Street Address (If rural, indicate location.)*
Is residence inside city limits?* Zip Code*
Parish*
State* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Usual residence of mother (city, town or location)*
Section Break Father's Last Name*
Father's First Name*
Father's Middle Name*
Father's City and State of Birth*
Father's Date of Birth*
MM slash DD slash YYYY
Section Break Mother's Maiden Name*
Mother's First Name*
Mother's Middle Name*
Mother's City and State of Birth*
Mother's Date of Birth*
MM slash DD slash YYYY
Section Break Do you want a social security number for this child?* Enroll child in immunization reminder system?* Section Break Father's Race Father's Race Asian Black/African Caucasian/White East Indian Hispanic/Latino Middle Eastern Native American Pacific Islander Other
Mother's Race Mother's Race Asian Black/African Caucasian/White East Indian Hispanic/Latino Middle Eastern Native American Pacific Islander Other
Section Break
If yes, please specify Mexican, Puerto Rican, Cuban, etc.
Father's Hispanic Origin
Mother's Hispanic Origin
Section Break Father's Education* Father's Education* Some High School High School Graduate or Equivalent Trade or Vocational Degree Some College Associate Degree Bachelor's Degree Graduate of Professional Degree
Mother's Education* Mother's Education* Some High School High School Graduate or Equivalent Trade or Vocational Degree Some College Associate Degree Bachelor's Degree Graduate of Professional Degree
Section Break Live Births (do not include this child)*
Now Living (specify zero if none)*
Now Dead (specify zero if none)*
Date of Last Live Birth (month, year)*
Date of Last Other Termination*
MM slash DD slash YYYY
Number of Other Terminations*
Spontaneous or induced at any time after conception. (specify zero if none)
Section Break Mother married? (at birth, conception or anytime between)*
Date of divorce if more than 10 months
MM slash DD slash YYYY
Date last normal menses began*
MM slash DD slash YYYY
Month pregnancy prenatal care began (first, second, third, etc.)*
Tobacco used during pregnancy?* Average number of cigarettes per day*
Alcohol used during pregnancy?* Average number of drinks per week*
Mother's Social Security Number*
Mother's Phone Number*
Father's Social Security Number*
Father's Phone Number*
Phone
This field is for validation purposes and should be left unchanged.