: Health and Safety Code Section 102425(c)

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23A Enter the genetic mother’s usual occupation, which is the work they have
Usual occupation done for the longest period of time. If the genetic mother is retired,
unemployed, disabled, or deceased, report their usual occupation when they
were working.

Acceptable Acceptable entries also include:

entries
 abbreviations

 unknown

 withheld

 never worked

What to do if… The table below provides examples of appropriate entries for Item 23A. For
additional information on occupations, refer to Appendix B.

If the genetic mother… Then specify…

is a doctor physician, dentist, veterinarian,
chiropractor, etc.
works in data processing computer programmer, keypunch
operator, etc.
is a nurse registered nurse, nurse-midwife,
nurse’s aide, nurse practitioner, etc.
is a farm worker farmer, farm hand, farm supervisor,
fruit picker, migratory farm hand, etc.
is a homemaker Homemaker. However, if the genetic
mother normally worked outside of the
home prior to their delivery then enter
that information.

NOTE:
Item 23A is optional. The genetic mother or informant may refuse
to provide information.
REFERENCE: Health and Safety Code Section 102425(c)

23B Enter the genetic mother’s kind of business or industry corresponding with
Kind of business Item 23A. The description should indicate clearly and specifically the kind
or industry of business or industry of employment.

Do not enter company names.

Continued on next page
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Acceptable Acceptable entries also include:

entries
 abbreviations

 unknown

 withheld

What to do if… The table below provides examples of appropriate entries for Item 23B. For
additional information on business or industry, refer to Appendix C.

If the business is… Then specify…

mine copper mine, etc.

retail bookstore, card store, etc.

manufacturer fountain pen manufacturer, etc.

construction road construction, housing

construction, etc.
oil and gas industry oil field drilling, petroleum refinery,
retail gasoline station, wholesale oil
distributor, natural gas pipeline, etc.

NOTE:
Item 23B is optional. The genetic mother or informant may refuse
to provide information.

REFERENCE: Health and Safety Code Section 102425(c)

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23C Use the Race/Ethnicity and Education Worksheet to gather information that
Education – best describes the highest degree or level of school completed by the genetic
Highest mother. Enter the education information on the birth certificate.
Level/Degree

What to do if… The table below provides additional instructions for completing Item 23C.

If the genetic mother… Then…

did not complete one full year of enter 0.
formal education
completed grades, 1, 2, 3…11 enter the highest year completed.
completed 12th grade, but did not enter 12 ND.
receive a diploma
graduated from high school or enter HS Graduate or GED.
completed the GED (General
Equivalency Diploma)
earned some college credit, but did not enter Some College.
receive a degree
received an Associate degree (e.g., enter Associate.
AA, AS)
received a Bachelors degree (e.g., BA, enter Bachelors.
AB, BS)
received a Masters degree (e.g., MA, enter Masters.
MS, MEng, MEd, MSW)
received a Doctorate (e.g., PhD, EdD) enter either Doctorate or
or Professional degree (e.g., MD, Professional.
DDS, DVM, LLB, JD)
attended a specialty school such as a do not include in the number of
beauty, barber, business or technical school years completed.
school
was educated outside of the United identify and enter the number of
States of America (U.S.A.) years completed or degree received
compared to U.S.A. education.
no information is available enter Unk.

information is refused enter Withheld.

NOTE:
Item 23C is optional. The genetic mother or informant may refuse
to provide information.
REFERENCE: Health and Safety Code Section 102425(c)

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24A Enter the full street or rural address of the birth parent’s usual residence.
Birth Parent’s
Residence -
Street and
Number, or
Location

Definition The residence of the birth parent is the place where their household is
located. This is not necessarily the same as the home state, voting
residence, mailing address, or legal residence, but must reflect where the
birth parent actually lives most of the time.

REFERENCE: Health and Safety Code Section 102425(b) (4) and

Government Code Section 244

Unacceptable P.O. Boxes number and General Delivery addresses are not acceptable
entries residence address entries.

What to do if… The table below provides additional instructions for completing Item 24A.

If the birth parent… Then enter…

lives in an institution such as a the address of the place they lived prior
group home, mental institution, to being hospitalized.
penitentiary, etc.
lives in an institution and their the address of the institution.
prior address is unknown
has always resided in an the address of the institution.
institution
is homeless a physical description of the location of
their most recent habitat, e.g., Under
the XYZ Bridge.
is on tour of military duty or their college or military address.
attending college
is a surrogate or foundling refer to Other Types of Birth
Registration Section.
refuses to provide their address the address listed for the birth parent in
the medical records file. If no
information is available, enter Unk.

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24B Enter the birth parent’s U.S. county or Canadian province of residence.
County/Province

What to do if… The table below provides additional instructions for completing Item 24B.

If the birth parent… Then enter…

resides out-of-state and in the the name of the out-of-state county.
U.S.
resides out-of-state in an Unk.
unknown county or province
resides in Canada the name of the Canadian province
resides outside of the U.S. or a dash.
Canada
refuses to provide the a dash.
information and it is not
available in the medical file

24C Enter the name of the city, town, or location where the birth parent lives. If
City the birth parent refuses to provide the information and it is not available in
the medical file enter Unk.

24D Enter the birth parent’s U.S. state, U.S. territory, or foreign country of
State/Foreign residence.
Country If the birth parent usually resides outside the U.S., enter the name of the
foreign country in Item 24D, and five zeros in Item 24E.
If the birth parent refuses to provide the information and it is not available
in the medical file enter Unk.

24E Enter the birth parent’s Zip Code in Item 24E if residence is in the U.S. or
Zip Code U.S. territory.
The Zip Code entry must be a minimum of five digits, but an entry of nine
or eleven digits is acceptable.
Do not use a dash to separate the numbers in a nine or eleven digit Zip
Code.
If the birth parent refuses to provide the information and it is not available
in the medical file enter Unk.

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Electronic Item Enter the full street address or post office box at the location where the birth
mailing address parent receives mail.
street or post
office box
NOTE:

Check with SSA in regards to their mailing address requirements.

Electronic Item Enter the county in which the birth parent’s mailing address is located if the
mailing address mailing address is in the U.S., or the province if mailing address is in
county/province Canada.

Electronic Item Enter the name of the city, town or location where the birth parent receives
mailing address mail.
city

Electronic Item Enter the U.S. state, U.S. territory or foreign country where the birth parent
state/foreign receives mail.
country

Electronic Item Enter the Zip Code if the birth parent’s mailing address is in a U.S. state or
mailing address U.S. territory.
Zip Code

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Medical Data

Description The information collected in this section pertains to the birth parent and
child’s medical data. For pregnancies involving surrogate parents, refer to
Other Types of Birth Registration Section.

In this section Information collected under the “Medical Data” heading includes:

Item Number Item Title See Page

Electronic Did Birth Parent Receive Women, Infants and 166
Children (WIC) food?
Electronic Cigarette Smoking Before or During 166
Pregnancy
Electronic Birth Parent’s Pre-pregnancy Weight 166
Electronic Birth Parent’s Weight at Delivery 166
Electronic Birth Parent’s Height 167
Electronic APGAR Score at 1, 5 and 10 minutes 167
25A Data Last Normal Menses Began 168
25AA Date First Prenatal Care Visit 169
25B Month Prenatal Care Began 170
25BA Date Last Prenatal Care Visit 171
25C Number of Prenatal Visits 172
25D Principle Source of Payment for Prenatal Care 173
26 Birth Weight 175
26A Obstetric Estimate of Gestation at Delivery 175
26B Hearing Screening 175
27A Live Births – Now Living 176
27B Live Births – Now Dead 176
27C Date of Last Live Birth 177
27D Other Terminations – Before 20 Weeks 178
27E Other Terminations – After 20 Weeks 178
27F Date of Last Other Termination 179
28A Method of Delivery 180
28B Expected Principal Source of Payment for 182
Delivery
29 Complications and Procedures of Pregnancy 184
and Concurrent Illness
30 Complications and Procedures of Labor and 185
Delivery
31 Abnormal Conditions and Clinical Procedures 186
Related to the Newborn

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Electronic Item Did the birth parent receive WIC food during the pregnancy?
Did the birth
parent receive Acceptable entries include:
WIC food?  Yes
 No
 Unknown

Electronic Item Enter the average number of cigarettes that the birth parent smoked per day:
cigarette 1. During the three months prior to becoming pregnant with this child.
smoking before 2. During the first three months of pregnancy.
and during 3. During the second three months of pregnancy.
pregnancy 4. During the third trimester of pregnancy.

What to do if… The table below provides additional instructions for completing this item.

If… Then…
the birth parent did not smoke enter 0 for each time period.
the birth parent reports packs of convert packs smoked to cigarettes
cigarettes smoked smoked, at the rate of 20 cigarettes per
pack.
no information is provided for enter Unk for that time period.
one or more of the four time
periods

Electronic Item Enter the birth parent’s weight (in pounds) when they became pregnant with
birth parent’s this child.
prepregnancy
weight If no information is available, enter Unk.

Electronic Item Enter the birth parent’s weight (in pounds) at the time of delivery.
birth parent’s
weight at If no information is available, enter Unk.
delivery

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Electronic Item Enter the birth parent’s height in feet and inches.
birth parent’s
height If no information is available, enter Unk.

Electronic Item Enter the APGAR score for this child at:
APGAR score 1. One minute after birth.
at one, five and 2. Five minutes after birth.
ten minutes 3. Ten minutes after birth.

What to do if… The table below provides additional instructions for completing this item.

If… Then enter…

the APGAR score was not taken for Unk for that time period.
one or more of the three time
periods
the APGAR score is unknown for Unk for that time period.
one or more of the three time
periods
the APGAR score is not taken Not Taken

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25A Enter the date the last normal menses began in numeric format. Do not leave
Date last blank or use dashes to separate the month, day, and year.
normal menses
began NOTE: This information can be obtained from the medical or pre-natal
records if necessary.

Example Format: MM/DD/CCYY

Example: 12/17/2015

What to do if… The table below provides additional instructions for completing Item 25A.

If… Then enter…

the exact date is unknown the best estimate. You may also ask
the birth parent for their original due
date and then use the pregnancy wheel
to go backwards to find the date of last
menses.
the birth parent has no menses prior date of conception (estimate) and go
to pregnancy confirmation backwards two weeks. The doctor can
also provide an estimate based on an
ultrasound.
the birth parent had a menses prior the date last normal menses began.
to pregnancy confirmation
the birth parent had a menses or date of conception (estimate) and go
bleeding during pregnancy backwards two weeks.
the day is unknown month and year only, e.g., 12/--/2015
the month and day are unknown year only, e.g., --/--/2015
the year is unknown, or if no Unk.
information is available

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25AA Enter the date, in numeric format, of the first prenatal care visit to a
Date first physician, certified nurse midwife, nurse practitioner, or physician’s
prenatal care assistant. Do not leave blank or use dashes to separate the month, day and
visit year.

Example Format: MM/DD/CCYY

Example: 12/10/2015

What to do if… The table below provides additional instructions for completing 25AA.

If … Then enter …
the day is unknown month and year only, e.g., 12/--/2015.
the month and day are unknown year only, e.g., --/--/2015.
the year is unknown, or if no Unk.
information is available
there were no prenatal visits None.
there was only one prenatal visit the same information in 25AA and
25BA.
the exact date is unknown the best estimate

NOTE:
In determining the date of the first prenatal visit:
 do not include visit to confirm pregnancy
 do not include emergency room visits for non-pregnancy related
problems
 do not include visits to a nutritionist, dietitian, health educator, or
other health care professional not listed above.

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25B Enter the month of the pregnancy in which the birth parent first received
Month prenatal prenatal care, e.g., 1st, 2nd, 3rd, etc.
care began
Do not enter the name of the month, e.g., January, etc. Do not leave this
item blank.

NOTE:

 If no prenatal care was received, enter None in Items 25AA (Date

First Prenatal Care Visit) and in 25BA (Date Last Prenatal Care
Visit). Enter 0 in Items 25B (Month Prenatal Care Began) and in
25C (Number of Prenatal Visits) and enter a 00 in Item 25D
(Principal Source of Payment for Prenatal Care).

 If the exact month of pregnancy in which prenatal care began is

unknown, enter the best estimate.

 If absolutely no information is available, enter Unk.

REFERENCE: Health and Safety Code Section 102425(b)

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25BA Enter the date, in numeric format, of the last prenatal care visit to a
Date last physician, certified nurse midwife, nurse practitioner, or physician’s
prenatal care assistant. Do not leave blank or use dashes to separate the month, day and
visit year.

Example Format: MM/DD/CCYY

Example: 12/10/2015

What to do if… The table below provides additional instructions for completing 25AA.

If … Then enter …
the day is unknown month and year only, e.g., 12/--/2015
the month and day are unknown year only, e.g., --/--/2015.
the year is unknown, or if no Unk.
information is available
there were no prenatal visits None.
there was only one prenatal visit the same information in 25AA and
25BA.
the exact date is unknown the best estimate

NOTE:
In determining the date of the last prenatal visit:
 do not include visit to confirm pregnancy
 do not include emergency room visits for non-pregnancy related
problems
 do not include visits to a nutritionist, dietitian, health educator, or
other health care professional not listed above.

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25C Enter the estimated number (1 through 98) of prenatal care visits to a
Number of physician, certified nurse-midwife, nurse practitioner, or physician’s
prenatal visits assistant. Do not leave blank.

Acceptable Acceptable entries also include:

entries
 Unk

 0, if no prenatal care was received

NOTE:
In determining the number of prenatal visits:

 do not include visit to confirm pregnancy

 do not include emergency room visits for non-pregnancy related

problems

 do not include visits to a nutritionist, dietitian, health educator, or

other health care professional not listed above

 do not include stress tests or ultrasound

REFERENCE: Health and Safety Code Section 102425(b)(6)

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25D Enter only one code from the Medical Data Supplemental Worksheet (VS
Principal 10A) to indicate the principal source of payment for prenatal care. Do not
source of leave this item blank or enter free text.
payment for
prenatal care

Code Name Description

02 Medi-Cal, without Title XIX of the Federal Medicare Act (PL 89-
CPSP Support 971). Refer to Code 13 for a definition of the
Services Medi-Cal CPS Program.
05 Other Government Any form of payment by government agencies,
Programs (Federal, whether federal (including Indian Health
State, Local) Service, or CHAMPUS/TRICARE), state, or
local except Medi-Cal.
07 Private Insurance Payment covered by any private or commercial
Company insurance carrier, including Health Maintenance
Organizations.
09 Self Pay Payment directly by the patient, relatives, or
friends.

13 Medi-Cal, with This program allows for expanded Medi-Cal

CPSP Support reimbursement for providers in the
Services Comprehensive Perinatal Services (CPS)
Program. Providers can receive reimbursement
for care given to Medi-Cal eligible women for
assessment, reassessment, and intervention
services in obstetrics, nutrition, health
education, psycho-social, and prenatal vitamin
and mineral supplements.
14 Other Any third-party payment not included in the
above options. Coded here is payment by self-
insured or self-funded plans, or by local
organized charities, such as the Cerebral Palsy
Foundation. (This category does not include an
unknown payment source.)

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Code Name Description

00 No prenatal This code may only be used if 0 was entered in
care Item 25B (Month Prenatal Care Began) and 0 was
entered in Item 25C (Number of Prenatal Visits).
99 Unknown This code may be used if absolutely no
information regarding the source of payment for
prenatal care is available.

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26 Convert the child’s birth weight from pounds and ounces to grams and enter
Birth weight in Item 26. Enter full grams only. Do not use decimals.
See Conversion table on page 187.
NOTE:
If birth weight is under 1,000 grams and Item 15A (Date of Death) is blank,
or the birth weight is over 6,500 grams, the local registrar must:

 confirm the accuracy of birth weight with the hospital

 document the confirmation on the back of the certificate to include
the name of person who verified the birth weight, date verified, and
the initials of the person who contacted the hospital for verification

26A Enter the obstetric estimate of gestation in completed weeks based on the
Obstetric birth attendant’s final estimate of gestation which should be determined by
estimation of all perinatal factors and assessments such as ultrasound, but not the neonatal
gestation at exam. Do not round-up.
delivery

Acceptable Acceptable entries also include Unk.

entries

26B Enter the results of the newborn hearing screening test.

Hearing
screening

What to do if... The table below provides additional instructions for completing this item.
If... Then enter...
both ears passed test Pass (both ears).
one ear passed test, one ear failed Refer (one ear).
test
both ears failed test Refer (both ears).
the newborn has been screened, but Results pending.
the test results are not currently
known
the parent(s) refuse the screening Waived.
test
the newborn was not screened due to Not Med indicated.
a medical condition
screening is not offered, or the Test not available.
newborn has not been screened by
the time that the birth certificate is
completed

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27A Count all births now living except this child.

Live births now
living

What to do if... The table below provides additional instructions for completing this item.

If... Then...
this child is a twin, triplet, etc. include the first sibling(s) if now
living.
no previous live births enter 0.
no information is available enter Unk.

27B Count all live births now dead.

Live births now
dead

What to do if... The table below provides additional instructions for completing Item 27B.

If... Then...
this child is a first twin count the second twin if now dead.

this child is a second twin count the first twin if now dead.

no previous live births now dead enter 0.

no information is available enter Unk.

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27C Enter the date of last live birth in numeric format.

Date of last live
birth Do not use dashes to separate month, day, and year.

Example Format: MM/DD/CCYY

Example: 12/17/2015

Unacceptable Unacceptable entries:

entries
 withheld

 refused

 not given

 declined

 blank

What to do if... The table below provides additional instructions for completing Item 27C.

If... Then ...

the day is unknown enter month and year only, e.g.,
12/--/2015.
the month and day are unknown enter year only, e.g., --/--/2015.

the year is unknown, or if no enter Unk.

information is available

the entry is greater than 0 in Items dashes may not be entered in Item
27A or 27B 27C.

no previous live births, either enter a dash (-).

living or dead

this child is a second twin enter birth date of the first twin.

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27D Enter the number of terminations that occurred prior to 20 weeks into
Other pregnancy (20 weeks gestational age). Exclude induced abortions.
termination
before 20 weeks

What to do if... The table provides additional instructions for completing Item 27D.

If... Then…
this child is a second twin count the first twin if terminated prior
to 20 weeks gestational age.

information is not available enter Unk.

none enter 0.

a prior pregnancy resulted in count all fetuses terminated prior to 20

multiple fetuses weeks.

27E Enter the number of all previous other terminations that occurred at or after
Other 20 weeks into pregnancy (20 weeks gestational age). Exclude induced
terminations abortions.
after 20 weeks

What to do if... The table below provides additional instructions for completing Item 27E.

If... Then...
this child is a second twin count the first twin if terminated after
20 weeks gestational age.

information is not available enter Unk.

none enter 0.

a prior pregnancy resulted in count all fetuses terminated after 20

multiple fetuses weeks.

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27F Enter the month and year only for date of last termination.
Date of last/other
termination Do not leave blank.

Example Format: MM/CCYY

Example: 12/2015

Acceptable Acceptable entries also include:

entries
 dash

 unknown

What to do if... The table below provides additional instructions for completing Item 27F.

If... Then...
the month is unknown enter year only, e.g., --/2015.

the year is unknown, or if no enter Unk.

information is available

the entry is greater than 0 in Items dashes may not be entered in Item
27D or 27E 27F.

no previous terminations enter a dash (-).

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28A (A-E) Enter the appropriate code(s) or number from each section (A, B, C, D, E)
Method of of the VS 10A for this item. Separate each section entry with a comma. Do
delivery not enter free text, or leave any section blank.

28A (A) Enter one code for the final route of delivery.
Final delivery
route

Acceptable Valid codes are:

entries

01 Cesarean – primary
11 Cesarean – primary, with trial of labor attempted
21 Cesarean – primary, with vacuum
31 Cesarean – primary, with vacuum and trial of labor attempted
02 Cesarean – repeat
12 Cesarean – repeat, with trial of labor attempted
22 Cesarean – repeat, with vacuum
32 Cesarean – repeat, with vacuum and trial of labor attempted
03 Vaginal – spontaneous
04 Vaginal – spontaneous, after previous Cesarean
05 Vaginal – forceps
15 Vaginal – forceps, after previous Cesarean
06 Vaginal – vacuum
16 Vaginal – vacuum, after previous Cesarean

28A (B) Enter the number of Cesarean deliveries the birth parent had prior to this
Previous delivery.
Cesarean(s)
How many?

What to do if… The table below provides additional instructions for completing this section.

If… Then enter…

there were no previous Cesareans 0
there were previous Cesareans the number (1-9).
no information is available Unk

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28A (C) Enter one code for fetal presentation at birth.

Fetal
presentation at
birth

Acceptable Valid codes are:

entries
20 Cephalic fetal presentation at delivery
30 Breech fetal presentation at delivery
40 Other fetal presentation at delivery
90 Unknown

28A (D) Enter the code which indicates whether or not a vaginal delivery with
Vaginal delivery forceps was attempted, but was unsuccessful.
with forceps
attempted, but
unsuccessful

Acceptable Valid codes are:

entries
50 Yes
58 No
59 Unknown

28A (E) Enter the code which indicates whether or not a vaginal delivery with
Vaginal delivery vacuum was attempted, but was unsuccessful.
with vacuum
attempted, but
unsuccessful

Acceptable Valid codes are:

entries
60 Yes
68 No
69 Unknown

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28B Enter only one code from the VS 10A which indicates the expected
Expected principal source of payment for delivery. Do not leave this item blank or
principal source enter free text.
of payment for
delivery

Definition The expected principal source of payment is the one which is expected to
pay the greatest share of the birth parent’s bill for delivery.

Code Name Description

02 Medi-Cal The payment category defined in Title XIX
of the Federal Medicare Act (PL 89-971).

05 Other Government Any form of payment by government

Programs (Federal, agencies, whether federal, state, or local
State, Local) except Medi-Cal, Indian Health Service, or
CHAMPUS/TRICARE.

07 Private Insurance Payment covered by any private or

Company commercial insurance carrier, including
Health Maintenance Organizations.

09 Self pay Payment directly by the patient, relatives, or

friends.

15 Indian Health The federal health program for American

Service Indians and Alaska Natives.

16 CHAMPUS/ The Department of Defense health care

TRICARE program for members of the uniformed
services, their families and survivors, and
retired members and their families.

