BirthCertificateAuthorizationForm

Full Name of Child

Sex of child: Male Female

Date of Birth: /  / 

Month Day Year

Place of Birth- Hospital/Clinic (if applicable)

____________________ 

Place of Birth- City Place of Birth- State

The measurement of children’s health is a primary research aim of the National Children’s Study (NCS). Information from the birth certificate, such as birth weight, will help us better understand children’s growth and development throughout childhood. We are asking you to authorize the state office of vital records to release the health‐related birth certificate information of the child named above to researchers from the NCS.

Your child’s birth certificate information will be used for research purposes only. All information will be kept strictly confidential. Names and other identifying information will not be released without your permission.

 I PERMIT the NCS to obtain my child’s health‐related birth certificate information.

 I DO NOT PERMIT the NCS to obtain my child’s health‐related birth certificate information.

_________________________________________ _________________________________________________

Printed parent/guardian name (first, middle, last) Signature of parent/guardian

_________________________________________________

Relationship to Child

Date signed: // - -

m m d d y y y y Phone number

Questions related to the collection of health‐related birth certificate information can be answered by NCS staff at 1-877-865-2619.

CON HIPAA Authorization Form for Release of Child Birth Certificate, MDES 3.5, V1.0 0