mothers worksheet

Vital Statistics Services

Vital Statistics Services 1

Quick Information ALL facility births are to be filed electronically. Birth certificates must be filed with the local

registrar within 10 days from the date of birth. The medical certifier/attendant must certify to

the birth within 7 days after the date of birth. If the attendant has not signed the certificate

within seven (7) days of the date of the birth, the person in charge of the institution or a designated representative shall complete and sign the certificate.


Checklist for Filing a Birth Certificate (Mother’s Worksheet)PLEASE MAKE SURE:

The worksheet has an accurate description in English for each field

The worksheet is completely filled out, readable and accurate

If there is missing information please make sure to obtain it before filing the record

Dates should follow the format: month/day/year

Mom signed the worksheet, verifying the information was accurate

If the mother didn’t sign the informant (person providing the information) has provided the information to the best of their knowledge and is an adult


Filing a Birth Certificate


Getting Logged In Go to https://vss.health.wyo.gov Log in with the userID and password

provided by Vital Statistics Services. If you forgot the password or userID

please contact Vital Statistics Services at [email protected].


https://vss.health.wyo.gov/

Confidentiality When logging in for the first time and

every quarter you will have to agree to a user confidentiality agreement. Do not share your password with any

other user! If you don’t agree to the terms, you will

not be allowed to use the system.


Part II


Worksheets All items on the mother’s worksheet

must be completed and the document must be signed.

If there are ANY blanks OR conflicting information, those items must be completed or verified.

The mother’s worksheet SHOULD NOT BE ACCEPTED IF ANY ITEM IS NOT COMPLETE.


Create the Birth Record Choose the “New Record” link from the grey

toolbar. Enter the full name of the child. Enter the date of birth. The Birth Facility defaults based on your

facility. Choose the medical certifier.

In some cases this will be a dropdown menu with different facilities. Choose the facility in which the certifier is associate with.

Registration countyDefaults based your facility. It can not be changed.


New Record


1. Once all pieces have been entered, choose “Create”.2. The system will run a check to make sure this is not a duplicate record.3. If the system doesn’t find a duplicate record, you will see the “Birth Mother’s Information” page.

Birth Mother’s Information Once the record is created you will be

taken to the mother’s information page. You will notice that this page is broken

up into four different sections:ChildMotherFatherInformation


Child Section The child’s name, date of birth, and the

facility are already filled in based on the information entered to create the record.

If the child has a suffix, you will still have to enter that information using the drop down list.

Enter the time of birth using military time.


Child Section


When entering the time of birth be sure to enter the time using Military time.

Military Time


Mother Section• Enter the mother’s full current legal name.

○ The information entered into the first and middle name fields of her current name will auto-fill those same fields in the mother’s name prior to first marriage.

• Enter the mother’s date of birth. Enter the mother’s name prior to first marriage. You will be required to enter the mother’s maiden name, her

last name prior to marriage. Enter the mother’s birthplace. You must choose a country first and then choose a state. Enter the mother’s residence and whether or not

the residence is inside city limits.


Mother’s Information


The information entered into the first and middle names of the mother’s Legal name will auto-fill those same fields in the mother’s name Prior to first Marriage.

When entering the mother’s residence be sure to enter the address in the first line. The only information that should be in Line 2 is an apartment, lot, or space number.

If there is no PHYSICAL address, only a PO box, you MUST enter “Unknown” for the residence address information. You MUST still enter the rest of the information. Only put the PO box information in the mailing address

Father’s Information Enter the full name of the father.

The only name that can be listed here is the natural father of the child.

Enter the father’s date of birth. Enter the father’s birthplace.

You must choose a country before you can pick a state.

When a father is named on the record, these fields are required.


Father’s Information


If the father is to be named on the record, this information is REQUIRED. If a father will not be named, you can skip this section.

Other Information Enter the mother’s mailing address.

You are allowed to enter PO box number for this field. However, you are still required to enter the city and zip code information as well.

Choose the mother’s marital status. This information must be entered exactly as it is shown on the mother’s worksheet.When Vital Statistics Services has questions about

the marital status we will go back and review the worksheet completed by the mother.

If there are questions about this section, call VSS for additional information

Choose whether or not a Paternity/Denial Affidavit has been completed.


Other Information


When entering the mailing address, be sure that ALL fields are complete.

Mother’s Marital Status If the mother was married at the time of

conception, birth, or anytime in between and her husband is the father:Wyoming statute 35-1-411 “Name of father

on birth certificate”, The husband’s name shall be entered on the Birth Certificate as the father.

You may run into situations in which the mother refuses to name or provide information about the father, please call VSS when this happens.


Naming the Father Please use the following chart to help determine

if a father can be named on the birth record:


Is Mother Married?

Is Husband the Father?

Paternity Acknowledgement

Signed and Notarized

Denial Affidavit Signed and Notarized?

Can Father’s Name be on the Record?

YES YES N/A N/A YES (Required by

Law)

YES NO YES YES YES

YES NO NO YES NO

YES NO NO NO CONTACT VSS OFFICE

YES NO YES NO NO

NO N/A YES N/A YES

NO N/A NO N/A NO

Other Information Continued Information Released to obtain:

Social Security Number?○ If the mother chooses “YES”, Vital Statistics Services

will send the information automatically to the SSA and the mother will receive the card via mail within 3-6 weeks.

Enroll child in immunization registry?○ The immunization registry is a computerized

information system used to collect vaccination information to help assure that immunizations are given to protect individuals, especially children, from vaccine-preventable diseases.