14 Other Any third-party payment not included in the

above options. Coded here is payment by
self-insured or self-funded plans, or by local
organized charities, such as the Cerebral
Palsy Foundation. (This category does not
include an unknown payment source.)

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Code Name Description

00 Medically This code may only be used if the delivery is
unattended unattended by medical personnel and there is
delivery no expected source of payment.

99 Unknown This code may be used if absolutely no

information regarding source of payment for
delivery is available.

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29 Enter up to 12 codes from Item 29 on the VS 10A for the most important
Complications complications and/or procedures.
and procedures
of pregnancy Do not enter free text. Do not leave this item blank. Do not enter dashes.
and concurrent
illnesses
DIABETES INFECTIONS PRESENT AND/OR
09 Prepregnancy (Diagnosis prior to this TREATED DURING THIS PREGNANCY
pregnancy) 42 Chlamydia
31 Gestational (Diagnosis in this pregnancy) 43 Gonorrhea
44 Group B streptococcus
HYPERTENSION 18 Hepatitis B (acute infection or carrier)
03 Prepregnancy (Chronic) 45 Hepatitis C
01 Gestational (PIH, Preeclampsia) 16 Herpes simplex virus (HSV)
02 Eclampsia 46 Syphillis

OTHERCOMPLICATIONS/ PRENATAL SCREENING DONE FOR

PREGNANCIES INFECTIOUS DISEASES
32 Large fibroids 51 Chlamydia
33 Asthma 52 Gonorrhea
34 Multiple pregnancy (more than 1 fetus this 53 Group B streptococcal infection
pregnancy) 54 Hepatitis B
35 Intrauterine growth restricted birth this 55 Human immunodeficiency virus (offered)
pregnancy 56 Syphilis
23 Previous preterm birth (<37 weeks gestation)
36 Other previous poor pregnancy outcomes NONE OR OTHER COMPLICATIONS/
(includes perinatal death, small-for- PROCEDURES NOT LISTED
gestational age/intrauterine growth restricted 00 None
birth, large for gestational age, etc.) 30 Other Pregnancy
Complications/Procedures not Listed
OBSTETRIC PROCEDURES
24 Cervical cerclage
28 Tocolysis
37 External cephalic version – Successful
38 External cephalic version – Failed
39 Consultation with specialist for high risk
obstetric services

PREGNANCY RESULTED FROM

INFERTILITY TREATMENT
40 Fertility-enhancing drugs, artificial
insemination or intrauterine insemination
41 Assisted reproductive technology (e.g., in
vitro fertilization (IVF), gamete intrafallopian
transfer (GIFT)

What to do if… The table below provides additional instructions for completing Item 29.

If… Then enter…

there are multiple complications each two-digit code separated by a
comma, e.g., 09, 03, 32, etc.
there are no complications 00.

there is no information available Unk.

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30 Enter up to 9 codes from Item 30 on the VS 10A for the most important
Complications complications or procedures.
and procedures
of labor and Do not enter free text. Do not leave this item blank. Do not enter dashes.
delivery
ONSET OF LABOR COMPLICATIONS OF PLACENTA,
CORD, AND MEMBRANES
10 Premature rupture of membranes (≥ 12
hours) 38 Rupture of membranes prior to onset
07 Precipitous labor (< 3 hours)) of labor
08 Prolonged labor (≥ 20 hours) 13 Abruptio placenta
39 Placental insufficiency
CHARACTERISTICS OF LABOR AND 20 Prolapsed cord
DELIVERY 17 Chorioamnionitis
11 Induction of labor
12 Augmentation of labor
32 Non-vertex presentation MATERNAL MORBIDITY
33 Steroids (glucocorticoids) for fetal lung 24 Maternal blood transfusion
maturation received by the mother prior 40 Third or fourth degree perineal
to delivery laceration
34 Antibiotics received by the mother 41 Ruptured uterus
during labor 42 Unplanned hysterectomy
35 Clinical chorioamnionitis diagnosed 43 Admission to ICU
during labor or maternal temperature 44 Unplanned operating room procedure
≥ 38°C(100.4°F) following delivery
19 Moderate/heavy meconium staining of
the amniotic fluid NONE OR OTHER
36 Fetal intolerance of labor such that one COMPLICATIONS/ PROCEDURES
or more of the following actions was NOT LISTED
taken: in-utero resuscitative measures, 00 None
further fetal assessment, or operative 31 Other Labor/Delivery Complications/
delivery Procedures not Listed
37 Epidural or spinal anesthesia during
labor
25 Mother transferred for delivery from
another facility for maternal medical or
fetal indications

What to do if… The table below provides additional instructions for completing Item 30.

If… Then enter…

there are multiple complications each two-digit code separated by a
comma, e.g., 10, 11, 24, etc.
there are no complications 00.

there is no information available Unk.

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31
Abnormal Enter up to 10 codes from Item 31 on the VS 10A for the most important
conditions and conditions and/or procedures.
clinical
procedures Do not enter free text. Do not leave this item blank. Do not enter dashes.
relating to the
newborn

CONGENITAL ANOMALIES ABNORMAL CONDITIONS

01 Anencephaly 66 Significant birth injury (skeletal
02 Meningomyelocele/Spina bifida fracture(s), peripheral nerve injury,
76 Cyanotic congenital heart disease and/or soft tissue/solid organ
77 Congenital diaphragmatic hernia hemorrhage which requires
78 Omphalocele intervention)
79 Gastroschisis
80 Limb reduction defect (excluding ADDITIONAL ABNORMAL
congenital amputation and dwarfing CONDITIONS/ PROCEDURES
syndromes) Assisted ventilation required
28 Cleft palate alone 71 immediately following delivery
29 Cleft lip alone Assisted ventilation required for more
30 Cleft palate with cleft lip 85 than 6 hours
57 Down’s Syndrome – Karyotype NICU admission
confirmed 73 Newborn given surfactant
81 Down’s Syndrome – Karyotype pending 86 replacement therapy
82 Suspected chromosomal disorder – Antibiotics received by the newborn
Karyotype confirmed 87 for suspected neonatal sepsis
83 Suspected chromosomal disorder – Seizure or serious neurological
Karyotype pending 70 dysfunction
35 Hypospadias Newborn transferred to another
88 Aortic stenosis 74 facility within 24 hours of delivery
89 Pulmonary stenosis
90 Atresia NONE OR OTHER ABNORMAL
62 Additional and unspecified congenital CONDITIONS/PROCEDURES NOT
anomalies not listed above LISTED
None
00 Other Conditions/Procedures not
75 Listed

What to do if… The table below provides additional instructions for completing Item 31.

If… Then enter…

there are multiple abnormal each two-digit code separated by a
conditions comma, e.g., 01, 29, 73, etc.
there are no abnormal conditions 00.

there is no information available Unk.

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TABLE FOR CONVERTING POUNDS AND OUNCES TO GRAMS

OUNCES
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

0 -- 28 57 85 113 142 170 198 227 255 284 312 340 369 397 425
1 454 482 510 539 567 595 624 652 680 709 737 765 794 822 851 879
P 2 907 936 964 992 1021 1049 1077 1106 1134 1162 1191 1219 1247 1276 1304 1332
3 1361 1389 1418 1446 1474 1503 1531 1559 1588 1616 1644 1673 1701 1729 1758 1786
O 4 1814 1843 1871 1899 1928 1956 1985 2013 2041 2070 2098 2126 2155 2183 2211 2240
5 2268 2296 2325 2353 2381 2410 2438 2466 2495 2523 2552 2580 2608 2637 2665 2693
U
6 2722 2750 2778 2807 2835 2863 2892 2920 2948 2977 3005 3033 3062 3090 3119 3147
N 7 3175 3204 3232 3260 3289 3317 3345 3374 3402 3430 3459 3487 3515 3544 3572 3600
8 3629 3657 3686 3714 3742 3771 3799 3827 3856 3884 3912 3941 3969 3997 4026 4054
D 9 4082 4111 4139 4167 4196 4224 4253 4281 4309 4338 4366 4394 4423 4451 4479 4508
10 4536 4564 4593 4621 4649 4678 4706 4734 4763 4791 4820 4848 4876 4905 4933 4961
S
11 4990 5018 5046 5075 5103 5131 5160 5188 5216 5245 5273 5301 5330 5358 5387 5415
12 5443 5472 5500 5528 5557 5585 5613 5642 5670 5698 5727 5755 5783 5812 5840 5868
13 5897 5925 5954 5982 6010 6039 6067 6095 6124 6152 6180 6209 6237 6265 6294 6322
14 6350 6379 6407 6435 6464 6492 6521 6549 6577 6606 6634 6662 6691 6719 6747 6776
15 6804 6832 6861 6889 6917 6946 6974 7002 7031 7059 7088 7116 7144 7173 7201 7229

1 Ounce = 28.35 Grams 1 Pound = 453.60 Grams EXAMPLE: 8 Pounds, 2 Ounces = 3,686 Grams

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Social Security Numbers

Description The information collected in this section pertains to the parents’ Social
Security Numbers (SSN).

Both parents should provide their social security numbers in order for the
child to receive an automatic social security number through the Newborn
Automatic Number Assignment (NANA) program. However, it is not
required that parents provide their social security numbers.

REFERENCE: Health and Safety Code Section 102425(d)

32 Enter this parent’s nine-digit SSN including the dashes that separate the
Parent segments.
(listed in 6A-6C)
SSN

Example 444-44-4444

What to do if… The table below provides additional instructions for completing Item 32.

If… Then enter…

the parent refuses to provide SSN Withheld.

the parent does not have a SSN None.

information is not available Unk.

33 Enter this parent’s nine-digit SSN including the dashes that separate the
Parent segments.
(listed in 9A-9C)
SSN

Example 555-55-5555

Continued on next page

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What to do if… The table below provides additional instructions for completing Item 33.

If… Then enter…

the parent refuses to provide SSN Withheld.

the parent does not have a SSN None.

information is not available Unk.

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State Registrar Items
Description The boxes located at the bottom of the birth certificate are for CDPH-VR
use only. If the hospital is using an electronic birth registration system, the
values are system generated.

Coded Items The information that is coded for each box is provided in the table below.

Item Item Subject See Page

A Hospital Code 191

B Birth Parent’s County of Residence 191

D Type of Attendant/Certifier 191

F NANA 191

Census Census Tract 192

Tract

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Box A The code assigned to the hospital or place of birth as reported in place of
Hospital Code birth (Item 5A).

Box B The code assigned to the county where the birth parent usually resides as
Birth Parent’s reported in Item 24B, or if the birth parent resides outside of California, the
County of code corresponding to the resident state or country of the birth parent.
Residence

Box D Type of attendant/certifier who signed in Item 13 to verify the fact of birth.
Type of
Attendant/
Certifier

Box F Codes indicating the parents desire to have this birth information
NANA
(1) sent to the SSA for issuance of a SSN for the child, and

(2) only allow the CDPH to see whether a social security number has
been assigned.

NOTE:

The mailing address for the birth parent, if different from the birth
parent’s residence address, will be used in conjunction with Box F
to issue a SSN for the child. A SSN can only be issued through the
birth registration process if the address is within a U.S. state, the
District of Columbia, or Puerto Rico.

A sample consent form is on page 196. Individual facilities may

photocopy this sample, or they may incorporate the consent into their
own worksheet.

Continued on next page

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What to do if… The table below provides specific instructions for completing Box F when
the NANA work sheet is completed as follows:

If… Then enter…

questions 1 and 2 were both answered YY.
Yes
question 1 was answered Yes and YN.
question 2 was answered No
questions 1 and 2 were answered No NN.

the baby is to be adopted Consult with the parents.

This was a surrogate pregnancy Consult with the intended parents.

the parent(s) have no permanent Consult with the parents. They
address may have an address where they
can receive mail.
the parent(s) did not sign the NANA NN.
form
the baby is not yet named Inform the parents that the SSA
may not issue a card without a
name.

the hospital is not on an electronic NN.

birth registration system
hospital does not participate in NANA NN.

NOTE:
A blank entry must be treated as a No.

Census Tract A code based on the most recent publication of census tracts, indicating a
specific geographic location for the birth parent’s residence is entered in this
box.

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Use this page for notes.

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Numbering the Birth Certificate
Description The Local Registration Number (LRN) is in the upper right corner of the
certificate. This number is used to track and identify certificates which are
approved and registered by the local registrar.

Format The LRN consists of 13-digits entered in the following format:

 1 to indicate a birth event

 four numbers indicating the century and year of event

 two numbers indicating the local registration district code

 six numbers indicating the consecutive number of the birth for that year

Example 1 2016 34 000001

The above example LRN is for a birth that occurred in 2016 in Sacramento
County and was the first birth registered in the county. The first certificate
registered in each calendar year is numbered 000001 and each succeeding
document receives the next number.

NOTE:
The year of event in the LRN must match the year of the birth in
Item 4A (Date of Birth). The LRD code in the LRN must match the
county identified in Item 5D.

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LRD Codes The table below provides the numeric codes for each LRD.

Numeric Codes for Local Registration Districts

LRD LRD LRD
Code LRD Code LRD Code LRD
01 Alameda 21 Marin 41 San Mateo
02 Alpine 22 Mariposa 42 Santa Barbara
03 Amador 23 Mendocino 43 Santa Clara
04 Butte 24 Merced 44 Santa Cruz
05 Calaveras 25 Modoc 45 Shasta
06 Colusa 26 Mono 46 Sierra
07 Contra Costa 27 Monterey 47 Siskiyou
08 Del Norte 28 Napa 48 Solano
09 El Dorado 29 Nevada 49 Sonoma
10 Fresno 30 Orange 50 Stanislaus
11 Glenn 31 Placer 51 Sutter
12 Humboldt 32 Plumas 52 Tehama
13 Imperial 33 Riverside 53 Trinity
14 Inyo 34 Sacramento 54 Tulare
15 Kern 35 San Benito 55 Tuolumne
16 Kings 36 San Bernardino 56 Ventura
17 Lake 37 San Diego 57 Yolo
18 Lassen 38 San Francisco 58 Yuba
19 Los Angeles 39 San Joaquin 61 Berkeley
20 Madera 40 San Luis 62 Long Beach
Obispo 63 Pasadena

SFN The SFN is the sequential number assigned by CDPH-VR in the space
provided in the top left corner of the certificate.

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Newborn’s Automatic Number Assignment

NOTICE TO PARENTS: Completion of this form in the hospital will enable you to receive a valuable
service from the federal government. Federal law requires that a Social Security Number be provided for
all dependents listed on federal tax forms. A Social Security Number is also necessary when applying for
welfare or other public assistance benefits for your child. By completing this form and requesting a
Social Security Number for your new baby, the California Department of Public Health will transmit your
request to the Social Security Administration, and a card will be mailed to you usually within six weeks,
eliminating the need for you to personally visit a Social Security office with evidence of your child’s
identity, birth date, and citizenship.

If you choose to participate in this program, and the parent(s) Social Security Number(s) are provided on
the birth certificate, the parents(s) Social Security Number(s) will be disclosed to the Internal Revenue
Service. The Social Security Number(s) will be used by the Internal Revenue Service solely for the
purpose of tax benefits based on support or residence of a child, pursuant to 42 USC 405 (c)(2) as
amended by Section 1090(b) of Public Law 105-34. For further information about this program, please
contact the Social Security Administration at (800) 772-1213.

For certified copies of your child’s birth certificate, contact the health department or the recorder’s office
of the county where the birth occurred. You may also obtain an application for a certified copy through
the California Department of Public Health by calling (916) 445-2684 or by visiting the web site at
www.cdph.ca.gov.

NEWBORN AUTOMATIC NUMBER ASSIGNMENT

(NANA)
Baby’s Name as Reported on Birth Certificate

(A Social Security number cannot be issued for a child that has not been named.)

1. Do you want a Social Security number for your new baby? _____ Yes _____ No
2. May the Social Security Administration share it with the California Department of Public
Health? _____ Yes _____ No
___________________________________________
Parent’s Signature
___________________________________________
Parent’s Name (Please print)
___________________________________________
Medical Record Number
Instructions to Birth Clerks: This consent form is to be completed and signed by the newborn’s parent(s). After
proper coding of Box F on the birth certificate, RETAIN THIS FORM in the parent’s medical records.

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BIRTH REGISTRATION
 OTHER TYPES OF BIRTH REGISTRATION

Other Types of Birth Registration

Overview This section includes registration procedures for other types of births, e.g.,
finding of an unidentified child or safely surrendered child, surrogate births,
out-of-hospital births, and procedures for delayed and court ordered delayed
birth registration.

In this section Information contained in this section includes:

Subsection Title See Page

Certificate of Finding of Unknown Child or Safely 203
Surrendered Child (VS 136)

Registration of Surrogate Births 206

Delayed Registration of Birth (VS 85) 210

Court Order Delayed Registration of Birth (VS 108) 214

Out-of-Hospital Birth Registration 216

Sample: Certificate of Finding of Unknown Child (VS 136) 218

Sample: Safely Surrendered Child (VS 136) 219

Sample: Delayed Registration of Birth (VS 85) 220

Sample: Court Order Delayed Registration of Birth (VS 108) 221

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Use this page for notes.

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 OTHER TYPES OF BIRTH REGISTRATION

Certificate of Finding of Unknown Child or Safely

Surrendered Child
Description A VS 136 for an unidentified live child of less than one year of age is to be
registered with the local registrar of births and deaths by the person or
institution with whom the child is placed within four days following the
finding. See sample of the VS 136 on pages 218 and 219.

The VS 136 must also be used to register the birth of any Safely Surrendered
child, regardless if the child was actually born in the hospital or dropped off.
In doing so, the personal data of the parents will remain confidential as
mandated by California law.

NOTE:
If a certificate is not filed within a year from the date of the finding, a
VS 85 will be required. See page 210 for instructions on completing
the VS 85.

REFERENCE: Health and Safety Code Sections 1255.7(k) and 102500

Completing the The certificate is to be as complete as possible, including:

VS 136
 name of child as given by the person or institution with whom the child
is placed (Items 1A through 1C)

 sex (Item 2)
 race (Item 3)
 legal date of birth (determined as closely as possible) (Item 4)
 date of finding (Item 5)
 place of finding (Items 6A through 6B)
 name of the person or institution with whom the child is placed (Item 7)
 address of person or institution (Items 8A through 8D)
 certification of finding (Items 9A through 10D)
 certification of surrender (Items 11A through 12D)
REFERENCE: Health and Safety Code Sections 102505 and 102510

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 OTHER TYPES OF BIRTH REGISTRATION

AVSS Users If the VS 136 is being prepared for a child that is Safely Surrendered, please
add “Safe Surrender” to the comments section in AVSS.

If the VS 136 is being prepared for a child that is a Certificate of Finding of

Unknown Child, please add “Certificate of Finding of Unknown Child” to
the comments section in AVSS.

The comments section may be accessed by editing the record after the file is
recorded. If you have any questions regarding this procedure, please contact
AVSS.

What to do if… The table below provides instructions for completing the birth
certificate, when the birth is a safely surrendered or certificate of finding
of unknown child.

If… Then…
a baby is born in a hospital or this is considered a safely surrendered child.
other California location and A VS 136 should be prepared certifying that
the birth parent or individual this is a safely surrendered child.
who has lawful custody of the
child either states they want to
safely surrender the baby that is
72 hours old or younger or
abandons a child at a
designated safe surrender site
or within a public or private
hospital

(Health & Safety Code Section

1255.7)
a baby is born in a hospital or a VS 136 should NOT be prepared since the
other California location and child is over 72 hours. Contact the county
the birth parent or individual social services for guidance.
who has lawful custody of the
child states they want to safely
surrender the baby that is over
72 hours old at a designated
safe surrender site or within a
public or private hospital
a birth certificate is registered a safe surrender birth certificate is not
and signed by the birth parent required as a regular birth certificate would
and within 72 hours of the have been prepared upon birth of the child.
child’s birth, they surrender the
baby

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 OTHER TYPES OF BIRTH REGISTRATION

If … Then …
the birth parent drops the baby this is considered a safely surrendered child.
off at a designated safe A VS 136 should be prepared.
surrender site (i.e., hospital or
fire department or other
designated areas) and the baby
is 72 hours old or younger
a baby is born in a hospital or this is considered an adoption. A VS 10D
other California location and should be prepared. After adoption of the
the birth parent states they want child, a new birth certificate will be prepared.
to put their baby up for
adoption
an unidentified live child of less A VS 136 form should be prepared,
than one year of age is found completing the Certification of Finding of
Unknown Child portion.
a regular birth certificate is a court order is required to seal the birth
prepared for a child that is later certificate and obtain a safely surrendered
surrendered certificate.

The VS 136 shall be processed, numbered, and filed in the same manner as a
regular birth certificate. The local registration number shall be sequential with
regular birth registrations.
umbered, and
NOTE:
 If the child is identified after the VS 136 is filed, and a VS 10D is
How to process
located or obtained, that fact is to be reported to CDPH-VR. At that
time, the VS 136 will be sealed by CDPH-VR and the LRD will be
notified. The LRD shall not remove the VS 136 until instructed to do
so by the State.

 If the child is identified but no birth certificate is located, one must be

registered on the basis of information available.

 Upon adoption of the child, the VS 136 will be sealed and a new birth
certificate prepared.

REFERENCE: Health and Safety Code Sections 102515 and 102520

Certified copy After the VS 136 is registered, certified copies may be made available from the
county office or state registrar, upon submission of an application, notarized
sworn statement (if applicable) and payment of the required fee.

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 OTHER TYPES OF BIRTH REGISTRATION

Registration of Surrogate Births

Overview In cases of surrogate pregnancies, all information on the birth certificate should be
factual information based on the gestational (birth) parent, unless otherwise
specified in a court order. However, the birth parent’s address (Items 24A-24E)
must always contain the address of the gestational (birth) parent.

Definitions Surrogate is the person who gestates for another.

Genetic mother is the person who produces an egg that results in an embryo.

Gestational (birth) parent is the person who gestates an embryo throughout the
pregnancy.

Intended parent(s) are the person(s) named in a court order, as the parent(s) of the
child.

