Certificate of Live Birth Worksheet - Arizona Department of Health Services
This document is a worksheet for parents or informants to fill out information required for the Arizona Certificate of Live Birth. It collects details about the child's birth, parents' information, and other relevant data. This form must be reviewed, signed and verified for accuracy.
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How do I fill this out?
To start filling out this worksheet, carefully review each field and provide accurate information. Ensure you have all necessary details about the child's birth, parents' information, and medical data. Once completed, review the information for accuracy before submitting.
How to fill out the Certificate of Live Birth Worksheet - Arizona Department of Health Services?
1
Review the information sections required on the worksheet.
2
Enter the child's birth details including name, sex, and date of birth.
3
Provide information about the parents including names and social security numbers.
4
Fill in the medical and prenatal information as required.
5
Review all entries for accuracy and completeness before signing the form.
Who needs the Certificate of Live Birth Worksheet - Arizona Department of Health Services?
1
Parents of a newborn child need this form to officially register the birth.
2
Hospitals and birthing centers need this form to report details of births they handle.
3
The Arizona Department of Health Services uses this form to maintain vital records.
4
Researchers and public health officials may require aggregated data from these forms for studies.
5
Legal guardians or informants may need this form if they are involved in the child's birth registration process.
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What are the instructions for submitting this form?
To submit this form, you may send it to the Arizona Department of Health Services via email at vitalrecords@azdhs.gov, or fax to (602) 364-1257. Alternatively, you can mail it to the Bureau of Vital Records, 1818 W. Adams, Phoenix, AZ 85007. Ensure all information is correct and the form is properly signed before submission. It is advisable to keep a copy of the form for your records.
What are the important dates for this form in 2024 and 2025?
Ensure timely submission of the form: January 1, 2024 for births occurring in 2024 and January 1, 2025 for births occurring in 2025.
What is the purpose of this form?
The purpose of this form is to collect and verify information necessary for the issuance of an official Certificate of Live Birth by the Arizona Department of Health Services. This data includes details about the child's birth, parents' names and information, and other relevant medical and demographic information. The completed form ensures the accurate registration of the birth and helps in maintaining vital health records for the state.
Tell me about this form and its components and fields line-by-line.
- 1. Child's First Name: Enter the first name of the newborn child.
- 2. Sex: Specify the sex of the child.
- 3. Date of Birth: Enter the date and time of birth.
- 4. Place Of Birth: Specify the place where the birth occurred including full address if applicable.
- 5. Parent/Informant Names: Provide the names of the parent or the informant including middle names and suffixes if any.
- 6. Mother's Details: Enter information about the mother including name prior to first marriage, date of birth, and place of birth.
- 7. Father's Details: Enter information required about the father including current legal name and place of birth.
- 8. Medical and Prenatal Information: Include details such as prenatal visits, APGAR scores, and birth weight and length.
- 9. Signature and Attestation: Signature fields where attendants and parent/informants must sign attesting the accuracy of the information provided.
What happens if I fail to submit this form?
Failure to submit this form can lead to complications in registering the birth officially. It is crucial to complete and submit this form promptly.
- Incomplete Birth Registration: Without this form, the birth may not be registered legally, affecting the child's official records.
- Eligibility for Services: Without a registered birth certificate, accessing certain services and benefits may be restricted.
How do I know when to use this form?
- 1. In-Hospital Births: Utilize this form for births occurring in hospitals.
- 2. Home Births: Complete this form if the birth takes place at home.
- 3. Birthing Centers: Required for births occurring in freestanding birthing centers.
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