○ All information is strictly confidential and may only be accessed by licensed physicians and public health authorities for the appropriate and timely vaccination of the child.


Parent’s Social Security Numbers Furnishing the parent’s Social Security

Numbers is required by Federal Law, 42 USC 405(c) (section 205(c)). The numbers will be made available to the

Wyoming Department of Family Services to assist with child support enforcement activities and to the IRS for the purpose of determining Earned Income Tax Credit compliance.

If either parent does not have a SSN you must enter 999-99-9999.If a father is not named, no SSN information is

required.


Other Information and Parent’s SSN


Furnishing the parent’s Social Security Numbers is required by Federal Law, 42 USC 405(c) (section 205(c)).

If either parent does not have a SSN you must enter 999-99-9999.If a father is not named, no SSN information is required.

Education Level Choose the box that indicates the highest

education level completed by the mother. If she is currently enrolled, check the box

that indicates the previous grade or highest degree received. Do not leave this item blank.

Education is highly related to fertility, health practices, and pregnancy outcome. It is also used as an indicator of socioeconomic status.


Hispanic Origin The Hispanic origin and Race questions should be asked

independently. ‘‘Hispanic’’ is not a race, and a mother/father who is of

Hispanic origin may be of any race. Do not leave this item blank. ‘‘Hispanic’’ is a self-

designated classification for people whose origins are from Spain, the Spanish-speaking countries of Central or South America, the Caribbean, or those identifying themselves generally as Spanish or Spanish-American.

Origin can be viewed as ancestry, nationality, or country of birth of the person or person’s parents or ancestors prior to their arrival in the United States.

Although the prompts include the major Hispanic groups, other groups may be specified under ‘‘Yes, other Spanish/Hispanic/Latino(a).’’


Hispanic Origin Continued Check the box that best describe

whether the mother/father is Spanish/Hispanic/ Latino(a).If the mother/father indicates an ethnic origin

not on the list, enter it in the ‘‘Specify’’ space.

If the mother/father is not of Hispanic origin, check the box indicating ‘‘No, not Spanish/Hispanic/Latino(a).”


Race The Race and Hispanic origin questions should be

answered independently. Do not leave item blank. If there is no checkbox for the response, check the box ‘‘Other (Specify)’’ and enter the response in the blank, even if it is not a race.

American Indian and Alaska Native refer only to those native to North and South America (including Central America) and do not include Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo or Cheyenne) for the American Indian or Alaska Native.

For Asians and Pacific Islanders, enter the national origin of the mother. For Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify Other Asian group; for Pacific Islanders check Hawaiian, Guamanian or Chamorro, Samoan, or specify Other Pacific Islander.


Race Continued In 1997, the Office of Management and Budget

mandated the use of specific guidelines in collecting information on race and ethnicity and provided an opportunity for individuals to choose more than one racial category if they wish to reflect multiple racial heritage.

Race is essential in producing data for minority groups and is an important variable in planning for and evaluating the effectiveness of health programs.

It is also used to study racial variations in childbearing, access to health care, and pregnancy outcomes (perinatal mortality and birth weight).


Education Level, Hispanic Origin, and Race


‘‘Hispanic’’ is not a race, and a mother/father who is of Hispanic origin may be of any race.

Mother’s Height Enter the mother’s height in feet and

inches. If the record indicates height in fractions such as 5 feet 6 and one-half inches, truncate and enter 5 feet, 6 inches.

In combination with prepregnancy weight, mother’s height is used to calculate the body mass index (BMI). Maternal BMI is associated with maternal morbidity and mortality. Maternal weight gain data are of little value without knowledge of maternal BMI.


Mother’s Pre Pregnancy Weight Record the weight in whole pounds only;

do not include fractions. This item collects the weight of the

mother immediately before she became pregnant.


Did the Mother get WIC Food during the Pregnancy WIC is a Special Supplemental Nutrition

Program for Women, Infants, and Children which serves to safeguard the health of low-income women, infants, & children up to age 5 who are at nutritional risk by providing nutritious supplemental foods, health and nutrition, screening and education, breastfeeding support, and referrals to healthcare.

Choose either YES or NO


Why is WIC Needed? Knowledge of participation in

government programs such as WIC is helpful in judging program use and its effect on health outcome. Participation in programs such as WIC is also an indicator of socioeconomic status.


Did the Mother Use Cigarettes? Enter the number of cigarettes the

mother smoked during an average day during the certain time periods before and during pregnancy.

When entering information only enter a value in one column (Cigarettes OR Packs), not both.


Cigarette Use Smoking during pregnancy has been

determined to have an adverse affect on pregnancy outcome.

This information is used to evaluate the relationship between certain lifestyle factors and pregnancy outcome and to determine at what levels these factors clearly being to affect pregnancy outcome.


Cigarette Use


Month Prenatal Care Began Enter the month of pregnancy when the

mother began going to the doctor for prenatal care. This question is asking if the mother began

prenatal care in the 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, or 10th month of pregnancy.

Acceptable values are only between 01 and 10.

Do not enter January, February, March, etc…


Mother’s Height, Pre-pregnancy Weight, WIC, and Prenatal Info.


Finished with Mother’s Worksheet Information Once you have answered the tobacco

use per day you will notice that you are done with the mother’s worksheet.

It is very important this worksheet is completed and signed, it provides all of the information to establish a birth record.If there are any questions unanswered you

should get a response so the worksheet is complete.