AVSS Users Please add “Surrogate Birth” to the comments section in AVSS.
The comments section may be accessed by editing the record after the file is
recorded. If you have any questions regarding this procedure, please contact
AVSS.
What to do if… The table below provides additional instructions for completing the birth certificate
when the birth involves a surrogate pregnancy.
If… Then…
the pregnancy involves a based upon a certified order from a Superior Court, the
surrogate parent names of the “intended” parent(s) may be listed on the
(including surrogates that original birth certificate (Items 6A-11). The personal
are the gestational parent information for the genetic parents should be listed in
only and surrogates that Items 18-23C. However, if either parent makes an
are both the gestational objection, these items may be withheld (Health and
and genetic parent) Safety Code Section 102425(c)).
The birth parent’s residence address field may not be
left blank and must include the gestational parent’s
address (Items 24A-24E). The Medical Data Section
on the birth certificate must contain information based
C on the gestational parent only (Items 25A-31).
a gestational (birth) the hospital should wait approximately 7 or 8 days after
parent has a baby and the the birth to receive the court order. If after that time
biological parents do not the court order has not been submitted, the hospital
have a court order should prepare the birth certificate with the gestational
(birth) parent’s information.
The birth certificate must be registered within 10 days
according to the law (Health and Safety Code Section
102400).
Continued on next page

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 OTHER TYPES OF BIRTH REGISTRATION

a Superior Court Order the “intended” parents may be listed on the birth
stipulates two persons to certificate based upon a certified Superior Court Order.
be listed as parents on the One person may be listed as the parent in Items 6A-6C
birth certificate and one person may be listed as the parent in Items 9A-
9C. The personal information for the genetic parents
should be listed in Items 18-23C. However, if either
parent makes an objection, these items may be
withheld (Health and Safety Code 102425(c). The
birth parent’s residence address field may not be left
blank and must include the gestational parent’s
address (Items 24A-24E). The Medical Data Section
on the birth certificate must contain information based
on the gestational parent only (Items 25A-31).

this is a surrogate follow the previous instructions. The “intended” single

pregnancy for a single parent may only be listed on the birth certificate in
parent adoption Items 9A-9C. Item 9C may not be left blank. The
personal information for the genetic parents is to be
listed in Items 18-23C. However, if the parent makes
an objection, these items may be withheld (Health and
Safety Code 102425(c). The birth parent’s residence
address may not be left blank and must include the
gestational parent’s address (Items 24A-24E). The
Medical Data Section on the birth certificate must
contain information on the gestational parent only
(Items 25A-31).

REFERENCE: Health and Safety Code Section 102425(c)

Continued on next page

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 OTHER TYPES OF BIRTH REGISTRATION

NOTE:
Current law does not authorize hospitals and local registrars to omit
the name of the person giving birth in Items 9A-9C, birth parent’s
address in Items 24A-24E, or to alter the birth certificate form.
Certified court orders requesting that the person giving birth’s
information be omitted or the birth certificate form be altered, are no
longer required to be forwarded to CDPH-VR with the birth
certificate.

REFERENCE: Health and Safety Code Section 102725

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 OTHER TYPES OF BIRTH REGISTRATION

Use this page for notes.

January 1, 2016 209

 OTHER TYPES OF BIRTH REGISTRATION

Delayed Registration of Birth

Overview Any birth not registered within one year of the date of birth must be
registered with the State Registrar by completing a VS 85. See sample of
VS 85 on page 220.

NOTE:
Birth certificates submitted for registration beyond the 10-day
mandate may be accepted by the local registrar, but they must be
properly registered within one year of the date of birth.

REFERENCE: Health and Safety Code Sections 102525 through 102610

Who may file The application for a VS 85 shall be made only by the person whose birth is
being registered if he or she is 18 years of age or over at the time of filing
the application. If the applicant is under 18 years of age, the application
shall be made only by the parents, legal guardian, or the attending physician
or principal attendant at birth.

NOTE:
Before the person applies for a Delayed Registration of Birth, please
advise the applicant to confirm that they do not have a registered birth
certificate on file with the State Registrar.

Required If the person whose birth is being registered is under 12 years of age:
evidence
 Two persons having knowledge of the facts of the birth and who were at
least five years old at the time of this event must sign the affidavit
(Items 17A through 18E on the VS 85). If the persons signing are not
relatives of the applicant, they must specify the reason for having
knowledge of the birth at the time of occurrence, e.g., “witnessed birth,”
etc. One document which confirms the date and place of birth and
which is dated more than two years prior to the date of this application is
required.
OR

 Two documents over two years old, which confirm the date and place of
birth. One document must confirm parentage.

Continued on next page

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 OTHER TYPES OF BIRTH REGISTRATION

If the person whose birth is being registered is 12 years of age or over:

 Two persons having knowledge of the facts of the birth and who were at
least five years old at the time of the event must sign the affidavit. One
document which confirms the date and place of birth and which is dated
more than five years prior to the date of this application is required.
OR

 Two documents which confirm the date and place of birth and which are
dated more than five years prior to the date of this application are
required. One document must confirm parentage.

NOTE:
If the child whose birth is being registered is under 2 years of age the
documents must have been established within the first 6 months of
the child’s life. The following may be used to document the birth:

 documentation on a physician’s letterhead

 newborn screening test
 ambulance records if the child was transported to the hospital
shortly after the birth
REFERENCE: Health and Safety Code Section 102585

Documentary Original or certified copies of documents which show birth information are
evidence considered documentary evidence.
Suggested documents that may verify date and place of birth or parentage of
the person whose birth is being registered are:

 hospital records of birth and other medical records (not immunization

records or “souvenir” copies of birth records)

 school, census, social security, military service, or voting registration

records. If school records are used the school must “seal” the
documents in a school envelope which is not to be opened by the
applicant.
 certificates of registry of marriage
 newspaper notice of the birth
REFERENCE: Health and Safety Code Section 102580

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 OTHER TYPES OF BIRTH REGISTRATION

What is If the child was born January 1, 1995 or later:

submitted with
the delayed  Completed VS 85
registration  Documentary evidence and affidavits
form?  Certified copy of parents’ marriage certificate or POP form (not
necessary if birth was prior to January 1, 1995)
 Notarized sworn statement to receive certified copy
 Processing fee

Registration The above information is mailed to the State Registrar. Upon receipt, the
State Registrar will verify all information contained in the documents. The
birth shall be registered if the application and evidence submitted comply
with the requirements.

Priority AB 1413 (Chapter 315, Statutes of 2003) requires that the State Registrar
processing give priority to the processing of an application for delayed registration of
birth for a child who has been adjudged a dependent of, and who is subject
to the jurisdiction of, the juvenile court pursuant to Section 300 of the
Welfare and Institutions Code
REFERENCE: Health and Safety Code Section 102600(b)

Certified copy The State Registrar shall send a certified copy of the delayed certificate of
birth to the applicant without additional cost.

Local office The State Registrar shall send a copy of the birth certificate to the county
copies recorder within the jurisdiction where the birth occurred.

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 OTHER TYPES OF BIRTH REGISTRATION

Use this page for notes.

January 1, 2016 213

 OTHER TYPES OF BIRTH REGISTRATION

Court Order Delayed Registration of Birth

Description When an applicant cannot provide sufficient documentation for a delayed
registration (if the birth is being registered after one year from the date of
birth), the State Registrar will advise the applicant of the right to file a
VS 108. See sample on page 221.

REFERENCE: Health and Safety Code Section 103450

Where to file The petition may be filed with the superior court of the county where the
event allegedly occurred or in the applicant’s county of residence.

REFERENCE: Health and Safety Code Section 103450

Who may file Any beneficially interested person, e.g., a parent, grandparent, social
worker, etc., may file a petition upon payment of the required fee with the
county clerk of the superior court for an order judicially establishing the
facts of birth if there is no birth record on file.

Health and Safety Code Sections 103450 and 103470

Verified petition The clerk of the Superior Court must verify that the proof of birth presented
by the petitioner contains all the facts necessary to enable the court to
determine the fact of and the time and place of birth.

If the time and place of birth are not known, the petition shall contain all of
the facts of birth as accurately as the circumstances permit. The petition
shall be verified as to the known facts only.

REFERENCE: Health and Safety Code Sections 103455 and 103460

Court hearing Upon filing of the petition a hearing shall be scheduled by the clerk and at
the convenience of the court not less than five nor more than 10 days after
the filing of the petition.

REFERENCE: Health and Safety Code Section 103465

January 1, 2016 214

 OTHER TYPES OF BIRTH REGISTRATION

Order of court If the allegations of the petition are established to the satisfaction of the
court, the court may make an order determining that the birth did in fact
occur at the time and place shown by the proof presented at the hearing.

If the actual time and place of birth are unknown, the court considers the
evidence and testimony available, and by court order, establishes the time
and place of birth.

Form of order The order shall be made on the VS 108.

Filing the VS 108 The VS 108 becomes effective after the applicant submits a court certified
copy of the VS 108 with the required filing fee to the State Registrar.

REFERENCE: Health and Safety Code Section 103485

Certified copy Upon registration by the State Registrar, a copy of the certificate is sent to
the applicant and to the county within which the event occurred.

NOTE:
Court ordered delayed birth certificates should be filed with other
certificates.

January 1, 2016 215

 OTHER TYPES OF BIRTH REGISTRATION

Out of Hospital Birth Registration

Description For live births that occur outside of a hospital or outside of a state-licensed
alternative birth center, as defined in paragraph (4) of subdivision (b) of
Section 1204 of the Health & Safety Code, the physician in attendance at
the birth or, in the absence of a physician, the professionally licensed
midwife in attendance at the birth or, in the absence of a physician or
midwife, either one of the parents shall be responsible for entering the
information on the certificate, securing the required signatures, and for
registering the certificate with the local registrar.

REFERENCE: Health and Safety Code Section 102415

For additional information concerning out-of-hospital births, refer to

Appendix D.

January 1, 2016 216

 OTHER TYPES OF BIRTH REGISTRATION

Use this page for notes.

January 1, 2016 217

 OTHER TYPES OF BIRTH REGISTRATION

Sample: Certificate of Finding of Unknown Child

January 1, 2016 218

 OTHER TYPES OF BIRTH REGISTRATION

Sample: Safely Surrendered Child

January 1, 2016 219

 OTHER TYPES OF BIRTH REGISTRATION

Sample: Delayed Registration of Birth (VS 85)

January 1, 2016 220

 OTHER TYPES OF BIRTH REGISTRATION

Sample: Court Order Delayed Registration of Birth (VS 108)

January 1, 2016 221

 OTHER TYPES OF BIRTH REGISTRATION

Sample: Court Order Delayed Registration of Birth (VS 108)

January 1, 2016 222

AMENDMENTS
 AMENDMENTS

Amendments

Overview This section addresses the various types of amendment forms that may be
used to amend vital event records.

In this section Information contained in this section includes:

Subsection Title Page

General Information for Usage of
Amendments 802

Instructions for Completing an

Amendment 804

Registration of Amendments by
Local Registrar 808

Birth Amendments 810

January 1, 2016 801

 AMENDMENTS

General Information for Usage of Amendments

Overview Amendment forms may be used to correct errors and/or add information that
was not known at the time the vital record is registered. Although both the
original vital event record and amendment may be submitted at the same
time, the original certificate must be acceptable on its own merit. The
amendment form is filed with and becomes a part of the record to which it
pertains. There is no limit to the number of amendments that may be applied
to any vital event record.

Amendments may not be used to change information that would require a

court order. Amendments may not be used to change or correct a signature.

REFERENCE: Health and Safety Code Sections 103225 and 103255

Certified copies When an amendment is filed within one year of the event, there is no fee to
and fees process the form, unless the amendment requires the preparation of a new
certificate, e.g., adjudication, paternity, gender error, etc. The VS 23 form
always requires a fee. The processing fee includes one certified copy. The
current fee schedule should be checked for appropriate fees.

If the fee is paid and the applicant is entitled to receive a certified copy of the
newly amended record, the applicant must supply a sworn statement stating
he or she is authorized to receive the certified copy. If the request for the
amendment is mailed, the sworn statement must also be notarized. If the
applicant is not an authorized individual he or she will receive an
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH
IDENTITY” certified copy.

REFERENCE: Health and Safety Code Sections 103700 through 103730,

and 103526

Amendment Applications to amend vital event records must be completed on the original
form amendment form as supplied by CDPH-VR. Photocopies of the amendment
forms are not acceptable.

Field item numbers that are not on the original vital event record cannot be
added via an amendment form. This is especially true for older vital event
records that do not contain the same fields as newer records.

REFERENCE: Health and Safety Code Section 102200

Continued on next page

January 1, 2016 802

 AMENDMENTS

General Information for Usage of Amendments, Continued

Durable ink The use of durable black ink is required on all vital event records, including
and no amendments. The amendment form is considered a legal document after
alterations registration and must be able to hold up in any court, unchallenged as to the
accuracy and reliability. Consequently, there can be no erasures, whiteout, or
other types of alterations to any amendment form. Corrections can be made
prior to registration with a “self-correcting” typewriter equipped with lift-off
correction ribbon, provided the original entries are not visible to the naked
eye.

REFERENCE: Health and Safety Code Section 102125 and 102140

Amending the Whenever the information originally furnished in the medical and health data
medical and section of any record of death, fetal death or live birth is modified by
health data supplemental information relative thereto, the certifying physician or coroner
having knowledge of this information must sign the amendment stating the
changes necessary to make the information correct.

REFERENCE: Health and Safety Code Section 103300

Turnaround For faster turnaround time in the processing of amendments, please ensure the
time appropriate 13-digit local file number is entered on all amendments.

AKA Legal names on certificates are those acquired by birth, adoption, court-
ordered name change, or naturalization. An AKA must not be entered on the
certificate, but may be added by amendment.

Amending Amendment forms may not be used to change or remove a signature on any
signatures registered certificates.

Continued on next page

January 1, 2016 803

 AMENDMENTS

Instructions for Completing an Amendment

Part I Information to Locate Record

Instructions Information on the form should be entered as follows:

Field Title Instruction

Local Registration Number Enter the appropriate 13-digit LRN if known.
Name Enter the name as it appears on the original
certificate or subsequent amendment. The
primary name listed on the certificate must be
entered regardless of any AKA subsequently
added.
Sex Enter the sex as listed on the original
certificate. Entries of “M” or “F” are
acceptable.
Date of Event Enter the date (month, day, year) of the event.
City of Event Enter the name of the city in which the event
occurred.
County of Event Enter the name of the county in which the
event occurred.
Full Name of Parent As Enter the exact information as it appears on
Stated on Original Record the original certificate or subsequent
amendment. If no information is available,
enter a dash (-).

NOTE:

When using the VS 24 form, the type of event at the top of the form should be
checked, e.g., Birth, Death or Fetal Death.

Continued on next page

January 1, 2016 804

 AMENDMENTS

Instructions for Completing an Amendment, Continued

Part II Statement of Corrections (Information to be Corrected)

Instructions Information on the form should be entered as follows:

Field Title Instruction

Item Number To Be Enter the item number to be corrected as
Corrected listed on the original certificate.
Incorrect Information That Enter the incorrect information as it is
Appears on Original Record reported on the original certificate or
subsequent amendment. List one item per
line.
Corrected Information As It Enter the information as it should appear on
Should Appear the original certificate or subsequent
amendment. List one item per line unless the
items being added are AKAs or additional
names. Names should be listed using as
many lines as necessary.
Reason for Correction List the reason that the correction is being
made, e.g., child’s name misspelled,
typographical error, information not known
originally, hospital error, funeral home error,
etc.

Continued on next page

January 1, 2016 805

 AMENDMENTS

Instructions for Completing an Amendment, Continued

Part III Affidavit and Signatures

Instructions Information on the form should be entered as follows:

Field Title Instruction

Signature of First/Second The persons asserting the error must sign
Person their usual and customary signature.
Printed Name Print the name of the person asserting the
error.
Title/Relationship to Person Enter the title or relationship of the individual
in Part I signing the amendment.

Date(s) Signed Enter the date(s) the individual(s) signed.

Addresses Enter the street or mailing address of the

individuals signing the amendment. Hospital
or mortuary staff may enter their business
address.

NOTE:

Two affidavit signatures are required on the VS 24 amendment form.

REFERENCE: Health and Safety Code Section 103225

Two signatures are not required when using this form for gender
reassignment. The only signature required is the physician’s.

Continued on next page

January 1, 2016 806

 AMENDMENTS

Instructions for Completing an Amendment, Continued

Affidavit The following instructions regarding affidavit signatures should be followed

signatures – when processing Birth Amendments:
Birth
 Two persons with knowledge of the facts must sign the VS 24.

 CDPH-VR recommends that one signature be that of a parent, relative or

friend.

 Amendments correcting hospital errors require the signature of the

physician or hospital medical records staff in addition to one other
credible person with knowledge of the facts.

January 1, 2016 807

 AMENDMENTS

Registration of Amendments by Local Registrar

Overview The table below provides information when an amendment may be accepted
for registration by the local registrar:

If… Then…
the original certificate has not been the local registrar may register the
forwarded to the state amendment if acceptable.
the original certificate is no longer at the amendment must be forwarded to
the local registrar’s office, but has the State Registrar for registering.
been forwarded to the State Registrar Upon acceptance at the state level, a
copy will be forwarded to the local
county office.

REFERENCE: Health and Safety Code Sections 103235,

103240 and 103245

Instructions for The following instructions should be followed when amendments are
local registrar accepted at the local registrar’s office:

 Ensure that the correct amendment form is being applied.

 Review the amendment form for completion. The amendment form must
list the name, date of event, and local file number as stated on the original
certificate or subsequent amendment(s).

 Verify that the correct affidavit signatures are present.

Continued on next page

January 1, 2016 808

 AMENDMENTS

Registration of Amendments by Local Registrar, Continued

State/Local The following instructions should be followed when the amendment is

Registrar Use accepted and registered by the local registrar:
only
 Enter the signature of the Local Registrar in the appropriate field.

 Enter the date the amendment was accepted for registration by the Local
Registrar.

 Issue certified copies upon request and payment. Upon registration, the
amendment becomes part of the original vital event record that it pertains
to.

 Original amendment forms are to be forwarded to the State Registrar with

the regular weekly shipment.

 The local registrar should maintain copies of certificates and amendments

for the current year and one-year prior. County Recorder’s offices should
have copies of all certificates and amendments on file in their office.

REFERENCE: Health and Safety Code Sections 102320, 103235, 103255,

All County Letter (ACL) 89-04 and ACL 07-18

NOTE:

Effective January 1, 2006, local county offices should no longer stamp

original certificates and amendments noting that the documents have been
amended.

REFERENCE: ACL 05-17

January 1, 2016 809

 AMENDMENTS
Birth Amendments

Overview This subsection addresses the various types of amendment forms and
processes that are used to amend birth certificates.

In this section Information contained in this subsection includes:

Birth Amendment Forms/Issues Page

Affidavit to Amend a Record (VS 24)
(Births)
811
Acknowledgement of Paternity/Parentage
(VS 22) 813

Declaration of Paternity (POP form)

CS 909
814
Adjudication of Facts of Parentage (VS 21)
816
Correcting Gender Errors On Birth
Certificates
817
Court Order Change of Name (VS 23)
819
Court Report of Adoption (VS 44)
821
Physician/Coroner Amendment (VS 24A) 824

Obtaining a New Birth Certificate After

Gender Reassignment (VS 24)
825
Sealing Notice and Certification
827
Supplemental Name Report – Birth
(VS 107)
828

January 1, 2016 810

 AMENDMENTS

Affidavit to Amend a Record (Births)

Application to The Application to Amend a Record may be used to correct the following on
Amend a birth certificates:
Record
(Births)  Correct spelling errors.

 Add the child’s name.

 Add the middle name for either parent or child.

 Correct the spelling of a parent’s name.

 Correct any item on the certificate.

 Add a title such as Jr., Sr., or III to the name.

 Correct parent’s relationship to the child.

Correcting the When correcting date, time, place of birth, or any medical and health
date, time, information on the birth certificate, one supporting affidavit must be signed
place of birth, by the physician or hospital medical records staff. If the physician or hospital
or medical/ medical records staff is not available, a court order will be required to
health establish the facts.
information
REFERENCE: Health and Safety Code Section 103300

Continued on next page

January 1, 2016 811

 AMENDMENTS

Affidavit to Amend a Record (Births), Continued

Hospital errors The following may be amended only if the original entry was due to a
hospital error. In those cases, one affidavit signature must be by a member of
the medical records staff:

 Completely change the first, middle, or last name of any person listed on
the birth certificate.

 Transpose the first and middle name of the registrant.

 Add to or change the first, middle, or last name of the registrant.

 Change either or both parents’ name(s).

 Translate registrant’s name into another language, e.g., Juan to John.

AKA If the parent has received a Court Order Change of Name or name change
through the naturalization process, they may apply an amendment to their
child’s birth certificate using the VS 24. In the field entitled “Reason for
Correction” on the amendment form, the parent(s) should note that an AKA is
being added pursuant to the court order or naturalization process. CDPH-VR
may require that the parent(s) provide supporting documentation.

Amendments may not be used to add an AKA for a child listed on the birth
certificate.

Certified copies If the fee is paid and the applicant is entitled to receive a certified copy of the
newly amended record, the applicant must supply a sworn statement stating
the requester is authorized to receive the certified copy. If the request for the
amendment is mailed, the sworn statement must also be notarized. If the
applicant is not an authorized individual he or she will receive an
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH
IDENTITY” certified copy.

REFERENCE: Health & Safety Code Section 103526

January 1, 2016 812

 AMENDMENTS

Acknowledgement of Paternity/Parentage
Overview If the parent’s name in Items 6A-6C is not added to the birth certificate at the time
of birth, the parents must sign a VS 22 to add the parent’s name to the birth
certificate, and submit one of the following if the birth occurred after January 1,
1995:
Unmarried parents must also sign the CS 909, with the appropriate witness and/or
notary, and submit with the appropriate processing fee.
Although the POP form is not required for unmarried parents registering a child’s
birth that occurred prior to 1995, unmarried parents may still opt to complete and
sign the form.
Married parents must forward a photocopy of their marriage certificate with the
VS 22 and appropriate processing fee.
SRDP parents must forward a photocopy of their declaration with the VS 22 and
appropriate processing fee.
REFERENCE: Health and Safety Code Section 102750

Surname If the child’s surname is to be changed to that of the parents’ they may complete
changes the VS 22. Upon receipt of the VS 22 signed by both of the parents and
appropriate fee, CDPH-VR will prepare a new certificate for the child.
This is acceptable even if the parent’s name is already listed in Items 6A-6C on
the child’s birth certificate. However, if the parents’ name is not listed in Items
6A-6C, the VS 22 form cannot be used to change the child’s surname to that of
the parent - unless the parent’s name is also being added to the birth certificate.

Sealing Notice Upon preparation of the new certificate, a sealing notice and certification will be
and prepared and forwarded to the appropriate county recorder and/or local registrar
Certification where the birth certificate is on file. The old certificate must be confidentially
disposed of and replaced with the newly created certificate.
All information regarding the original record must be omitted from files, logs,
indexes, and microfilm and computer records.
Any request for the information on the original birth record must be referred to
CDPH-VR.
A certified copy of the newly created record of birth shall be furnished to the
registrant without additional cost. However, the registrant must supply a sworn
statement that they are authorized to receive a certified copy. If the request for the
amendment is mailed, the sworn statement must be notarized.
REFERENCE: Health and Safety Code Sections 102755 through 102765,
and 103526

January 1, 2016 813

 AMENDMENTS

Declaration of Paternity

Overview Under California law, POP forms must be made available without charge at
all district attorney offices, offices of local registrars of birth and death,
courts, and county welfare departments. Staff in these offices should witness
the signatures and are responsible for forwarding the original signed
declarations to the California Department of Child Support Services.

REFERENCE: Family Code Section 7572

Universal form The POP form is considered a universal form and may be used with the
registration of births in other states. In addition, California may accept
paternity forms from other states as well.

Rejection of POP forms will be rejected for the following reasons:

POP forms
 The declaration form is not an original. (Photocopies are only acceptable
at CDPH-VR when accompanied with the VS 22 and required fee.)

 The biological parents did not sign the form.

 There is no date of birth listed for the child.

 The signatures on the form are not witnessed. The signature and address
of the witness must be included.

 The form was completed in pencil or any light colored ink (pink, orange,
etc.). Forms must be completed with dark ink and must be legible for
data entry and electronic scanning.

Continued on next page

January 1, 2016 814

 AMENDMENTS

Declaration of Paternity, Continued

Conflicting The POP form and VS 22 cannot be used to change parentage on the birth
parentage certificate. A VS 21 must be used to change or remove parentage
information information. See the Adjudication of Facts of Parentage sub-section for
additional information.

REFERENCE: Health and Safety Code Section 102750

Rescinding Parents may complete a Rescission form for the Declaration of Paternity form
and/or (CS 915) and mail it to the California Department of Child Support Services
canceling the (CDSS). However, this form only rescinds the POP form and will not
POP form change or rescind information on the child’s birth certificate. To remove
a parent's name on a birth certificate requires a court order. See the
Adjudication of Facts of Parentage subsection for additional information.

REFERENCE: Health and Safety Code Section 102725

Completed Original completed POP forms should be mailed to:

POP forms
California Department of Social Services – POP Unit
P.O. Box 419070
Rancho Cordova, CA 95741-9070

Copies Copies of the POP form may be obtained from the California Department of
Child Support Services at the above address.

Questions Questions regarding POP forms and/or information on ordering should be

referred to their toll free number at (866) 249-0773 or askpop@dcss.ca.gov.

Additional information may be obtained at the following website:

http://www.childsup.ca.gov/.

January 1, 2016 815

 AMENDMENTS
Adjudication of Facts of Parentage

Overview Whenever the existence or nonexistence of the parent and child relationship
has been determined by a court of this state or a court of another state, and
upon receipt of a certified copy of the court order and payment of the required
fee, the State Registrar shall establish a new birth certificate for the child if
the birth certificate is on file with the State Registrar.

REFERENCE: Health and Safety Code Section 102725

Determination Upon receipt of the VS 21, original certified copy of the court order and
of paternity appropriate fee; CDPH-VR will prepare a new certificate for the child listing
the parent’s name.

Determination The Adjudication of Facts of Parentage may also be used to determine non-
of non- paternity. The certified order from the court must very clearly state that the
paternity parent listed on the child’s birth certificate has been found not to be the parent
of the child and all information should be removed from the certificate.

The certified order from the court must also state how the new certificate
should be prepared, including any change to the child’s surname. If the court
order does not specifically address the child’s surname, CDPH-VR cannot
make changes to the surname without a VS 23.

Sealing Notice Upon preparation of the new certificate, a sealing notice and certification will
and be prepared and forwarded to the appropriate county recorder and/or local
Certification registrar where the birth certificate is on file. The old certificate must be
removed and replaced with the newly created certificate.

All information regarding the original record must be omitted from files, logs,
indexes, and microfilm and computer records.

Any request for the information on the original birth record must be referred
to CDPH-VR.

A certified copy of the newly created record of birth shall be furnished to the
registrant without additional cost. Because the request is based on a court
order, a sworn statement is not required for issuance of the certified copy.

REFERENCE: Health and Safety Code Sections 102730, 102735, and

103526

January 1, 2016 816

 AMENDMENTS

Correcting Gender Errors on Birth Certificates

Overview Upon finding that a birthing hospital or local registrar made an error in the
reporting of the gender when the original birth certificate was completed, the
person or parent and/or legal guardian may apply to the State Registrar for the
establishment and issuance of a new birth certificate.

REFERENCE: Health and Safety Code Section 103446

What is a A gender error is a true error made in the reporting of the gender on the
gender error? original certificate. The definition of gender error does not apply to an
individual that has undergone clinically appropriate treatment to alter their
sexual characteristics.

Process Upon receipt of the VS 24, notarized sworn statement, with the correct
signatures and payment of the required fee, CDPH-VR will review the
documents and, if acceptable, will seal the original birth certificate and issue a
new one in its place.

The new birth certificate shall in no way indicate that it is not the individual’s
original birth certificate and shall be the only birth certificate for that
individual open for public inspection.

The State Registrar shall inform the local registrar and county recorder where
the original certificate was filed to seal and/or destroy all information
regarding the original birth certificate.

A certified copy of the newly created record of birth shall be furnished to the
registrant without additional cost. However, the registrant must supply a
sworn statement that they are authorized to receive a certified copy. If the
request for the amendment is mailed, the sworn statement must be notarized.

REFERENCE: Health and Safety Code Sections 103447.5 through 103449,

and 103526

What if the The State Registrar will follow the above “seal and replace” procedures for
birth certificate anyone submitting a request to make the birth certificate one page with the fee
is currently and notarized sworn statement.
two-pages?

Continued on next page

January 1, 2016 817

 AMENDMENTS

Correcting Gender Errors on Birth Certificates, Continued

Necessary The affidavit must satisfy one of the following three conditions:
signature(s)
 Signature of the administrator of the birthing hospital (or the
administrator’s representative), who must indicate on the affidavit that
the gender error was due to a hospital error.

 Signature of the local registrar, who must indicate on the affidavit that
the gender error was due to an administrative error of the local registrar.

 Signature of the physician who attended the birth and signature of the
individual’s parent (or a relative who was at least five years old at the
time of the individual’s birth), who must indicate on the affidavit that the
listed individual’s gender at the time of birth was different from the
gender indicated on the original certificate.

REFERENCE: Health and Safety Code Section 103447

January 1, 2016 818

 AMENDMENTS

Court Order Change of Name

Overview Whenever a person born in this state has his or her name changed by order of
a court of this state, another state, the District of Columbia, or any territory of
the United States, an application including an affidavit of this fact may be
filed with CDPH-VR.
REFERENCE: Health and Safety Code Section 103400

When a court A court order change of name must be obtained for the following:
order is
required  Completely changing first or middle names of the registrant.

 Transposing first and middle names of registrant.

 Adding to or deleting first or middle names of the registrant.

 Changing the surname of the registrant. (If the surname change is to that
of the parents’, a Court Order Change of Name is not required. The
change to the parent’s surname may occur with an Acknowledge of
Paternity signed by both parents. See the Acknowledgement of Paternity
sub-section for additional information.)

Procedure Upon receipt of the VS 23, affidavit, certified copy of the court order and
payment of the required fee, CDPH-VR shall review the amendment for
acceptance, and if accepted will process the request. If accepted, the
amendment shall be filed with and become a part of the record to which it
pertains.

A certified copy of the newly amended record of birth shall be furnished to

the registrant without additional cost. Because the request is based on a court
order, a sworn statement is not required for issuance of the certified copy.
REFERENCE: Health and Safety Code Sections 103405, 103410, and
103526

Continued on next page

January 1, 2016 819

 AMENDMENTS

Court Order Change of Name, Continued

Naturalized Naturalized citizens may add an AKA amendment to their child’s birth
citizens certificate to reflect their new naturalized name. However, to change the
child’s surname to that of the naturalized name, the parents will be required to
obtain a Court Ordered Change of Name.

Safe at Home - Persons wishing to obtain a name change due to domestic violence must work
Name change with the Secretary of State’s Office. Upon receipt of a court order stating the
for victims of applicant has a new confidential name and their birth certificate should be
domestic sealed and replaced with the new name, CDPH-VR will prepare a new birth
violence certificate with the new name.

The State Registrar shall inform the local registrar and county recorder where
the original certificate was filed to seal and/or destroy all information
regarding the original birth certificate.

January 1, 2016 820

 AMENDMENTS

Court Report of Adoption

Overview The clerk of the court shall complete a court report of adoption within five
days after a decree of adoption has been entered declaring a child legally
adopted by any court in the state. The court report of adoption and a copy of
the final decree must be forwarded to the State Registrar for preparation of a
new certificate.

REFERENCE: Health and Safety Code Section 102625

Process Upon receipt of the court report of adoption and copy of the final decree from
the clerk of the court, the new birth certificate shall be prepared. The birth
certificate shall be identical to a regular birth certificate and contain the name
of the child, name and ages of the parents, etc.

If the adopting parents request, the new birth certificate will not include the
specific name and address of the hospital or other facility where the birth
occurred.

The new birth certificate shall supplant any birth certificate previously
registered for the child and shall be the only birth certificate open to public
inspection.

The State Registrar shall inform the local registrar and county recorder where
the original certificate is on file to seal and/or destroy all information
regarding the original birth certificate.

A certified copy of the newly created record of birth shall be furnished to the
registrant without additional cost. Because the request is based on a court
order, a sworn statement is not required for issuance of the certified copy.

REFERENCE: Health and Safety Code Sections 102645, 102680, 102685,

102710, and 103526

Special request The adopting parent or parents may request that the State Registrar not
prepare a new birth certificate.

REFERENCE: Health and Safety Code Section 102640

Continued on next page

January 1, 2016 821

 AMENDMENTS

Court Report of Adoption, Continued

Out-of-state Upon receipt of the court report of adoption and copy of final decree from any
adoptions court of record that has jurisdiction of the child of this state, another state, the
District of Columbia, in any territory of the United States, or in any foreign
country, for any child born in California and whose certificate of birth is on
file in the office of the State Registrar, a new birth certificate shall be
established.

The processing fee must accompany the out-of-state court report of adoption.
Failure to do so will result in a delay in processing.

Court reports of adoption received by the State Registrar for children born in
other states will be forwarded to the appropriate out-of-state registrar.

It is preferred that attorneys handling out-of-state adoptions also prepare a

VS-44 California form, as other state forms may not contain all the
information required for a California birth certificate. However, attorneys
may also provide the missing information in a cover letter to CDPH-VR.

REFERENCE: Health and Safety Code Sections 102630 through 102635

Adoption of The State Registrar shall prepare a court order delayed registration of birth for
children born children born outside of the United States, the territories of the United States,
outside of the or Canada. The court report should contain a statement of the date and place
United States of birth of the child.
or where no
original record
The State Registrar shall prepare a court order delayed registration of birth for
exists
a child born in California where no original birth record exists. The court
report should contain a statement of the date and place of birth of the child.

REFERENCE: Health and Safety Code Sections 102690 through 102695

Continued on next page

January 1, 2016 822

 AMENDMENTS

Court Report of Adoption, Continued

Access to Access to original birth information may be granted by a superior court upon
original sealed the setting forth of facts showing the necessity and good and compelling
information cause.

Upon receipt of a court order granting release of the original birth records and
receipt of the certified copy fee, the State Registrar will prepare a certified
copy of the original record and forward it to the court or to the petitioner, as
specified in the order.

REFERNCE: Health and Safety Code Section 102705

Set aside and The court may set aside the replacement record and restore the original birth
restore record. Upon receipt of the court order and fee, the State Registrar will
adoptions restore the original birth certificate.

January 1, 2016 823

 AMENDMENTS

Physician/Coroner Amendment

Overview The VS 24A may be used to amend information on the birth certificate;
however, this form is generally used for amending information on death and
fetal death certificates. This form requires the signature of the physician or
coroner.

REFERENCE: Health and Safety Code Section 103300

Process Upon receipt and acceptance by the State Registrar, the VS 24A becomes part
of the original record to which it pertains. If the amendment is for items
contained in the confidential portion of the birth certificate, the amendment is
also considered confidential.

If the fee is paid and the applicant is entitled to receive a certified copy of the
newly amended record, the applicant must supply a sworn statement stating
they are authorized to receive the certified copy. If the request for the
amendment is mailed, the sworn statement must also be notarized. If the
applicant is not an authorized individual he or she will receive an
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH
IDENTITY” certified copy.

REFERENCE: Health and Safety Code Sections 103255 and 103526

January 1, 2016 824

 AMENDMENTS

Obtaining a New Birth Certificate after Gender

Reassignment

Overview Whenever a person born in this state has undergone clinically appropriate
treatment for the purpose of gender transition, a new birth certificate shall be
prepared reflecting a change of sex without a court order. A new birth
certificate shall be prepared with a physician’s affidavit documenting the
gender reassignment and any change in name, if accompanied by an order of a
court of this state, another state, the District of Columbia, or any territory of
the United States for a change of name.

REFERENCE: Health and Safety Code Section 103425

Process The petition and application for a new birth certificate must be accompanied
by an affidavit of the physician documenting the sex change, a certified copy
of the court order granting the change and changing the applicant’s name (if
applicable), and the appropriate processing fee.

These documents must be forwarded to the State Registrar within 30 days of

the date of the decree.

Upon receipt and acceptance by the State Registrar a new birth certificate will
be established reflecting the new gender and any name change as appropriate.

A certified copy of the newly created record of birth shall be furnished to the
registrant without additional cost. Because the request is based on a court
order, a sworn statement is not required for issuance of the certified copy.
However, if the amendment is only amending the person’s sex, a notarized
sworn statement is required for issuance of the certified copy.

REFERENCE: Health and Safety Code Sections 103430, 103445 and

103526

Change of The petitioner may petition the court at the same time for a court order change
Name of name. The newly created birth certificate will then reflect the new sex and
any change of name.

REFERENCE: Health and Safety Code Section 103425

Continued on next page

January 1, 2016 825

 AMENDMENTS

Obtaining a New Birth Certificate after Gender

Reassignment, Continued

Sealing Notice Upon preparation of the new certificate, a sealing notice and certification will
and be prepared and forwarded to the appropriate county recorder and/or local
Certification registrar where the birth certificate is on file. The old certificate must be
removed and replaced with the newly created certificate.

All information regarding the original record must be omitted from files, logs,
indexes, and microfilm and computer records.

Any request for the information on the original birth record must be referred
to CDPH-VR.

REFERENCE: Health and Safety Code Section 103440

January 1, 2016 826

 AMENDMENTS

Sealing Notice and Certification

Overview CDPH-VR issues sealing notices on birth, death, fetal death, and marriage
certificates when appropriate. These notices may be issued for adoptions,
paternity actions, medical sex change operations, errors in reported gender,
etc.

CDPH-VR may also issue an administrative sealing notice for documented

fraudulent or erroneous filings, and/or duplicate records.

Information Upon preparation of the new certificate as required by state law, a sealing
regarding notice and certification will be prepared and forwarded to the appropriate
original record county recorder and/or local registrar where the birth certificate is on file.
The old certificate must be removed and replaced with the newly created
certificate.

All information regarding the original record must be omitted from files, logs,
indices, and microfilm and computer records.

Any request for the information on the original birth record must be referred
to CDPH-VR.

REFERENCE: Health and Safety Code Sections 102705, 102730, 102760,

102768, 103260, 103355, 103440, and 103448

January 1, 2016 827

 AMENDMENTS

Supplemental Name Report – Birth

Overview When a certificate of birth is registered without the name of the child being
entered on it, the local registrar shall deliver to the parents of the child a
Supplemental Name Report for the naming of the child.

REFERENCE: Health and Safety Code Section 103325

Procedure The local registrar should mail a Supplemental Name Report to the parents
whenever the first, middle, and/or last name of the child has not been entered
on the birth certificate.

If the Supplemental Name Report is filed one year or more after the date of
birth, a fee is required for the acceptance and filing. The fee includes one
certified copy. However, the parent(s) must include a signed sworn statement
stating they are authorized to receive a certified copy. If the request is
mailed, the sworn statement must also be notarized.

REFERENCE: Health and Safety Code Sections 103335 through 103340,

and 103526

Signatures The Supplemental Name Report amendment form requires the signature of at
least one parent. If one of the parents is not available for signature, the name
of the child must be added with the VS 24 form. The VS 24 may be signed
by any two persons with knowledge of the facts.

REFERENCE: Health and Safety Code Section 103330

January 1, 2016 828

CERTIFIED COPIES
 CERTIFIED COPIES

Certified Copies

Overview Certified copies of birth and death records shall only be made by the State
Registrar and by duly appointed and acting local registrars during their term
of office, and by county recorders. Providers such as hospitals and mortuaries
shall not release copies of birth or death certificates other than those already
certified by the local registrar.

REFERENCE: Health and Safety Code Section 103545

In this section Information contained in this section includes:

Subsection Title See Page

General Information 902

Authorized Certified Copies 905

Informational Certified Copies 908

Sensitized Security Paper Specifications 909

Procedures for Storing Security Paper 910

Exemplified/Apostille Seals 912

Where to Write for Vital Records 914

January 1, 2016 901

 CERTIFIED COPIES

General Information

Certified copies Any person may obtain a certified copy when information sufficient to
identify the record is provided to the custodian of the records and upon
payment of the required fee.
The applicant for a certified copy is required to sign a sworn statement that
they are authorized to receive the certified copy. If the applicant does not
meet the requirements of the law to receive an “authorized” certified copy,
they may receive a certified copy marked “INFORMATIONAL, NOT A
VALID DOCUMENT TO ESTABLISH IDENTITY.”
REFERENCE: California Code of Regulations 902, Health and Safety Code
Sections 103525 and 103526 (c)

Certification on Certified copies of vital records must contain the local registrar’s signature as
copy follows:
If the signature is… Then…
printed, stamped, or photographically the seal of the certifier’s office must
reproduced be superimposed over the facsimile
signature, unless presealed security
paper is being used.
Government Code Section 27210
Handwritten no impression seal is necessary.
Attorney General Opinion 48/224.
affixed to a certification statement by he or she must sign or initial his or
a deputy clerk her name next to the official’s
signature.
Attorney General Opinion NS4103.

Confidential The bottom portion of certificates of birth entitled “Confidential Information

section of birth for Public Health Use Only,” shall only be produced on certified copies when
certificate specifically requested by the registrant, parent who signed the certificate, or
birth parent. Certified copies that include the confidential portion may only
be obtained from the local county health office or CDPH-VR.
REFERENCE: Health & Safety Code Section 102430 and 103525

January 1, 2016 902

 CERTIFIED COPIES
General Information, Continued

Fetal death The fetal death certificate was revised January 1, 2007, to include a confidential
certificates portion. Now that the confidential information on the fetal death certificates is
protected by law, ACL 81-5 and ACL 86-4 are rescinded. With their rescission,
Local Registrars of Births and Deaths are authorized to keep copies of the entire
fetal death certificate and County Recorders are authorized to keep copies of the
public portion, beginning January 1, 2008.

County Recorders and Local Registrars of Births and Deaths are also authorized
to copy, microfilm, index, and otherwise preserve fetal death certificates.

Certified copies of fetal death certificates are not restricted and may be issued to
anyone requesting a copy, upon payment of the required fee. Any request for a
certified copy of a fetal death certificate that is not on file in the office of the local
registrar or county recorder should be directed to CDPH-VR for processing. The
confidential portion of the fetal death certificate may only be issued to those
persons identified in H&S Code Section 102430.

There are no current provisions in law that exempt the fetal death indices from
being released. Therefore, anyone can request to see a fetal death index.

REFERENCE: ACL 07-23 dated December 5, 2007

Certified copy A fee is required for making a certified copy of a vital record for any public
fees entity, e.g., the State, the Regents of the University of California, a county, city,
district, public authority, public agency, and any other political subdivision or
public corporation in the State.

REFERENCE: Health and Safety Code Section 103650

See Fee section for additional information.

January 1, 2016 903

 CERTIFIED COPIES

General Information, Continued

Free certified A custodian of records may issue free certified copies, under three circumstances,
copies as provided by statute.

Certified copies of any vital records may be issued without charge, as follows:

1. Child or spousal support enforcement

2. To determine benefits afforded by the Veteran’s Administration

Certified copies that are provided free in these two situations should be stamped
“For Official Government Use Only.”

Certified copies of birth records only, may be issued without charge, as follows:

3. To eligible homeless persons

The third circumstance allows only the issuance of birth records for no charge, to
homeless persons meeting certain criteria. Only county offices may issue birth
records to eligible homeless applicants. Counties should not use the “For
Government Use Only” stamp for birth certificates issued under this statute.

The California Victim Compensation and Government Claims Board, or victim

centers, are entitled to receive verifications only, at no cost. Statute does not
entitle them to free certified copies of vital records.

REFERENCE: Government Code Section 6103.9, 6107; Health and Safety Code
Section 103577; ACL 13-14, 15-05, and 15-10.

See Fees section for additional information.

January 1, 2016 904

 CERTIFIED COPIES

Authorized Certified Copies

Overview California Health and Safety Code Section 103526, permits only authorized
persons as defined below to receive certified copies of birth and death records.
To receive a certified copy, the applicant must sign a sworn statement that he
or she is authorized to receive the certified copy.

Those who are not authorized by law to receive an authorized certified copy
will receive a certified copy with the legend “INFORMATIONAL, NOT A
VALID DOCUMENT TO ESTABLISH IDENTITY.”

Authorized The following persons are authorized by law to receive a certified copy of a
persons that birth or death record:
may receive
certified copies  The registrant or a parent or legal guardian of the registrant.

 A party entitled to receive the record as a result of a court order, or an

attorney or a licensed adoption agency seeking the birth record in order to
comply with the requirements of Section 3140 or 7603 of the Family
Code.

 A member of a law enforcement agency or a representative of another

governmental agency, as provided by law, who is conducting official
business.

 A child, grandparent, grandchild, sibling, spouse, or domestic partner of

the registrant.

 An attorney representing the registrant or the registrant’s estate, or any

person or agency empowered by statute or appointed by a court to act on
behalf of the registrant or the registrant’s estate.

 Any agent or employee of a funeral establishment who acts within the

course and scope of his or her employment and who orders certified
copies of a death certificate on behalf of any authorized individual
specified above or in Health and Safety Code Section 7100.

REFERENCE: Health and Safety Code Section 103526 (c)

Continued on next page

January 1, 2016 905

 CERTIFIED COPIES

Authorized Certified Copies, Continued

Funeral Any agent or employee of a funeral establishment ordering death certificates

directors on behalf of an authorized individual is not required to provide a notarized
sworn statement. They are, however, required to provide sworn statements on
the application form.
Any person who asks a funeral director to request a death certificate on his or
her behalf warrants the truthfulness of his or her relationship to the decedent
and is personally liable for all damages occasioned by, or resulting from, a
breach of that warrant.
REFERENCE: Health & Safety Code Section 103526 (d)

Attorney CDPH-VR has defined “attorney” to mean any attorney acting on behalf of
the registrant or family

Power of CDPH-VR will accept power of attorneys provided that the power of attorney
attorney is valid and does not limit the authority to express actions or subjects. The
applicant will be required to sign the sworn statement, show identification (if
requested in person), and provide a copy of the power of attorney.
However, counties should follow procedures that have been developed for
each individual county office.

Authorized If the request for a certified copy of a birth or death certificate is received by
requests mail, a notarized statement sworn under penalty of perjury must accompany
received by the request stating the requestor is an authorized person as defined by law.
mail However, any agent or employee of a funeral establishment or member of law
enforcement or a representative of a state or local government agency, is not
required to notarize the sworn statement if the request for a certified copy is
mailed.
A faxed or digitized image copy of a notarized statement sworn under penalty
of perjury is acceptable if it is legible. If the notary’s seal is not
photographically reproducible, it must show the name of the notary, the
county of the notary’s principal place of business, the notary’s telephone
number and expiration date, and must be typed or printed in a manner that is
photographically reproducible below, or immediately adjacent to, the notary’s
signature in the acknowledgement.
REFERENCE: Health & Safety Code Section 103526(a) and ACL 14-01

Continued on next page

January 1, 2016 906

 CERTIFIED COPIES

Authorized Certified Copies, Continued

Verification of The law does not require verification of notary endorsements; however,
notary persons may visit the Secretary of State (SOS) website at www.sos.ca.gov or
endorsement in call SOS at (916) 653-3595 for verification of a California notary
California commission.

Verification of For verification of notary commissions outside of California, please visit the
notary National Association of SOS website at www.nass.org.
endorsement
outside of For foreign notary questions, it is recommended that the consulate’s office be
California contacted.

NOTE: Although notary commissions fall under the jurisdiction of the SOS
Office in California, they may fall under other jurisdictions outside of
California.

January 1, 2016 907

 CERTIFIED COPIES

Informational Certified Copies

Overview If an applicant does not meet the requirements set forth in law as an
authorized person to receive a certified copy of a birth or death certificate,
they may receive a certified copy of the certificate with the legend
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH
IDENTITY.”

Informational Informational certified copies must be issued on security paper. CDPH-VR

copy format uses a legend that is pre-stamped diagonally across the face of the banknote
security paper with red open letters. However, there are no specific
requirements on how the legend must appear or be displayed on the security
paper.

January 1, 2016 908

 CERTIFIED COPIES

Sensitized Security Paper Specifications

Overview All certified copies of birth and death records shall include the date issued, the
name of the issuing office, the signature of the issuing officer, and the seal of
the issuing office.

REFERENCE: Health & Safety Code Section 103526.5

Security paper All certified copies of birth and death records shall be printed on chemically
specifications sensitized security paper that measures 8 ½ by 11 inches and that has the
following features:

(A) Intaglio print

(B) Latent image
(C) Consecutive numbering with matching bar code *
(D) Microprint line
(E) Prismatic printing
(F) Watermark
(G) Void pantograph
(H) Fluorescent security threads
(I) Fluorescent fibers
(J) Any other security features deemed necessary by the State Registrar

Any other Although the law allows the State Registrar to add additional security features
security to the banknote paper as deemed necessary, no other features will be added at
features this time.
deemed
necessary Effective November 1, 2013, CDPH-VR discontinued embossing certified
copies of birth, death, fetal death and marriage records.

REFERENCE: ACL 13-23

* CDPH-VR learned it is impractical to print a fluorescent number with a

standard readable bar code. CDPH-VR therefore has omitted the fluorescent
requirement mentioned in law, and is seeking a legislative correction.

January 1, 2016 909

 CERTIFIED COPIES

Procedures for Storing Security Paper

Overview The State Registrar, local registrars, county recorders, and county clerks shall
take precautions to ensure that uniform and consistent standards are used
statewide to safeguard the security paper.

For clarification purposes, CDPH-VR is making a distinction between

“stored” and “in use” security paper. Security paper that is “in use” is not
considered “stored.”

“Stored” paper The following measures shall be adhered to for “stored” paper:
security
procedures  Upon receipt of the paper from the manufacturer, the serial numbers and
quantity of paper should be inventoried and cataloged in a log.

 The security paper must be stored in a locked depository and may not be
accessible to unauthorized staff or visitors.

 When an authorized person removes paper from the locked depository,

their entry and exit must be recorded on the log along with the serial
numbers of the security paper that is being removed.

 All spoilage shall be accounted for and subsequently destroyed by

shredding on the premises. For counties with several offices, this may be
the main building. The intent is that the paper may not be sent to an
outside vendor for shredding. Shredding may be contracted if it is done
on the premises.

 Counties may use additional security measures as necessary.

REFERENCE: Health & Safety Code Section 103526.5 (c) and ACL 03-07

January 1, 2016 910

 CERTIFIED COPIES

Procedures for Storing Security Paper, Continued

“In use” paper The following measures shall be adhered to for paper that is considered “in
security use:”
procedures
 Each employee must account for all paper used during the day on a usage
sheet.

 Security paper that is “in use” should be supervised at all times.

 Staff should not leave security paper unattended and/or unsupervised.

 Paper that is being used in printing or other certificate reproduction

devices is not considered to be “stored” while in use. However, paper left
in devices overnight or left unsupervised by vital records employees when
others are present is considered to be “stored.”

 If any error occurs when printing, the paper must be marked “void” and
the serial number shall be noted in the log. All voided copies must be
shredded on a regular basis. Shredding must be done on site. Each
county should develop their own shredding procedures based on their
volume of spoilage. All spoilage must be kept secure until shredded.

Visitors A visitor may be defined as any person visiting the office in a brief capacity
for business, social or friendship reasons. Visitors may also be employees of
the organization that do not normally work in the secured area.

For example, visitors to CDPH-VR must sign a register and wear a temporary
“Visitor” badge. Visitors are escorted and under the supervision of a CDPH-
VR employee at all times. These types of visitors should not have access to
the “stored” paper location.

January 1, 2016 911

 CERTIFIED COPIES

Exemplified/Apostille Seals

Introduction An “exemplified” or “apostille” seal may be applied to a certified copy of a

California vital event record when required by a foreign country. This seal
may be applied by the SOS or County Clerk’s office.

Background Nations generally recognize a need to accept various government issued

documents (such as birth, death, and marriage certificates) issued by other
nations. Most nations have an interest in ensuring that the documents are
genuine, and look to a validating agency to authenticate the signature on the
document. In California, the SOS or County Clerk’s office performs the
authenticating function.

In 1961, many nations joined together in the Hague Convention to create a

simplified method of validating documents issued by nation-members of the
Convention. Members of the Convention adopted an Apostille, which is the
standardized form the member nations accept as verifying the authenticity of
the document referred to in the Apostille.

Required The SOS office authenticates the signature of county clerks, county recorders,
validation superior court judges, superior court executive officers, superior court clerks,
court administrators, and the deputies for all of these officials.

The SOS does not authenticate the signatures of other county officials such as
health officers and registrars.

When authentication of a health officer’s or registrar’s signature is needed,

the county clerk will authenticate the signature of the official and forward the
document to the SOS for authentication of the county clerk’s signature.

Continued on next page

January 1, 2016 912

 CERTIFIED COPIES

Exemplified/Apostille Seals, Continued

How to request After an applicant has obtained a certified copy of a vital record, the applicant
an exemplified must contact the SOS to request an apostille. Additional information may be
copy or found at the following website: www.sos.ca.gov.
apostille
Mailing Address:
Secretary of State
Notary Public Section
P.O. Box 942877
Sacramento, CA 94277-0001

Office Location:
Secretary of State
1500 11th Street, 2nd Floor
Sacramento, CA 95814

Telephone Number: (916) 653-3595

January 1, 2016 913

 CERTIFIED COPIES

Where to Write for Vital Records

Where to write Information on where to write for copies of birth and death records is
for copies of provided in this section.
birth and death
records

California In California, CDPH-VR is the central depository for all original birth and
records death records registered by the 61 local registration district offices since
July 1, 1905.

The request for a certified copy, notarized sworn statement, and fee should be
mailed to:

California Department of Public Health

Vital Records – M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410

Local office Copies of all original records on file with CDPH-VR are also on file with
copies each county recorder’s office where the event occurred. If the record is not
available at the county level, the county should contact CDPH-VR for a local
office copy (LOC). Please fax a LOC form to (916) 552-8170. For requests
that require a status check, please contact the Document Retrieval Unit at
(916) 552-8168 or CDPH_DRUMail@cdph.ca.gov.
REFERENCE ACL 13-13

Local registrars for births and deaths (the health officer in an approved full-
time local health department) have copies of all certificates registered in their
jurisdiction for the current year and one-year prior.

Other states The vital statistics office of the state or territory where the event occurred
should be contacted to obtain a certified copy of those events.

The internet offers several sites and information for obtaining vital records
from other states and countries.

Continued on next page

January 1, 2016 914

 CERTIFIED COPIES

Where to Write for Vital Records, Continued

Births or For births of children to United States citizens in a foreign country which
deaths in a have been reported to the United States Consul, application for a certified
foreign country copy with the required fee should be sent to:
United States Department of State
1111 19th Street, Suite 510, N.W.
Washington, D.C. 20522
Telephone number: (202) 955-0307

Additional information may be obtained at the following website:

http://www.state.gov/.

Adoptions in a For information on adoptions of children in a foreign country, please contact

foreign country the U.S. Citizenship and Immigration Service (USCIS).
Telephone number: (800) 375-5283
Additional information may be obtained at the following website:
http://adoption.state.gov/.

Continued on next page

January 1, 2016 915

 CERTIFIED COPIES

Where to Write for Vital Records, Continued

Military deaths For certified copies of death certificates for military personnel, please contact
overseas the Department of Defense at the following website: www.defenselink.mil/.

Overseas For overseas deaths of members of the U.S. Coast Guard, please contact the
deaths of Coast Coast Guard at the following telephone number 202-267-2229 or website
Guard http://www.uscg.mil/.

Canada’s vital In Canada, the vital statistics office of the province or territory where the
records event occurred maintains records for each event.

Certified copies of these records may be obtained by writing to the Director of

Vital Statistics at the capitol of the province where the event occurred.

Mexico’s vital In Mexico, the nearest office of the Mexican Consul should be contacted for
records assistance in obtaining certified copies of vital records for events that
occurred in that country.

NOTE:
Additional information may be located at the following website:
www.travel.state.gov.

January 1, 2016 916

ACCESS
 ACCESS

Access to Vital Records

Overview Although most California vital event records are considered public records,
access to the bottom portion of the VS 10D, the Certificate of Fetal Death (VS
12), and access to birth and death indices are limited by statute. This section
identifies different types of confidential vital record information and those
persons authorized by statute to access the information.

REFERENCE: California Code of Regulations Section 902, Government

Code Section 6253, and Health and Safety Code Sections
102430

In this section Information contained in this section includes:

Subsection Title See Page

Confidential Vital Record Information 1002

Access to Confidential Information 1004

Access to Birth and Death Indices 1005

Vital Record Data Security 1006

January 1, 2016 1001

 ACCESS

Confidential Vital Record Information

Introduction The medical section on the birth certificate and fetal death certificate is
confidential information. Access to the confidential information on these
certificates is limited to persons specified by statute.

REFERENCE: Health and Safety Code Section 102430, California Penal

Code Section 529 (a), Business and Professions Code
Section 22430

Types of Confidential vital record data not available to the public is identified in the
confidential table below:
information

Type of confidential information Description

Medical data section of birth records Applies to birth records registered
after January 1, 1949

Fetal death/stillborn records Applies to records registered after

January 1, 1949

State birth and death index books State index books on loan to county
recorders for the official use of
recorders’ staff only

Reallocated records from other Copies of birth and death records

jurisdictions from other county or state agencies

Sealed records Applies to records that were sealed

after January 1, 1905 including:
 Adoption
 Paternity action
 Gender reassignment
 Gender error
 Documented fraud or erroneous
filing

Continued on next page

January 1, 2016 1002

 ACCESS

Confidential Vital Record Information, Continued

Confidential The medical and health section of birth and fetal death records is confidential.
information on Access to confidential information on these certificates is limited to only
vital records those persons specified by statute.

REFERENCE: Health and Safety Code Section 102430, Business and

Professions Code Section 22430

Reallocated Birth and death records received from other county or state agencies are
records from considered confidential, as other state laws may prohibit and/or limit access to
other certain vital event information. Copies of reallocated records are sent to the
jurisdictions county of residence for statistical purposes only. Upon extraction of the data,
copies of the records must be destroyed and may not be shared with outside
entities.

In-state death The death reallocation list of persons over the age of 18 years sent to the
reallocations registrar of voters, county welfare office, and the SSA may not contain out-of-
state reallocations.

Sealed records Vital records sealed by the State Registrar due to adoption, paternity action,
gender reassignment, gender error, derogatory names, racial slurs,
documented fraud, etc., are not available to the public. Access may only be
obtained via court order.

Upon receipt of a sealing notice by the State Registrar, all information

regarding the record must be obliterated, including information from
computers, microfilm, and indices. When a copy cannot be removed from a
local book, the sealing notice should be glued firmly over the face of the
record.

REFERENCE: Health and Safety Code Sections 102680, 102730, 102760,

102768, 103260, 103355

January 1, 2016 1003

 ACCESS
Access to Confidential Information

Persons California law restricts access to confidential information on birth certificates

authorized to to the following:
access
confidential  state and local registrar staff
information
 the county coroner

 persons with a valid scientific interest as determined by the State Registrar

 researchers who have approval from the Committee for the Protection of
Human Subjects and the Vital Statistics Advisory Committee (VSAC)

 the parent who signed the certificate or, if no parent signed the certificate,
the mother

 the person named on the certificate

REFERENCE: Health and Safety Code Section 102430

Reporting When access is granted to the confidential medical data information on any
access to birth certificate, such access must be logged on a record of access. The
confidential record of access must be open to public inspection. The record of access
information must include:

 name of person authorizing access

 name, title, and organizational affiliation of person given access

 specific purpose for which the information is to be used

 dates of access

REFERENCE: Health and Safety Code Section 102430 (b)

January 1, 2016 1004

 ACCESS
Access to Birth and Death Indices
Overview The State Registrar is required to prepare and maintain separate non-
comprehensive indices for all California birth and death records for public
release, as well as indices for purposes of law enforcement and/or preventing
fraud.

Requesters must complete a form and sign under penalty of perjury. Any
person that violates the provisions outlined is guilty of a misdemeanor and
should be denied further access.

REFERENCE: Health and Safety Code Section 102230

Non- Non-comprehensive birth record indices for public release shall be comprised
comprehensive of first, middle, and last name, sex, date of birth, and place of birth.
birth record
indices for REFERENCE: Health and Safety Code Section 102230 (b)(2)
public release

Non- Non-comprehensive death record indices for public release shall be comprised
comprehensive of first, middle, and last name, sex, date of birth, place of birth, place of
death record death, date of death, and father’s last name.
indices for
public release REFERENCE: Health and Safety Code Section 102230 (b)(3)

Non- Non-comprehensive birth record indices for the purpose of preventing fraud
comprehensive shall be comprised of first, middle, and last name, sex, date of birth, place of
birth record birth, and mother’s maiden name.
indices for law
enforcement
and/or
preventing
fraud REFERENCE: Health and Safety Code Section 102230 (c)(2)

Non- Non-comprehensive death record indices for the purpose of preventing fraud
comprehensive shall be comprised of first, middle, and last name, place of death, mother’s
death record maiden name, sex, social security number, date of birth, place of birth, date of
indices for law death, and father’s last name.
enforcement
and/or
preventing
fraud REFERENCE: Health and Safety Code Section 102230 (c)(3)

Comprehensive For more information regarding comprehensive indices please contact the
indices Public Health Policy and Research Branch at (916) 552-8095 or
HIRS@cdph.ca.gov.

January 1, 2016 1005

 ACCESS

Vital Record Data Security

Unauthorized Any person who releases a copy of the confidential portion of the certificate
release of of live birth, except as provided by state law, is guilty of a misdemeanor.
confidential
data The criminal penalty for unauthorized release is a fine of five hundred dollars
($500) or six months in jail. The criminal penalty shall not preclude suit for
civil or punitive damages by any individuals harmed by the unauthorized
release.

REFERENCE: Health and Safety Code Section 102475, California Penal

Code Section 529 (a), Business and Professions Code
Section 22430

Security To protect the integrity of vital records, the custodian of records should:
requirements
for vital record  prohibit public access where certificates are processed or stored
data
 control access to areas where certificates are being processed

 ensure that vital records are not left unattended during breaks and lunch
periods

 provide locked file cabinets or locked file rooms for certificates containing
confidential information

Access to Access to databases must be equally protected from unauthorized users.

automated
databases County personnel should maintain current logs of those persons accessing
databases and the level of access. These logs should be periodically reviewed
to avoid any breach in security and unauthorized use.

Continued on next page

January 1, 2016 1006

 ACCESS
Vital Record Data Security, Continued

Database Written authorization must be on file for state and local staff to access vital
security record databases as follows:

 justification for access to the vital record database

 confidentiality statement signed by the individual

 a statement that no one may be authorized to print or create documents

Monitoring Access to the automated database must be programmed to:

database access
 identify the user

 record access attempts

 identify the number of records accessed, and

 record the duration of access time

Unauthorized Access not determined to be required and consistent with job duties must be
access to terminated.
database

January 1, 2016 1007

VERIFICATION OF
RECORDS
 VERIFICATION OF RECORDS

Verification and Inspection of Non-Confidential Records

Overview This section provides information on verification of records without a fee for
purposes of school and employment. This section also addresses free access
to non-confidential records for reporters.

REFERENCE ACL 13-14

In this section Information contained in this section includes:

Subsection Title See Page

Verification of Date and Place of Birth 1102

Verification for School and Employment 1103

Inspection of Non-Confidential Records for Reporters 1104

January 1, 2016 1101

 VERIFICATION OF RECORDS

Verification of Date and Place of Birth

Verification of The state or local registrar or county recorder may, without fee, verify a birth
date and place date and place of birth when the applicant can present sufficient information
of birth to identify the birth record.

REFERENCE: Health and Safety Code Section 103575

The following sample request may be used by local offices for this
verification.

VERIFICATION REQUEST

This is NOT a birth certificate

TO BE COMPLETED BY APPLICANT

Full Name of Child _________________________________________________________

First Middle Last

Birthplace of Child _________________________________________________________

Claimed Date of Birth ______________________________________________________

FOR OFFICIAL USE ONLY

This is to VERIFY that the above birthplace and birth date are correct as they appear on the
child's record of birth, which is on file in this office of which I am the legal custodian.

Date Verified____________________ Signature__________________________________

Registrar

January 1, 2016 1102

 VERIFICATION OF RECORDS

Verification for School and Employment

Verification for A certification, limited to a statement as to the date of birth of any child
school and needed for admission to school or for the purposes of securing employment
employment shall be issued without fee by the local registrar or county recorder upon
request of any parent or guardian.

REFERENCE: Health and Safety Code Section 103570

The following sample request may be used by local offices for this
verification.

VERIFICATION REQUEST

This is NOT a birth certificate

TO BE COMPLETED BY APPLICANT

Full Name of Child _________________________________________________________

First Middle Last

Claimed Date of Birth ______________________________________________________

FOR OFFICIAL USE ONLY

This is to VERIFY that the above birth date is the correct date as it appears on the child's
record of birth, which is on file in this office of which I am the legal custodian.

Date Verified____________________ Signature__________________________________

Registrar

January 1, 2016 1103

 VERIFICATION OF RECORDS

Inspection of Non-Confidential Records for Reporters

Inspection of Reporters are entitled to free inspection of non-confidential records. No fee

non- shall be charged any publisher, editor, or reporter employed by a newspaper
confidential of general circulation or news service to inspect, in the scope of his or her
certificates or position or employment, any certificate or indices. Although reporters are
indices for authorized by law to inspect indices free of charge, they must sign the proof
reporters
of identity form required by Health and Safety Code Section 102230 (b) (4).
This section applies to the inspection of non-confidential records only; if a
copy is required the statutory fee shall be charged.

REFERENCE: Health and Safety Code Sections 103655, 102230 (b)(4)

January 1, 2016 1104

FEES
 FEES

Fees

Overview The fee for any search of the files and records performed by the custodian of
the records is the same whether a certified copy is issued or not issued.
Failure to collect the fees prescribed is a violation of the law.

REFERENCE: Health and Safety Code Section 103650

In this section Information contained in this section includes:

Subsection Title See Page

Fees for Search 1202

Certificate of No Public Record 1203

Fees - When not payable 1204

January 1, 2016 1201

 FEES
Fees for Search

Search fee A fee must be collected before a search is made, whether or not the record is
collection found. The registered certificate is a legal document to be sold upon request
for the statutory fee. Each subsequent certificate is also to be charged the
statutory fee. If no record is found, a "Certificate of No Public Record" is
issued.

REFERENCE: Health and Safety Code Sections 103625, 103650

Failure to Portions of each fee are allocated to the State and to various trust funds.
collect fee Failure to collect the fees prescribed is a violation of the law.

REFERENCE: Government Code Section 6100

Fee for A fee is required for making a certified copy of a vital record for any public
government entity, e.g., the State, the Regents of the University of California, a county,
entity city, district, public authority, public agency, and any other political
subdivision or public corporation in the State.

REFERENCE: Health and Safety Code Section 103660

January 1, 2016 1202

 FEES
Certificate of No Public Record

Certificate of When no record is found, a "Certificate of No Public Record" is issued by the

No Public custodian.
Record
The following State form may be adapted for use by local offices:

Certificate of No Public Record

Name(s): John Doe
Type of Event: Birth
Dates From: July 1905 Through: Present

This is to certify that a search has been made of the California Department of Public Health
(CDPH) Vital Records Statewide Index covering the event shown above, and no public record of
this event was found based on the information provided in your application.

The requested record could not be found due to one or more of the following reasons:

□ A public record matching the information you provided was not found.

□ Critical search information needed to identify this record (e.g., parent’s birth last
name, county of event, exact date of event) was not provided.

□ If your request was for a Certificate of Fetal Death, a registered Certificate of

Fetal Death matching the information provided could not be located. The county
is not required to register a fetal death that occurs within the first 20 weeks of the
pregnancy.

□ If your request was for a Certificate of Still Birth, a registered Certificate of Fetal
Death matching the information provided could not be located. A Certificate of
Still Birth can only be prepared from information contained in a registered
Certificate of Fetal Death.
If you have new or additional information to assist us in locating this record, please
submit a new request including fee and sworn statement (if appropriate).
For more information, visit our website at www.cdph.ca.gov.

CDPH VITAL RECORDS

January 1, 2016 1203

 FEES
Fees - When not payable

Fees - When There are three circumstances when the custodian of records may issue a free
not payable certified copy. Each situation is authorized in statute.

REFERENCE: Government Code Sections 6103.9, 6107; Health and Safety

Code Section 103577; ACL 13-14, 15-05, and 15-10.

What to do The table below provides instructions for issuing a free certified copy of a
vital record.

If request is for a free Then provide a…

copy for …
Child or Spousal Support Certified copy without charge to the local child
Enforcement support agency and/or the district attorney of
any state for cases involving the establishment
Reference: Government or enforcement of a child or spousal support
Code Section 6103.9 obligation.

Veterans' Official Use Certified copy without charge for any form of
allotment, allowance or benefit relating to
armed forces of the United States. The free
copy is to be provided to the Veterans Services
Reference: Government Office for processing.
Code Section 6107
Homeless Person, Child, Certified birth record without charge for a
or Youth homeless person, child or youth; or, any person
lawfully entitled to request a certified record of
live birth, on behalf of a homeless child or
youth only, not an adult. The applicant must
Reference: Health and also complete an affidavit, verifying status
Safety Code Section homeless status.
103577

For child or spousal support and veteran’s benefits requests, a fee exempt
certified copy may be issued for any type of vital record, as long as the request
meets all applicable statutory requirements. Copies issued under these two
categories should also be stamped “For Official Government Use Only.”

For homeless person, child, or youth requests, do NOT issue birth record with
“For Official Government Use only” stamp.

See General Information section (pages 902-904) for additional information.

Continued on next page

January 1, 2016 1204

 FEES
Fees - When not payable, Continued
Sample The following is a sample of a District Attorney's application for a free
certified copy of a birth record.

The complaining witness, ____________________________, maiden name

_____________________________, has filed with our office under the Aid
to Needy Children Program of ___________________________________.

Please furnish this office with a copy (s) of the birth certificate (s) for the
child/children involved in this case.

Name _________________________________________, born _________

Name _________________________________________, born __________

Parent’s name is listed as ___________________________. This document

is necessary for our legal file in order to establish a child support obligation.

Pursuant to Section 6103.9 of the California Government Code, there will be

no charge. Section 6103.9 states in part, "Notwithstanding any other
provision of law, except as provided in this section, the local child support
agency and the district attorney shall be exempt from the payment of any
fees, including fees for services of process and filing fees, in any action or
proceeding brought for the establishment of a child support obligation…"

Sincerely,

District Attorney

Fee Schedule Check All County Letters for the current Fee Schedule.

January 1, 2016 1205

APPENDIX A
 APPENDIX A
Vital Statistics Forms

General CDPH-VR prescribes and furnishes to the local registrars all forms for the
Information registration of birth, fetal death, and death. All events must be registered on
state-provided forms. It is not permitted to reproduce registration forms.

Supplies should be ordered by form number and name. Use form VS 140e when
ordering forms.

Sufficient supplies to last approximately six months should be ordered at one

time.

For items not listed below, please visit CDPH-VR website at:
http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/default.aspx

REFERENCE: Health and Safety Code Section 102100

Form Form Name

Number
VS 5 Transmittal of Fees – Certified Copies
VS 6 Fees Received – Certified Copies
VS 7 Fees Received – Permit for Disposition of Human Remains
VS 8 Transmittal of Fees to State – Permit for Disposition of Human
Remains
VS 9(e) Application and Permit for Disposition of Human Remains
(e-form only, PDF fillable)
VS 10A(e) Certificate of Live Birth & Fetal Death – Medical Data
Supplemental Worksheet (e-form only)
VS 10B Race Identification Work Sheet
VS 10D Certificate of Live Birth
VS 10M Certificate of Live Birth (Multiple parents – State use only)
VS 11 Certificate of Death
VS 11e Certificate of Death – (prints back side only-EDRS use)
VS 12 Certificate of Fetal Death/Worksheet
VS 12e Certificate of Fetal Death – (prints back side only-FDRS use)
VS 21 Application to Amend a Birth Record - Adjudication of Facts of
Parentage
VS 22 Application to Amend a Birth Record - Acknowledgement of
Paternity
VS 23 Application for Amendment of Birth Record to Reflect Court
Order Change of Name
VS 24 Affidavit to Amend a Record – Birth, Death, and Fetal Death
VS 24A Physician’s/Coroner’s Amendment
VS 24C Application to Amend a Marriage Record
VS 43 Sealing Notice
VS 44(e) Court Report of Adoption (e-form only)
January 1, 2016 1301
 APPENDIX A
Vital Statistics Forms, Continued

Form Form Name

Number
VS 45 Monthly Transmittal of Fees to State – Petitions for Adoption

VS 60A (e) Ledger Book Record of California Marriage (02/09)

(e-form only, PDF fillable)
VS 61(e) Ledger Book Record of California Birth (e-form only)
VS 85 Delayed Registration of Birth
VS 105 Court Order Delayed Registration of Fetal Death
VS 106(e) Local Registrar’s Transmittal Report (e-form only)
VS 107 Supplemental Name Report - Birth
VS 108 Court Order Delayed Registration of Birth
VS 109 Court Order Delayed Registration of Death
VS 110(e) Ledger Book Record of California Death (e-form only, PDF)
VS 115 fillable) and Certificate of Marriage for Denominations Not
License
Having Clergy
VS 116 License and Certificate of Declaration of Marriage
VS 117 License and Certificate of Marriage
VS 117B(e) Application for License to Marry (e-form only)
VS 118(e) Souvenir Marriage Certificates (e-forms only)
VS 119 Monthly Transmittal of Fees – Marriage Licenses and
Dissolutions of Marriage
VS 122 Court Order Delayed Certificate of Marriage
VS 123 License and Certificate of Confidential Marriage
VS 136 Certificate of Finding of Unknown Child or Safely Surrendered
VS 140e ChildStatistics Forms Request (e-form only)
Vital
VS 246 Monthly Transmittal Fees to State Petitions of Dissolution of
Marriage, Judgment of Nullity, or Legal Separation
VS-PUB 109 Blank Amendment Paper (28 lb. white ledger)

January 1, 2016 1302

 APPENDIX A

Use this page for notes.

January 1, 2016 1303

APPENDIX B
 APPENDIX B

APPENDIX B. Sample Occupation Table

The U.S. Department of Labor’s “Dictionary of Occupational Titles” has been
replaced by O*NET (The Occupational Information Network):
http://www.onetonline.org/. On the O*NET home page, there is a “Find
Occupations” feature that allows users to search for occupations by industry.
The O*NET program is the nation's primary source of occupational
information. Central to the project is the O*NET database, containing
information on hundreds of standardized and occupation-specific descriptors.
The database, which is available to the public at no cost, is continually updated
by surveying a broad range of workers from each occupation. Information
from this database forms the heart of O*NET OnLine, an interactive
application for exploring and searching occupations.

If the person says Find out what Type, for instance:

Occupation Group is:
Adjuster Claim adjuster, brake adjuster, machine adjuster,
complaint adjuster, insurance adjuster, etc.

Agent Advertising agent, freight agent, insurance agent,

purchasing agent, sales agent, manufacturer’s agent,
real estate agent, etc.

Analyst Program, systems, policy, etc.

Apprentice Baker’s apprentice, butcher’s apprentice, carpenter’s

apprentice, compositor’s apprentice, fireman’s
apprentice, pipefitter’s apprentice, tailor’s apprentice,
etc.

Architect Software, residential, industrial, etc.

Assembler Balance assembler, bench assembler, clamp-jig

assembler, fireworks assembler, piano assembler,
turbine assembler, watch assembler, etc.

Assistant Administrative assistant, assistant cook, laboratory

assistant, office assistant, printer’s assistant, research
assistant, roofer’s assistant, assistant speech therapist,
etc.

Barber/ Hair
Cosmetologist
Continued on next page

January 1, 2016 1401

 APPENDIX B

Builder/ Contractor House builder, boat builder, highway construction

contractor, farm laborer contractor, plumbing
contractor, etc.

Caretaker/ Custodian Janitor, guard, building superintendent, gardener,

groundskeeper, farm foreman, locker attendant, vault
attendant, etc.

Child Care Provider Daycare, preschool, after school program, etc.

Clerk Stock clerk, bookkeeper, statistical clerk, adding

machine operator, typist, sales clerk, general office
clerk, etc.

Doctor Physician, veterinarian, osteopath, chiropractor,

dentist, etc.

Domestic Butler, cook, housekeeper, etc.

Engineer Civil engineer, mechanical engineer, locomotive

engineer, stationary engineer, steam shovel engineer,
etc.

Entertainment Film, music, etc.

Esthetician Skin, make-up, etc.

Factory worker Type of assembler, binder, weaver, knitter,

seamstress, punch press operator, sorter, etc.

Farm worker/ farmer Farm owner, ranch owner, farm tenant, farm cropper,
farm laborer, cowhand, farm hand, cotton picker,
farm manager, farm foreman, farm overseer, etc.

Continued on next page

January 1, 2016 1402

 APPENDIX B

Fireman Locomotive fireman, stationary fireman, city

firefighter, kiln fireman, fireguard, etc.

Food Service Cook, dishwasher, food server, head chef, etc.

Handyman Home repair, home maintenance, etc.

Helper Anglesmith’s helper, baker’s helper, cableman’s

helper, chemist’s helper, kiln operator helper,
mover’s helper, office helper, etc.

Inspector Buckle inspector, carpet inspector, housing inspector,

police inspector, traffic inspector, weed inspector,
etc.

Laborer Porter, janitor, window washer, car cleaner, section

hand, gardener, farm laborer, etc.

Machinist Precision measuring instrument machinist, metal part

machinist, (not repairer, mechanic, or welder), etc.

Manager Building manager, apartment house manager, display

manager, farm manager, office manager, etc.

Mechanic Automobile mechanic, airplane mechanic, radio

mechanic, etc.

Technician Nail, radiology, pharmacy, laboratory

Nurse Registered nurse, practical nurse, nurse’s aide,

licensed practical nurse, licensed vocational nurse,
etc.

Office worker Receptionist, file clerk, bookkeeper, word processing

machine operator, statistical clerk, etc.

Continued on next page

January 1, 2016 1403

 APPENDIX B

Optician Eye glasses, contact lenses, etc.

Painter Building painter, artist, sign painter, etc.

Repairer Appliance repairer, electric motor repairer, gear

repairer, instrument repairer, watch repairer, rubber
goods repairer, etc.

Salesperson Advertising salesperson, insurance salesperson,

(Salesman, etc.) newspaper deliverer, driver salesperson, etc.

Secretary Office work secretary, corporate secretary, etc.

Sports Tennis, bowling, baseball, soccer, basketball,

football, hockey, etc.

Student High school, welding school, medical school, etc.

Supervisor/ Typing supervisor, chief bookkeeper, section

Foreman foreman, yard foreman, kitchen supervisor,
supervising nurse, etc.

Teacher Seventh grade math teacher, college English

professor, high school auto shop teacher, second
grade teacher, art teacher, private dancing teacher,
etc.

January 1, 2016 1404

 APPENDIX B

What to do if… The table below provides additional instructions for completing the
occupation and industry items.

If… Enter this for Enter this for

occupation… business or
industry…
homemaker Homemaker Own Home

retired usual occupation while usual business or

working industry while working
self-employed functional occupation the related business or
industry
institutionalized, usual occupation if usual business or
disabled, and individual ever worked industry if individual
unemployed ever worked
student Student High School, Welding
School, Medical
School, etc.
infant Infant a dash

child Child a dash

never worked Never Worked a dash

unknown Unk a dash

refused Withheld a dash

NOTE:
Unemployed is not an acceptable entry.

January 1, 2016 1405

APPENDIX C
 APPENDIX C

APPENDIX C. Sample Business/Industry Table

If the person says Find out what Type, for instance:
Industry is:

Agency Collection agency, advertising agency, real estate

agency, employment agency, travel agency, etc.

Agriculture Cattle ranch, fruit farm, fishery, horticultural ranch,

crop farming, etc.

Bakery Wholesale bakery, retail bakery, bread manufacturing,

etc.

Club Golf club, night club, fraternal club, etc.

Education City school, public school, teachers’ association, state

education organization, etc.

Factory or mill Steel rolling mill, hardware factory, aircraft factory,

flour mill, lumber mill, planing mill, etc.

Government Public school, state public health agency, state

hospital, city water department, federal tax agency,
federal shipyard, etc.

Lumber Lumber camp, lumberyard (wholesale), retail lumber

sales, etc.

Military, Armed Military police, motor pool, fighter planes, chemical

Forces, etc. warfare, nuclear weapons, tank crew, damage control,
finance office, etc.

Continued on next page

January 1, 2016 1501

 APPENDIX C

Mine Coal mine, gold mine, iron mine, copper mine, lead
mine, marble quarry, etc.

Nursery Nursery school, day nursery, plant nursery, etc.

Oil Oil burners, oil drilling, oil pumping station, oil

extraction, etc.

Office Dentist’s office, life insurance company, state agency,

physician’s office, etc.

Packing house Meat packing plant, fruit cannery, vegetable packing

house (specify wholesale, retail), etc.

Petroleum Refinery, petroleum extraction, petroleum wholesale

sales, etc.

Public utilities Gas, electric, water, telephone, list combinations, such

as gas and electric, etc.

Repair shop Shoe repair shop, radio repair shop, welding shop,
auto repair shop, machine repair shop, etc.

Restaurant Fast food, fast casual, casual dining, fine dining, etc.

Retail store Grocery store, retail lumberyard, retail general store,

retail drugstore, retail florist, retail liquor store, etc.

Transportation Trucking company, airline company, railroad, taxicab

company, moving and storage company, shipping
company, etc.

Continued on next page

January 1, 2016 1502

 APPENDIX C

What to do if… The table below provides additional instructions for completing the
occupation industry items.

If… Enter this for Enter this for business

occupation… or industry…
homemaker Homemaker Own Home

retired usual occupation while usual business or

working industry while working
self-employed functional occupation the related business or
industry
institutionalized, usual occupation if usual business or
disabled, and individual ever worked industry if individual
unemployed ever worked
student Student High School, Welding
School, Medical
School, etc.
infant Infant a dash

child Child a dash

never worked Never Worked a dash

unknown Unk a dash

refused Withheld a dash

January 1, 2016 1503

 APPENDIX C
Use this page for notes.

January 1, 2016 1504

APPENDIX D
 OUT-OF-HOSPITAL BIRTH REGISTRATION

Guidelines for Out-of-Hospital Birth Registration

Registration These guidelines for out-of-hospital birth registration are intended to help the
guidelines registrar assure the accuracy and validity of the birth certificate. These
guidelines are not all-inclusive. Registrars should supplement these
guidelines if needed to verify the circumstances of the birth.

In this chapter This chapter contains the following sections:

Subsection Title See Page

General Information 1602

Responsibilities of the Local Registrar 1606

Recommended Procedures 1610

Physician/Midwife Attended Out-of-Hospital Attachment 1

Birth Packet
(for physicians, midwives or parents to use to
register the birth)
Parents’ Out of Hospital Birth Packet (for parents Attachment 2
to use to register the birth

January 1, 2016 1601

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Use this page for notes.

January 1, 2016 1602

 OUT-OF-HOSPITAL BIRTH REGISTRATION

General Information

Persons For live births that occur outside a hospital or Alternative Birth Center (ABC),
responsible for the physician in attendance at the birth; or in the absence of a physician
registering attending the birth, the midwife attending the birth, or in the absence of a
birth midwife, either one of the parents shall be responsible for entering the
information on the certificate, securing the required signatures, and for
registering the birth with the local registrar.

REFERENCE: Health and Safety Code Section 102415

Registration Registration prior to one year: Each live birth that occurs in California shall
timeframe be registered with the local registrar for the district in which the birth
occurred within 10 days following the date of the birth.

Birth certificates submitted for registration beyond the 10 day mandate may
be accepted by the local registrar, but these certificates must be properly
registered within one year of the date of birth.

REFERENCE: Health and Safety Code Section 102400

Registration after one year: Certificates registered on or after the child’s first
birthday must be processed by the CDPH-Vital Records as a Delayed
Registration of Birth

REFERENCE: Health and Safety Code Section 102525

Registration A packet is included to help physicians, midwives, and parents register out-of-
packet hospital births. This packet is:

 Physician/Midwife Attended Out-of-Hospital Birth Packet, and

The local registrar should provide the appropriate packet to the physician,
midwife, or parent(s) prior to the registration appointment. This packet
includes worksheets that the physician, midwife, or parent(s) should complete
and bring to the registration appointment.

Detailed Instructions for completing the VS10D are detailed in the Birth Chapter of
instructions this handbook. Exceptions that pertain only to out-of-hospital or ABC births
are listed on the following page.

Continued on next page

January 1, 2016 1603

 OUT-OF-HOSPITAL BIRTH REGISTRATION

General Information, Continued

4B Hour – For unattended births, enter the birth parent’s best estimate of the time of birth.
Unknown time “Unknown” is an acceptable entry only if the birth parent is unable to
of birth reasonably estimate the time of birth.

5A The table below provides instructions for completing Item 5A for out-of-
Place of birth hospital births

If the birth occurred in a… Then enter…

Place other than a hospital a description such as: residence,
automobile, doctor’s office, clinic, etc.
Prison, shelter for unwed/battered a dash. Complete Items 5B through 5D
person with the address of the facility.
Bus, automobile, train, or ambulance Bus, automobile, train, or ambulance as
appropriate and indicate the nearest
cross streets or position on highway,
e.g., Intersection 4th and Main or X
miles east of Metro City on U.S. 105.
Complete Items 5B and 5C.
Airplane Airplane en route to…, and specify
latitude and longitude in Item 5B. Enter
the name of the city where the airport is
located in Item 5C and the county
having jurisdiction over that city in Item
5D.
Ship at sea Ship en route to…, and specify latitude
and longitude in Item 5B. Enter the
port of call (city) in Item 5C and the
county having jurisdiction over that city
in Item 5D.

Reporting The birth of a child at sea or on any moving public conveyance such as a bus,
births at sea, on ambulance, train, ship, or airplane is required to be reported to the local
a bus, train, etc. registrar having jurisdiction over the place of the first stop or first port of call.

Continued on next page

January 1, 2016 1604

 OUT-OF-HOSPITAL BIRTH REGISTRATION

General Information, Continued

12A Parent or A child may sign as an informant or as an attendant for an out-of-hospital

other informant- birth. The child’s age is not a consideration, provided the child is able to
signature attest to the correctness of the information and is able to print or write
his/her name, or is able to make a “mark.”

13A Attendant
or Certifier- If the birth was attended by a… Then…
Signature physician or professionally licensed instruct the attendant to sign the
Degrees or midwife who is registering the birth completed certificate and enter
Title at the local registration district their degree or title.
physician or professionally licensed Enter “unavailable.”
midwife who is unavailable to
register the birth at the local
registration district
a child (the child’s age is not a Instruct the child to print or write
consideration, provided the child is their name, or make a “mark.”
able to attest to the correctness of the
information and is able to print or
write their name, or is able to make
a “mark”
See 13A in the Birth Section of this handbook for additional instructions.

13B License Enter the California license number if the birth was attended by a physician
number or professionally licensed midwife. If there was no attendant, enter a dash.
See 13B in the Birth Section of this handbook for additional instructions.

To verify the physician’s or midwife’s license number, please visit:

http://www2.dca.ca.gov/ or contact the California Medical Board at:

The Medical Board of California

2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
(916) 263-2382

13C Date The attendant is to enter the date they sign the completed birth certificate. If
signed there was no attendant or the attendant is unavailable, enter a dash.

Continued on next page

January 1, 2016 1605

 OUT-OF-HOSPITAL BIRTH REGISTRATION

General Information, Continued

13D Typed If the birth was attended by a… Then…

name, title and physician or professionally licensed type the name and title of the
mailing address midwife who is registering the birth physician or midwife who is
of attendant at the local registration district and certifying the fact of birth.
an affidavit has been signed,
physician or professionally licensed type the name and title of the
midwife who is unavailable to physician or midwife who is
register the birth at the local certifying the fact of birth.
registration district and an affidavit
has been signed,
physician or professionally licensed do not type the name and title of the
midwife who is unavailable to physician or midwife who attended
register the birth at the local the birth. Enter “unavailable.”
registration district and an affidavit
has not been signed,
the birth parent delivered alone enter “unattended”

a child type the child’s name

January 1, 2016 1606

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Responsibilities of the Local Registrar

Who should In order to register an out-of-hospital birth, the local registrar must require the
appear at the personal appearance of:
Health
Department to  The physician and parent(s), or parent(s) with the physician’s sign affidavit, for
register the physician attended births, or
birth  The midwife and parent(s), or parent(s) with the midwife’s signed affidavit, for
certificate? midwife attended births, or
 The parent(s) and attendant (if appropriate), for non-physician, non-
midwife attended births.

NOTE: They do not necessarily need to come into the office at the same
time.

Certificate to The birth certificate must be completed at the local registrar’s office. To assure the
be completed at security of blank birth certificates, the local registrars must not provide blank birth
registrar’s certificates to anyone to be completed and returned later.
office

Assurance of Out of hospital births not attended by a physician or midwife (or when the
accuracy and physician or midwife who attended is unable to appear in person at the local
validity of birth registration district):
certificate
The local registrar must assure the accuracy and the validity of the VS 10D. This is
accomplished by requiring the parent(s) to provide evidence of:
a) Identity of the parent(s).
b) Pregnancy of the person giving birth.*
c) Infant was born alive.
d) Birth occurred in the county where the child is to be registered, and*
e) Identity of the witness if a witness attended the birth.*
*If the physician or midwife who attended the birth is unavailable to appear at the local
registration district, they may send a signed affidavit with the parents. Upon
review of the affidavit, the local registrar may accept the affidavit as evidence to prove
b, d & e. However, the parent(s) will still need to provide evidence for a & c.

Physician or midwife attended births when the physician or midwife appear in

person at the local registration district to register the birth:
For physician or midwife attended births, accuracy and validity are achieved by
requiring the physician or midwife to provide evidence of the following:

 Identity of the physician or midwife.

 Identity of the parent(s).
 Infant was born alive.
NOTE: The physician or midwife’s signature on the birth certificate certifies to the
pregnancy of the person giving birth and that the baby was born in the county
where the child’s birth is being registered.

Continued on next page

January 1, 2016 1607

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Responsibilities of the Local Registrar, Continued

a) Identity of A valid picture identification card issued to the physician or midwife and to
the physician, the parent(s) by a governmental agency should be provided to prove identity.
midwife and Some recommended forms of identification that may be used are listed below:
parent(s)
□ California deriver’s license or California identification card issued by the
Department of Motor Vehicles.
□ U.S. Passport.
□ U.S. Military Identification Card, or
□ Temporary Resident Identification Card (green card).
□ Other valid picture identification card issued by a foreign government.

If the person giving birth gave birth in California but is not here legally, they
might be able to get identification verification from their consulate.

b) Pregnancy To prove the pregnancy of the person giving birth, a pregnancy test
of the birth verification form, a signed letter, or a signed “Affidavit of Birth Information
parent for Out-of-Hospital Births” that meets all the following conditions should be
provided:

□ Written on the doctor’s, midwife’s, or clinic’s official stationery (not on a

prescription pad) or on the “Affidavit of Birth Information for Out-of-
Hospital Births” form.
□ Signed (not stamped) by the California doctor, midwife, or clinic
representative/nurse, and
□ Contains the current California-issued professional license number of the
physician or midwife who signed the letter or affidavit.

The letter or affidavit must include the following information:

□ The person giving birth’s name.

□ The date the person giving birth was first seen by the doctor or midwife
(this date may be after the date of birth).
□ The results of the person giving birth’s prenatal or postpartum
examinations or pregnancy tests or completing the medical data section
on the affidavit (e.g. complications and procedures of pregnancy and
concurrent illness, and clinical procedures related to the newborn).
□ The date of the person giving birth’s last menstrual period.

c) Infant was □ THE BABY SHOULD BE BROUGHT TO THE APPOINTMENT.

born alive The appointment should not be conducted if the baby is not present.

Continued on next page

January 1, 2016 1608
 OUT-OF-HOSPITAL BIRTH REGISTRATION

Responsibilities of the Local Registrar, Continued

Birth occurred Information must be provided showing that the person giving birth was in the
in California county where the child’s birth is to be registered on the date that the birth
occurred. Information to confirm the person giving birth’s presence may
include any of the following:

□ If the birth occurred at the person giving birth’s residence, furnish an

electric power, natural gas, or water bill for the period when the birth
occurred. The copy of the bill (or statement from the company) must
show the name of the utility company, the address of the residence where
the birth occurred, and the name of either parent listed on the birth
certificate.

□ An affidavit from a person with the person giving birth at the time of the
infant’s birth. The affidavit must contain the address of the person with
the person giving birth, and the location of the birth.

□ A driver’s license, current rent receipt, or other similar document that

shows the person giving birth’s name and current address, or

□ A statement from an official of a state or local government agency that

requires proof of residency in California that the person giving birth was
receiving services on the date of the child’s birth (e.g. WIC or Medi-Cal).

Identity of the For non-physician or non-midwife attended births, if a witness attended the
witness birth, a witness is required to accompany the parent to the appointment.

A witness may include any of the following:

□ Spouse, SRDP or other family member.

□ Friend.

□ Child old enough to write their name (if the child does not have a
picture identification card, the parent may bring a picture of the child with
the child’s social security card and birth certificate. This applies only to
children).

Continued on next page

January 1, 2016 1609

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Responsibilities of the Local Registrar, Continued

Identity of the □ Paramedic or fire department staff.

witness
(continued) If a paramedic or fire department staff was present at the birth, the parent
can obtain a copy of the official report stating the treatment or service
they provided. (Note: There may be a fee charged for a copy.) The staff
does not have to be present at the appointment, nor does the parent have
to bring a copy of their identification.

If the paramedic arrived after the baby’s birth, the parent is instructed to
bring a copy of the 911 call or an official report of the contents of the 911
call, along with a copy of the paramedic’s report.

√ If the paramedic cut the cord, or was present when the cord was cut, the
report should so state.
√ If the paramedic delivered the placenta, the report should so state.

Valid form of A valid picture identification card issued to the witness by a government
identification agency must be provided to prove identity. Only the original or a certified
copy of one of the following documents is acceptable:

□ California driver’s license or California identification card issued by the

Department of Motor Vehicles.
□ U.S. Passport.
□ U.S. Military Identification Card, or
□ Temporary Resident Identification Card (green card)

Verification The local registrar may verify the accuracy of all information provided to
register an out-of-hospital birth.

Registrar’s If the requirements of Health and Safety Code 102415 and of the enclosed
right to refuse registration packet or other bona fide evidence are not presented to the
to register birth registrar, then the registrar must refuse to registrar the birth certificate. In
these cases, the birth certificate may be registered only by authority of a
superior court.

REFERENCE: Health and Safety Code Section 103450

January 1, 2016 1610

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Recommended Procedures

Entering Health and Safety Code Section 102415 states in part that the physician,
information on midwife, or parent is responsible for entering the information on the
the certificate certificate. CDPH-VR interprets this to mean the physician, midwife, or
parent is responsible to see that the information is entered and is correct.
Therefore, CDPH-VR recommends that the local registrar enter information
on the certificate for the physician, midwife and parent(s).

This procedure should minimize the number of improperly completed

certificates. The physician or midwife and parent signatures on the certificate
will then verify their concurrence with the information entered by the
registrar.

Registration It is recommended that the local registrars require that out-of-hospital births be
appointment- registered on an appointment-only basis. Separate appointments can be made
only basis to accommodate the physician’s, midwife’s and parents’ schedules. If
separate appointments are requested, the parents’ appointment should be
scheduled prior to the physician’s or midwife’s appointment.

This approach should provide both the registrar and the physician or midwife
and parent(s) with efficient use of time.

Pending At times, preparation of a certificate for out-of-hospital births may be started,

registration but for some reason is not completed promptly. If this occurs, registrars may
retain the incomplete certificate in a pending file but must shred it if the
certificate is still incomplete after one year from the date of birth.

Worksheet and While the worksheet is intended to facilitate the registration process, the
affidavit affidavit is intended to certify the accuracy of the information entered on the
retention worksheet. Neither the worksheet nor the affidavit are permanent records.
Registrars may retain the worksheet and affidavit in a file and discard them
one year after the date signed by the local registration district staff.

Social security The NANA program, operated by the SSA, is only available for newborns
numbers for delivered in hospitals. Parents of newborns delivered out-of-hospital should
newborns be referred to the SSA to obtain a social security number for their newborn.

Continued on next page

January 1, 2016 1611

 OUT-OF-HOSPITAL BIRTH REGISTRATION

Recommended Procedures, Continued

Additional These guidelines are not all-inclusive. Registrars should supplement these
verification, if guidelines if needed to verify the circumstances of the birth.
needed

January 1, 2016 1612

 Physician/Midwife Attended – Attachment 1

Out-of-Hospital Birth Packet

When a birth occurs outside

a hospital, the physician or
midwife in attendance at
birth, or in the absence of a
physician or midwife, the
parents must register the
birth of the baby.

This packet contains an

IMPORTANT worksheet
which the physician,
midwife, or parents must
complete and take to their
local health department
within 10 days following
the date of the baby’s
birth. This worksheet will
be used to register the
birth of the baby.
 Registering an out-of-hospital birth
Dear Physician/Midwife:
CDPH-VR understand that you have recently attended the birth of a child outside a hospital. You may be
aware that under current State law (Health and Safety Code §102415), you are required to register the birth of
this child with the LRD.
The enclosed packet provides instructions on how to register this child’s birth. Additionally, this packet
contains an important worksheet that must be completed to register the birth of this child. CDPH-VR asks
that you read the entire packet, fill out the worksheet, and gather needed documents related to the birth.
Please call ( ) ____________________ to schedule an appointment with the LRD to complete the birth
certificate. Please share the worksheet with the parent(s) of the child prior to the registration
appointment so they can assist in gathering worksheet information. Additionally, please advise the
parents that they need to visit the LRD to sign the birth certificate. Although CDPH-VR suggests that the
parents sign the certificate at the time of our appointment, a separate appointment can be made to
accommodate their schedule. The birth will not be registered until all signatures are in place.
By law, the birth certificate must be registered within 10 days of the birth. (Health and Safety Code
§102400)
In some instances you may be unable to physically visit the LRD to register the births that you attend.
In such cases please refer to the following:
If… Then…

You want your typed 1. Fill out the “Worksheet and Affidavit for Out-of-Hospital Births” in this packet.
name on title on the 2. Refer the parent(s) to the “Parents’ Out-of-Hospital Birth Packet.”
birth certificate 3. Instruct the parents to take the signed affidavit and other evidence to prove the five
facts listed below to the LRD when they register the birth:

a) Identity of parent(s)
b) Pregnancy of the person giving birth
c) Infant was born alive
d) Birth occurred in the county where the birth certificate is to be registered
e) Identity of witness

Please note that the signed affidavit from a physician or midwife may be enough evidence
to prove b, d, and e, but the parents will still need to provide evidence for facts a and c.

4. Upon review and acceptance of the affidavit, the clerk will type your name and
title on the birth certificate (Item 13D). However, the signature box (Item 13A)
will state “Unavailable.”
You want your 1. Follow the instructions in this packet.
signature and typed 2. Fill out the “Worksheet and Affidavit for Out-of-Hospital Births.”
name and title on the 3. Call the LRD to schedule an appointment to come in and complete the certificate.
birth certificate 4. Instruct the parent(s) that they need to visit the LRD to sign the certificate and
provide evidence for facts a and c above. They can go at the same time of your
appointment or a separate appointment can be made to accommodate their
schedule.
You do not want your 1. Refer the parents to the instructions in this pamphlet.
signature or typed 2. Inform parents that without a signature from a physician or midwife on the birth
name and title on the certificate, they will need to provide evidence of the five facts listed above.
birth certificate

Thank you for your time and help in registering the birth of this child.
Chief Deputy Registrar, Vital Records
 Physician/Midwife Instructions

Actions Complete the enclosed “Worksheet and Affidavit for Out-of-Hospital Births”
required prior prior to your appointment with the local registrar.
to appointment
The enclosed worksheet will be used to register the child’s birth and prepare
the birth certificate. Therefore, fill out the worksheet accurately with facts as
of the day that the child was born. CDPH-VR prefer that all items be
completed or accounted for, including public health data on the lower half of
the worksheet. However, the following items, which apply to information for
both the parents, are optional at the discretion of the parents: race and
ethnicity, education, usual kind of business or industry, usual occupation, and
social security numbers. CDPH-VR have enclosed coding sheets for your use
in completing the public health data portion. Contact CDPH-VR if you have
any questions regarding registering the child’s birth.

Proof of Please be aware that we will expect the physician or midwife and the parents
identity to produce written documentation of their identities at the time they sign the
birth certificate. Further discussion of the documentation required is
discussed below.

Identity of the A valid picture identification card issued to the physician or midwife and to
physician/ the parent(s) by a governmental agency should be provided to prove identity.
midwife and Some recommended forms of identification that may be used are listed below:
parent(s):
 California driver’s license or California identification card issued by the
Department of Motor Vehicles
 U.S. Passport
 U.S. Military Identification Card, or
 Temporary Resident Identification Card (green card)
 Other valid picture identification card issued by a foreign government

If the parents are not legally in California, they may be

able to get identification verification from their consulate.

Additionally:
Physicians and midwives must provide their professional license number for
verification purposes.

Continued on next page

 Instructions for registering an out-of-hospital birth

Physician/Midwife Instructions, Continued

Declaration of If the person giving birth is not married or in a SRDP, the other parent’s name
Paternity shall not be listed in Items 6A-6C unless both are biological parents and both
sign a voluntary CS 909. Call the POP at (916) 464-1982 or the local health
department if you have any questions.

Verification The County Registrar may verify the accuracy of all information provided to
register an out-of-hospital birth.

Registrar’s If the requirements of the Health and Safety Code and of the enclosed
right to refuse registration packet or other bona fide evidence are not presented to the
to register birth registrar, then the registrar must refuse to register the birth certificate. In these
cases, the birth certificate may be registered only by authority of a superior
court.

REFERENCE: Health and Safety Code Section 103450.

 Parents’ Out-of-Hospital Birth Packet - Attachment 2

Congratulations!
When a birth occurs outside
a hospital, the physician or
midwife in attendance at
birth, or in the absence of a
physician or midwife, the
parents must register the
birth of the baby.

This packet contains an

IMPORTANT worksheet
which the physician,
midwife, or parents must
complete and take to their
local health department
within 10 days following
the date of the baby’s
birth. This worksheet and
affidavit will be used to
register the birth of the
baby.
 Questions frequently asked by parents

Why do I need to register my baby’s birth?

You need to register your baby’s birth to comply with state law. For children not born in a
hospital, California law requires the physician or midwife in attendance at the birth; or in the
absence of a physician or midwife, either one of the parents to register the birth of your baby
born in California. (Health and Safety Code Section 102415)
You also need to register your baby’s birth so that your baby can obtain an official birth
certificate. During the course of your baby’s life, they will need an official birth certificate on
many occasions. For example, an official birth certificate (a certified copy of the birth
certificate) may be required to:

 Obtain a SSN  Apply for a driver’s license

 Enroll in school  Obtain a passport
 Register to participate in sports  Apply for various benefits
(Social Security, military)

Birth certificates are also valuable to establish:

 Proof of parentage  Inheritance rights

 Identity  Citizenship

A certified copy of a birth certificate is a legal record of your child’s birth. Certified copies are
recognized in any court.

What will I need to register my baby’s birth?

The out-of-hospital birth packet tells you everything you need to register your baby’s birth,
including worksheets and detailed instructions. This packet is available from your local health
department or from CDPH-VR. The mailing address for CDPH-VR is P.O. Box 997410,
Sacramento, CA 95899-7410, or you may call (916) 445-8494.

Who should register my baby’s birth?

When a baby is born at home or otherwise outside a hospital, the physician or midwife who
attended the birth, or in the absence of a physician or midwife, either one of the parents is
responsible for registering the baby’s birth with the local health department.

When should I register my baby’s birth?

By law, you must register the birth of your child within 10 days of the birth. There is no fee to
register your baby’s birth. However, you will be charged a fee if you do not register within the
child’s first year. Any birth registered on or after the child’s first birthday must be processed by
the State Vital Records as a Delayed Registration of Birth. If you cannot meet the requirements
for a Delayed Registration of Birth, you will have to apply to your local superior court for a
Court Order Delayed Registration of Birth. Out-of-hospital births are harder to register the
longer you wait after the date of birth.
 Questions frequently asked by parents, page 2

How can I make sure the certificate is completed correctly?

Please be sure to review your child’s birth certificate for accuracy before signing it. Never sign a
blank birth certificate. If you sign a blank birth certificate, the person filling it out may make errors.
Once the record has been filed, any corrections, such as corrections of misspellings or omissions, must
be made through the CDPH-VR, and a fee may be charged.

What if there is a mistake on the birth certificate?

After your child’s birth certificate has been registered, the original certificate, with the exception of
gender errors, cannot be changed. Errors may be corrected by filing a VS 24, which is available from
your local health department, or the CDPH-VR. When accepted, the affidavit will be attached to
the original certificate and will become part of the legal birth record.
If there is a gender error on your child’s birth certificate, please contact your local registration district
to speak with someone about how to correct it.

What if part (or all) of the baby’s name was left off the birth certificate?
After your baby’s birth certificate has been registered, the original certificate cannot be changed.
If part (or all) of the baby’s name was left off the birth certificate, and you wish to add the baby’s
name, a VS 107 or VS 24 can be used. This form is available from your local health department, or
the CDPH-VR. The completed application, when accepted, will be attached to the orginal
certificate and will become part of the legal birth record.
NOTE: If you wish to change your child’s name after the birth has been registered, you will need to
obtain a court order.
For amendments made within one year of the child’s birth, there is no processing fee, unless you
are correcting a gender error. For amendments made one year or more after the child’s birth,
there is a fee for filing the application.

How can I get a certified copy of the birth certificate?

You will not automatically receive a certified copy of your baby’s birth certificate. Once your baby’s
birth is registered, you can request a certified copy of your baby’s birth certificate from either the
local health department, or County Recorder in the county where your child was born, or the CDPH-
VR. The mailing address for CDPH-VR is P.O. Box 997410, Sacramento, CA 95899-7410. A fee is
charged for each certified copy of a birth certificate.

How do I get an SSN for my child?

You can get a SSN for your child by contacting the nearest Social Security office. There is NEVER
a charge for a Social Security number and card from the SSA. For more information about Social
Security, contact your nearest Social Security office or call the toll-free number (800) 772-1213
between 7 a.m. and 7 p.m. any business day.
 Questions frequently asked by parents, page 3

Who collects the information on the birth certificate?

The information you enter on the enclosed worksheet will be transferred to the VS 10D and
collected by CDPH-VR, P.O. Box 997410, Sacramento, CA 95899-7410, telephone number
(916) 445-2684. The information is required by Division 102 of the Health and Safety Code.
The VS 10D is open to public access except where prohibited by statute. (Refer to the attached
flyer, “Importance of Collecting Complete and Accurate Birth Certificate Information”)

Am I required to complete every part of the worksheet?

You must complete each field of information on the worksheet, except for the fields located
between the double bold lines in the center of the front page. CDPH-VR asks that you provide
this optional information as well, so that the records are complete. However, you are not
required to do so. The voluntary fields for both parents are:

 race and ethnicity

 education
 usual kind of business or industry
 usual occupation, and
 social security numbers

Additionally, for non-physician, non-midwife attended births, there are three voluntary fields
(see asterisks on the worksheet) which apply to medical data:

 complications and procedures of pregnancy and concurrent illnesses

 complications and procedures of labor and delivery, and
 abnormal conditions and clinical procedures related to the newborn

These three fields are required for physician or midwife attended births.

What is the information on the birth certificate used for?

The State of California, Department of Public Health collects birth information for population
studies and for studies about diseases in groups of people.
 Worksheet for Out-of-Hospital Births

Please Bring This Completed Form To Register This Child’s Out-Of-Hospital Birth
Child’s First Name Middle Last (Birth)
Information
Sex This Birth Specify 1=Single, 2=Twin, 3=Triplet, Etc.

Date of Birth Time of Birth □ a.m. □ p.m.

Place of Birth Street Address

City County Zip Code

Parent’s First Name Middle Last (Birth) □ Mother

Information □ Father
□ Parent
State of Birth Date of Birth

Person First Name Middle Last (Birth) □ Mother

Giving □ Father
□ Parent
Birth’s State of Birth Date of Birth
Information

The Following is Confidential Information and Will be Used for Public Health Purposes Only
Genetic Race (list up to 3) Hispanic: □ Yes □ No Date Last Worked
Father’s
Information See Attached Race/Ethnicity Worksheet Specify:
__________________________________
Usual Occupation Usual Kind of Business or Education – Years Completed Social Security Number
Industry

Genetic Race (list up to 3) Hispanic: □ Yes □ No Date Last Worked

Mother’s
Information
See Attached Race/Ethnicity Worksheet Specify:
__________________________________
Usual Occupation Usual Kind of Business or Education – Years Completed Social Security Number
Industry

Person Residence – Street Name and Number County

Giving
Birth’s City State Zip
Address
Mailing Address – If Different From Residence Address County
Street Name and Number or P.O. Box

City State/Foreign County Zip

Continued on Back
 Worksheet for Out-of-Hospital Births (Continued)

The Following is Confidential Information and Will be Used for Public Health Purposes Only
Medical Did Person giving birth Receive WIC (Womens, Infants & Children) Food While Pregnant?
Data
Average Number of Cigarettes/Packs Per Day Average Number of Cigarettes/Packs Per Day
First Three Months Prior to Pregnancy First Trimester

Average Number of Cigarettes/Packs Per Day Average Number of Cigarettes/Packs Per Day
Second Trimester Third Trimester

Prepregnancy Weight in Pounds Delivery Weight in Pounds Height Feet Height Inches

APGAR Score at 1 Minute APGAR Score at 5 Minutes APGAR Score at 10 Minutes Date Last Normal Menses Began
(00-10, Unknown, or Not Taken) (00-10, Unknown, or Not (00-10, Unknown, or Not
Taken) Taken)

Date First Prenatal Care Visit Month Prenatal Care Began Date Last Prenatal Care Visit Number of Prenatal Visits

Obstetric Estimate of Gestation at Delivery Hearing Screening: (Pass (Both Ears); Refer (One Ear); Refer
(Completed Weeks) (Both Ears); Results Pending; Waived; Not Medically Indicated;
Test Not Available)

PREGNANCY HISTORY (Complete Each Section)

Live Births (Do not count this child) Other Terminations (Exclude induced abortions)

Now Living Now Dead Before 20 Weeks After 20 Weeks

Date of Last Live Birth Date of Last Other Termination

Enter Principal Source of Payment Birthweight in Grams (See attached Method of Delivery (See attached VS 10A
Appropriate for Prenatal Care birth weight conversion table) worksheet)
Codes From
Worksheets
Principal Source of Payment * Complications and Procedures of Pregnancy and Concurrent Illnesses (See attached VS 10A
for Delivery worksheet) Enter 00 for NONE

* Complications and Procedures of Labor and Delivery * Abnormal Conditions and Clinical Procedures Related to the
(See attached VS 10A worksheet) Enter 00 for NONE Newborn (See attached VS 10A worksheet) Enter 00 for NONE

* The attending physician or midwife shall complete these three fields for physician- or midwife-attended out-of-hospital births.
These three fields are optional for non-physician- or non-midwife-attended out-of-hospital births.
 Affidavit of Birth Information for Out-of-Hospital Births

This Affidavit is to be Completed at the Local Health Office

I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the
child named herein was born alive to the stated parent at the place, date, and time shown on this worksheet.
This worksheet was completed with the understanding that the facts so stated herein afford a full, complete, and truthful
representation of facts and what my testimony shall be should I be asked or directed to testify to the facts herein in a court
of law. I realize that any false statement of facts or information made herein could subject me to the risk of criminal
liability, including, but not limited to, prosecution for perjury.
Parent Printed Name Written Signature
Verification ►
Relationship to Child Date Signed Phone Number
( )
□ Mother
□ Father
□ Parent
Witness Printed Name Written Signature
Verification ►
Address – Street Name and Number County

City State Zip

Relationship to Child Date Signed Phone Number

( )

Attendant Printed Name Written Signature

Verification ►
Address – Street Name and Number County
(Physician,
Certified Nurse- City State Zip
Midwife, or
Licensed State License Number Date Signed Phone Number
Midwife) ( )

Local Printed Name Written Signature

Registration ►
District Staff Date Signed Inventory Control Number
Verification □ Registered □ Denied ___________________

Privacy Notification

The information entered on the worksheet will be transferred to the Certificate of Live Birth (VS 10D) and will be collected
by the California Department of Public Health-Vital Records, M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410,
telephone number (916) 445-2684. This information is required by Division 102 of the Health and Safety Code. Every
element on the worksheet is mandatory, except the items between the double bold lines on the first page of the worksheet.
Failure to comply by every person, except a parent informant, is a misdemeanor. The Certificate of Live Birth is open to
public access except where prohibited by statute. The principal purposes of this record are to: 1) Establish a legal record of
each vital event, 2) Provide certified copies for personal use, 3) Furnish information for demographic and epidemiological
studies, and 4) Supply data to the National Center for Health Statistics for federal reports. The parents’ Social Security
numbers are included pursuant to Section 102425 (b) (15) of the Health and Safety Code, and may be used for child support
enforcement purposes.
 CERTIFICATES OF LIVE BIRTH AND FETAL DEATH
MEDICAL DATA SUPPLEMENTAL WORKSHEET
VS 10A (Rev. 1/2016)

Use the codes on this Worksheet to report the appropriate entry in items numbered 25D and 28A through 31 on the
“Certificate of Live Birth” and for items 29D and 32B through 35 on the “Certificate of Fetal Death.”
Item 25D. (Birth) PRINCIPAL SOURCE OF PAYMENT FOR PRENATAL CARE
Item 29D. (Fetal Death) (Enter only 1 code)
02 Medi-Cal, without CPSP Support Services 07 Private Insurance Company
99 Unknown
13 Medi-Cal, with CPSP Support Services 09 Self Pay
00 No Prenatal Care
05 Other Government Programs (Federal, State, Local) 14 Other
Item 28A. (Birth) METHOD OF DELIVERY
Item 32A (Fetal Death) (Enter only 1 code/number under each section, separated by commas: A,B,C,D,E,F)
A. Final delivery route B. If birth parent had a previous Cesarean—How many?
01 Cesarean—primary _______
11 Cesarean—primary, with trial of labor attempted (Enter 0 – 9, or U if Unknown)
21 Cesarean—primary, with vacuum
C. Fetal presentation at birth
31 Cesarean—primary, with vacuum & trial of labor attempted
02 Cesarean—repeat 20 Cephalic fetal presentation at delivery
12 Cesarean—repeat, with trial of labor attempted 30 Breech fetal presentation at delivery
22 Cesarean—repeat, with vacuum 40 Other fetal presentation at delivery
32 Cesarean—repeat, with vacuum & trial of labor attempted
90 Unknown
03 Vaginal—spontaneous
04 Vaginal—spontaneous, after previous Cesarean D. Was vaginal delivery with forceps attempted, but unsuccessful?
05 Vaginal—forceps 50 Yes 58 No 59 Unknown
15 Vaginal—forceps, after previous Cesarean E. Was vaginal delivery with vacuum attempted, but unsuccessful?
06 Vaginal—vacuum
60 Yes 68 No 69 Unknown
16 Vaginal—vacuum, after previous Cesarean
88 Not Delivered (Fetal Death Only) F. Hysterotomy/Hysterectomy (Fetal Death Only)
70 Yes 78 No
Item 28B. (Birth) EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY
Item 32B (Fetal Death) (Enter only 1 code)
02 Medi-Cal 05 Other Government Programs (Federal, State, Local) 14 Other
15 Indian Health Service 07 Private Insurance 99 Unknown
16 CHAMPUS/TRICARE 09 Self Pay 00 Medically Unattended Birth
Item 29. (Birth) COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES
Item 33. (Fetal Death) (Enter up to 16 codes, separated by commas, for the most important complications/procedures.)
DIABETES INFECTIONS PRESENT AND/OR TREATED DURING THIS
09 Prepregnancy (Diagnosis prior to this pregnancy) PREGNANCY
31 Gestational (Diagnosis in this pregnancy) 42 Chlamydia
43 Gonorrhea
HYPERTENSION
44 Group B streptococcus
03 Prepregnancy (Chronic)
18 Hepatitis B (acute infection or carrier)
01 Gestational (PIH, Preeclampsia)
45 Hepatitis C
02 Eclampsia
OTHER COMPLICATIONS/PREGNANCIES 16 Herpes simplex virus (HSV)
46 Syphilis
COMPLICATIONS/PREGNAN
32 Large fibroids
33 Asthma
47
48
Cytomegalovirus (Fetal Death Only)
Listeria (Fetal Death Only)
CIES
34 Multiple pregnancy (more than 1 fetus this pregnancy)
35 Intrauterine growth restricted birth this pregnancy
49
50
Parvovirus (Fetal Death Only)
Toxoplasmosis (Fetal Death Only)
23 Previous preterm birth (<37 weeks gestation) PRENATAL SCREENING DONE FOR INFECTIOUS DISEASES
36 Other previous poor pregnancy outcomes (Includes
perinatal death, small-for-gestational age/intrauterine DISEASES
51
52
Chlamydia
Gonorrhea
growth restricted birth, large for gestational age, etc.)
53 Group B streptococcal infection
OBSTETRIC PROCEDURES
54 Hepatitis B
24 Cervical cerclage
55 Human immunodeficiency virus (offered)
28 Tocolysis
56 Syphilis
37 External cephalic version—Successful
NONE OR OTHER COMPLICATIONS/PROCEDURES NOT LISTED
38 External cephalic version—Failed
COMPLICATIONS/PROCEDUR
00 None
39 Consultation with specialist for high risk obstetric services 30 Other Pregnancy Complications/Procedures not Listed
PREGNANCY RESULTED FROM INFERTILITY TREATMENT
40 Fertility-enhancing drugs, artificial insemination or
TREATMENT
intrauterine insemination
ES NOT LISTED
41 Assisted reproductive technology (e.g., in vitro fertilization
(IVF), gamete intrafallopian transfer (GIFT)

See reverse side for codes to Birth Items 30 and 31 and Fetal Death Items 34 and 35.
Do not enter any identification by patient name or number on this worksheet. Discard after use.
Do not retain the worksheet in the medical records or submit with the “Certificates of Live Birth or Fetal Death.”
CERTIFICATES OF LIVE BIRTH AND FETAL DEATH —MEDICAL DATA SUPPLEMENTAL WORKSHEET (Continued)
Item 30 (Birth) COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY
Item 34 (Fetal Death) (Enter up to 9 codes, separated by commas, for the most important complications/procedures.)
ONSET OF LABOR COMPLICATIONS OF PLACENTA, CORD, AND MEMBRANES
10 Premature rupture of membranes ( 12 hours) 38 Rupture of membranes prior to onset of labor
07 Precipitous labor (< 3 hours) 13 Abruptio placenta
08 Prolonged labor (20 hours 39 Placental insufficiency
CHARACTERISTICS OF LABOR AND DELIVERY 20 Prolapsed cord
11 Induction of labor 17 Chorioamnionitis
12 Augmentation of labor MATERNAL MORBIDITY
32 Non-vertex presentation 24 Maternal blood transfusion
33 Steroids (glucocorticoids) for fetal lung maturation received 40 Third or fourth degree perineal laceration
by the birth parent prior to delivery 41 Ruptured uterus
34 Antibiotics received by the birth parent during labor 42 Unplanned hysterectomy
35 Clinical chorioamnionitis diagnosed during labor or maternal 43 Admission to ICU
temperature 38°C100.4°F 44 Unplanned operating room procedure following delivery
19 Moderate/heavy meconium staining of the amniotic fluid NONE OR OTHER COMPLICATIONS/PROCEDURES NOT LISTED
36 Fetal intolerance of labor such that one or more of the 00 None
following actions was taken: in-utero resuscitative measures,
further fetal assessment, or operative delivery 31 Other Labor/Delivery Complications/Procedures not Listed

37 Epidural or spinal anesthesia during labor

25 Birth Parent transferred for delivery from another facility for
maternal medical or fetal indications

Item 31 (Birth) ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
Item 35 (Fetal Death) ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE FETUS
(Enter up to 10 codes, separated by commas, for the most important conditions/procedures.)
CONGENITAL ANOMALIES (NEWBORN OR FETUS) ABNORMAL CONDITIONS (NEWBORN OR FETUS)
01 Anencephaly 66 Significant birth injury (skeletal fracture(s), peripheral nerve
injury, and/or soft tissue/solid organ hemorrhage which requires
02 Meningomyelocele/Spina bifida intervention)
76 Cyanotic congenital heart disease ADDITIONAL ABNORMAL CONDITIONS/PROCEDURES
(NEWBORN ONLY)
77 Congenital diaphragmatic hernia
71 Assisted ventilation required immediately following delivery
78 Omphalocele
85 Assisted ventilation required for more than 6 hours
79 Gastroschisis
73 NICU admission
80 Limb reduction defect (excluding congenital amputation and
dwarfing syndromes) 86 Newborn given surfactant replacement therapy
28 Cleft palate alone 87 Antibiotics received by the newborn for suspected neonatal
sepsis
29 Cleft lip alone
70 Seizure or serious neurological dysfunction
30 Cleft palate with cleft lip
57 Down’s Syndrome—Karyotype confirmed 74 Newborn transferred to another facility within 24 hours of
delivery
81 Down’s Syndrome—Karyotype pending
NONE OR OTHER ABNORMAL CONDITIONS/PROCEDURES NOT
82 Suspected chromosomal disorder—Karyotype confirmed LISTED
83 Suspected chromosomal disorder—Karyotype pending 00 None (Newborn or Fetus)
35 Hypospadias 75 Other Conditions/Procedures not Listed (Newborn Only)
88 Aortic stenosis 67 Other Conditions/Procedures not Listed (Fetal Death Only)
89 Pulmonary stenosis
90 Atresia
62 Additional and unspecified congenital anomalies not listed
above
Race abbreviations:

American Indian = AMERI IND

Asian Indian = ASIA IND

Cambodian = CAMBODIA

Vietnamese = VIETNAM

Guamanian = GUAMIAN

Pacific Islander = PACIF IS

 TABLE FOR CONVERTING POUNDS AND OUNCES TO GRAMS

OUNCES
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

0 -- 28 57 85 113 142 170 198 227 255 284 312 340 369 397 425
1 454 482 510 539 567 595 624 652 680 709 737 765 794 822 851 879
P 2 907 936 964 992 1021 1049 1077 1106 1134 1162 1191 1219 1247 1276 1304 1332
3 1361 1389 1418 1446 1474 1503 1531 1559 1588 1616 1644 1673 1701 1729 1758 1786
O 4 1814 1843 1871 1899 1928 1956 1985 2013 2041 2070 2098 2126 2155 2183 2211 2240
5 2268 2296 2325 2353 2381 2410 2438 2466 2495 2523 2552 2580 2608 2637 2665 2693
U
6 2722 2750 2778 2807 2835 2863 2892 2920 2948 2977 3005 3033 3062 3090 3119 3147
N 7 3175 3204 3232 3260 3289 3317 3345 3374 3402 3430 3459 3487 3515 3544 3572 3600
8 3629 3657 3686 3714 3742 3771 3799 3827 3856 3884 3912 3941 3969 3997 4026 4054
D 9 4082 4111 4139 4167 4196 4224 4253 4281 4309 4338 4366 4394 4423 4451 4479 4508
10 4536 4564 4593 4621 4649 4678 4706 4734 4763 4791 4820 4848 4876 4905 4933 4961
S
11 4990 5018 5046 5075 5103 5131 5160 5188 5216 5245 5273 5301 5330 5358 5387 5415
12 5443 5472 5500 5528 5557 5585 5613 5642 5670 5698 5727 5755 5783 5812 5840 5868
13 5897 5925 5954 5982 6010 6039 6067 6095 6124 6152 6180 6209 6237 6265 6294 6322
14 6350 6379 6407 6435 6464 6492 6521 6549 6577 6606 6634 6662 6691 6719 6747 6776
15 6804 6832 6861 6889 6917 6946 6974 7002 7031 7059 7088 7116 7144 7173 7201 7229

1 Ounce = 28.35 Grams 1 Pound = 453.60 Grams EXAMPLE: 8 Pounds, 2 Ounces = 3,686 Grams

January 1, 2007
State of California California Department of Public Health

Importance of Collecting Complete and Accurate Birth Certificate Information

Why is the birth The birth certificate information is collected based on California Health and
certificate Safety Code Section 102425. This law lists all the information required to
information be on the California birth certificate. This law also makes all medical
collected? information confidential.

What is the birth The information collected is used to record what happened during pregnancy,
certificate labor, and delivery, and any issues the newborn experienced. The
information used information will be used to understand and help prevent birth defects,
for? preterm babies, maternal deaths, and other labor, delivery and birth
outcomes. Information collected also assists local and state public health
leaders in making decisions that address programs needed in the community
such as diabetes care, teen pregnancy, WIC (Women Infants Children), etc.

What birth All medical information is considered confidential and not released to the
certificate public. This includes the parents’ race, education, occupation, social security
information is number(s), and address. The only persons that may access the confidential
confidential on the information are the California Department of Public Health, local county
birth certificate? health department, persons with a valid scientific interest as determined by
the State Registrar and Committee for Protection of Human Subjects,
parent who signed the certificate or mother of the baby, and the child
named on the birth certificate.

What if the parent All information is required by law with the exception of the parents’ race,
does not want to occupation, education, and social security number(s). Although not required,
provide the race, occupation, and education are very important for understanding and
information? eliminating negative outcomes and developing needed programs.

Who collects the The birth certificate information is collected by the birth clerk and it is
birth certificate sent to the local county health department who forwards it to the California
information? Department of Public Health, Vital Records.

Who should I Please contact the California Department of Public Health, Vital Records at
contact if I still (916) 445-8494.
have questions?

Center for Health Statistics and Informatics Vital Records

Estado de California Departamento de California De La Salud Pública

Importancia de la Recolección de Información Completa y Precisa del Certificado de Nacimiento

¿Por qué es que la La información del certificado de nacimiento se recoge sobre la base de Salud de
información del California y el Código de Seguridad Sección 102425. Esta ley enumera toda la
certificado de información necesaria para estar en el certificado de nacimiento de California. Esta
nacimiento es ley también hace que toda la información médica sea confidencial.
conseguida?

¿Cuál información del La información recogida se utiliza para registrar lo que pasó durante el embarazo, el
certificado de parto y el parto, y cualquier otro problema del recién nacido que conducto
nacimiento se utiliza? experiencia. La información será utilizada para comprender y ayudar a prevenir
defectos de nacimiento, los bebés prematuros, las muertes maternas, y los
resultados del trabajo de otros, el parto y nacimiento. La información recopilada
también ayuda a los líderes locales y estatales de salud pública en la toma de
decisiones que los programas de dirección necesarias en la comunidad, tales como el
cuidado de la diabetes, el embarazo adolescente, el programa WIC (Mujeres,
Infantes para niños), etc.

¿Qué información es Toda la información médica es confidencial y no se provee al público. Esto incluye la
confidencial en el raza de los padres, educación, ocupación, número de seguro social (s) y dirección. Las
certificado de únicas personas que pueden acceder a la información confidencial, son el
nacimiento? Departamento de Salud Pública de California, departamento local de salud del
condado, las personas con un interés científico válido según lo determinado por el
Secretario de Estado y el Comité para la Protección de Sujetos Humanos, el padre
que firmó el certificado o la madre de el bebé y el niño nombrado en el certificado de
nacimiento.

¿Qué pasa si el padre Toda la información es requerida por la ley con la excepción de la raza de los padres,
no desea proporcionar ocupación, educación, y número de seguro social (s). Aunque no es obligatorio, la raza,
la información? la ocupación y la educación son muy importantes para la comprensión y la eliminación
de resultados negativos y desarrollar los programas necesarios.

¿Quién recoge la La información del certificado de nacimiento es recogido por el secretario de

información del nacimiento y se envía al Departamento de Salud local que lo envía al Departamento
certificado de Estatal de Salud Pública, Registro Civil.
nacimiento?

¿A quién debo Por favor comuníquese con el Departamento Estatal de Salud Pública, Registro Civil al
contactar si tengo (916) 445-8494.
preguntas?

Centro para las Estadísticas de Salud y la Informática Registro Civil

 WHAT YOU NEED TO KNOW ABOUT YOUR CHILD’S BIRTH
CERTIFICATE

Birth certificates last forever. Please be certain the information on the certificate
is accurate and complete before you sign them.

 A birth certificate is a legal document.

 An amendment form is required to make corrections to the birth certificate.
 The birth certificate will become a two-page document if an amendment is
requested after the original has been processed.
 Many changes on the birth certificate require the applicant to go to court for a
court order, including reversing the order of last names (surnames).
 Parents may have problems receiving benefits, traveling on an airline, obtaining
a passport or social security number for their child if the birth certificate is not true
and correct.
 It can take several months to apply an amendment. The processing time for
amendments can be located on our website at:

http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/ProcessingTimes.aspx

Common mistakes that require amendments or court orders:

 Misspelled first, last and middle names of child and/or parents

 Incorrect state, country and/or birth date of parent(s)
 Reversed order of last (family) names
 Adding extra names to parent(s) or child later
 Incorrect gender (sex) of child
 Incorrect birth date

Errors on birth certificates

cannot be corrected on the original certificate.

The original birth certificate does not change, but an amendment

is attached to create a two-page document.

 Parents please review the information on the birth certificate carefully before you
sign it.
 Your signature confirms that you have reviewed the information and that the facts
are correct.

Amendment forms may be obtained at local health departments or county recorder’s offices.

California Department of Public Health – Vital Records January 2013

 LO QUE USTED NECESITA SABER ACERCA DEL
CERTIFICADO DE NACIMIENTO DE SU HIJO

Los Certificados del nacimiento duran para siempre. Por favor asegurase de que
la información en el certificado este exacta y completa antes de que usted firme.

 Un certificado del nacimiento es un documento legal.

 Un formulario de enmienda es necesario para hacer correcciones al certificado
de nacimiento.
 El certificado del nacimiento llegará a ser un documento de dos páginas si usted
solicita una enmienda después de que el acta original se haya procesado.
 Muchos cambios en el certificado del nacimiento requieren al solicitante ir a la
corte, es necesario hacer un Cambio de Nombre por medio de la Corte cuando
uno cambia la orden de los nombres y apellidos.
 Padres pueden tener problemas para recibir los beneficios viajando en una línea
aérea, obteniendo un pasaporte o el número del seguro social para su hijo si el
certificado del nacimiento no es verdadero y correcto.
 Puede tomar unos meses para aplicar una enmienda.
 El tiempo de procesamiento de las enmiendas se puede encontrar en nuestro
sitio de web:

http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/ProcessingTimes.aspx

Los comunes errores que requieren enmiendas o orden de corte:

 Nombres mal escrito como el primero, segundo y apellido de hijo y los padres.
 El estado o país o la fecha del nacimiento de los padres incorrecto.
 Orden inverso de apellidos (familia) y nombres.
 Agregando más nombres y apellidos a los nombres de los padres y el hijo
después que la original se ha procesado.
 El género incorrecto de hijo
 La fecha de nacimiento incorrecto de su hijo.

El certificado original del nacimiento no cambia,

Pero una enmienda hace
Que su acta sea
Un documento de dos páginas sea la acta original y enmienda

 Padres revisan por favor la información en el certificado del nacimiento con

cuidado antes de firmar.
 Su firma confirma que usted ha revisado la información y los hechos son
correctos.
Las formas de la enmienda se pueden obtener en departamentos locales de salud o las oficinas
de condado.

California, Departamento de Salud Pública – Registro Civil Enero 2013

INDEX