Enumeration at Birth - Hospital Staff Relaying State Birth Certificate Data to SSA

ALASKA VITAL RECORDS PARENT WORKSHEET
Parent(s) Complete(s) Pages 1 & 2

Please print neatly as errors are difficult and expensive to correct and result in an amended record.
The information provided on this form is used to create your child’s birth certificate. A birth certificate is used for legal purposes to prove your
child’s age, citizenship, and legal parentage. This document will be used throughout your child’s entire life. To ensure conf identiality, State and
Federal laws govern release of information collected on this form.
You may name your child whatever you want with some exceptions. Social Security requires that the 26 letters of the English alphabet and
standalone hyphens (-) or apostrophes (‘), not accents or diacritical marks, are used. Once the birth is registered, a court-ordered legal name
change is required to alter any part of the child’s name.
Please provide complete and accurate information for all items. Not only will this information be used for legal purposes, but additional statistical
information is also used by health and medical researchers to improve the health of infants and mothers. These items include parents’ education,
race, and smoking history. These items will only be used for approved studies. These items will never appear on certified copies of the certificate
issued to you or your child. Once registered, you may order a certified copy of your child’s birth certificate at
www.vitalrecords.alaska.gov for a fee.

Child
First Name

Middle Name

Date of Birth (mm/dd/yyyy)

Last Name

Time of Birth (24 hours)

Do you want to get a Social Security Number for your Child?

:
/

Suffix (Sr, Jr, II, III, etc.)

 Yes, I authorize you to send my child’s birth
information to the Social Security Administration (SSA).

/

 No

Parent Signature (must be signed in order to send birth information to SSA)

Mother
Current Legal First Name

Current Legal Middle Name

Current Legal Last Name

Suffix (Sr, Jr, II, III, etc.)

First Name Before First Marriage

Middle Name Before First Marriage

Last Name Before First Marriage

Suffix (Sr, Jr, II, III, etc.)

 Check if none.

SSN #
-

Date of Birth (mm/dd/yyyy)

I

-

/

Age

I

/

Residence Address: Number and Street/P.O. Box
City or Town

I

I

Mailing Address (If different from residence address)
Number and Street:

 8th Grade or less
 9th - 12th Grade; no diploma
 High School Graduate or GED completed
 Some college credit, but no degree
 Associate degree (e.g. AA, AS)
 Bachelor's degree (e.g. BA, AB, BS)
 Master's Degree (e.g. MA, MS, MEng, MEd,
MSW, MBA)

 Doctorate (e.g. PhD, EdD, MD)
 Unknown
Did Mother receive WIC?

Yes

No

Mother’s Height:

I

Birth center (Not a Hospital)
Home
Hospital
Other - Specify ______________________
Unknown

Birthplace (State, Territory)

Country

 Yes









City

I

I

Unknown
State

I

Zip Code

I

Hispanic Origin: Check the appropriate box or check "No" if
not Spanish/Hispani c/L atin a(o )

 Native Hawaiian
 Guamanian orChamorro
 Samoan
 Other Pacific Islander

(Tribe):
Asian Indian
(Specify):
Chinese
 Other
Filipino
(Specify):
Japanese
Korean
Vietnamese
Other Asian (Specify):
Mother’s pre-pregnancy weight
Inches

State

I

Telephone Number

 No

Race: (Check one or more races as applicable)

 White
 Black or African American
 Alaska Native or American Indian

I

I Inside City Limits?
I
I

Feet
When labor began, where was mother planning to deliver?







Apt. No

Zip Code

Mother’s Email Address:
Education: Check box that describes the highest
degree or level of school completed.

Country of Birth

 No,not Spanish/Hispanic/Latina
 Yes, Mexican, Mexican American, Chicana(o)
 Yes, Puerto Rican
 Yes, Cuban
 Yes, other Spanish/Hispanic/Latina(o)
(Specify):
___________________________________

Did Mother smoke tobacco?

 Yes

 No

# of cigarettes

The planned primary Birth Attendant when labor began was?

-









Certified Direct Entry Midwife (CDM)
Certified Nurse Midwife (CNM)
Medical Doctor (MD)/Doctor of Osteopathy (DO)
Midwife – Unknown Certification
Nurse Practitioner (NP)/Physician Assistant (PA)
Other - Specify ______________________
Unknown

# of packs

Three months before pregnancy
First three months of pregnancy

Second three months of
pregnancy
Last three months of pregnancy

Please complete page 2.
Page 1 of 2

06-5356 (Rev. 12/2021)

Birth Parents’ Marital Status
This information is required by A.S. 18.50.16(d) & (e) to register the birth certificate andestablish legal parentage. If you do not
complete this section accurately, you may not be able to order a certifiedcopy of the birth certificate until it is resolved.








Yes 
Yes 
Yes 
Yes 
Yes 
Refused
Yes 

Was mother ever married?
Was mother married at the time the child was conceived; during this pregnancy; or at the time of birth?*
Is the husband the father of the child?
Will the biological father sign the Affidavit of Paternity?
Has the Affidavit of Paternity been completed and witnessed or notarized?

No
No*
No*
No
No

No
Is the Affidavit of Paternity attached to the Parent Worksheet?
*If no, and you want the father’s name on the birth certificate, an Affidavit of Paternity must be completed and attached to this form. If mother
is married at any time during the pregnancy, A.S. 18.50.160(d) & (e) requires that her legal husband’s name is listed on the birth certificate. If husband
is not the legal father, refer to the Affidavit of Paternity for further instructions.

 Father or  Parent 2
Current Legal First Name

 Check if none.

SSN #
-

Current Legal Middle Name

Date of Birth(mm/dd/yyyy)

-

/

Age

Country of Birth

Apt. No

City or Town

MSW, MBA)

 Doctorate (e.g. PhD, EdD, MD)
 Unknown

Person completing this Parent Worksheet
 Mother  Hospital Staff
 Father
 Other

I

Zip Code

I

Mailing Address (If different from residence address)
Number and Street:

 8th Grade orless
 9th - 12th Grade; no diploma
 High School Graduate or GED completed
 Some college credit, but no degree
 Associate degree (e.g. AA, AS)
 Bachelor's degree (e.g. BA, AB, BS)
 Master's Degree (e.g. MA, MS, MEng, MEd,

Birthplace (State, Territory)

/

Residence Address: Number and Street/P.O. Box

Education: Check box that describes the
highest degree or level of school completed.

Suffix (Sr, Jr, II, III, etc.)

Current Legal Last Name

Country

State

I

Inside City Limits?
 Yes
 No

I

Telephone Number
 Unknown

City

I
(Tribe):









Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify):

Zip Code

I

I

Hispanic Origin: Check the appropriate box orcheck "No" if
not Spanish/Hispani c/L atin a(o )

Race: (Check one or more races as applicable)

 White
 Black or African American
 Alaska Native or American Indian

I

State

 Native Hawaiian
 Guamanian orChamorro
 Samoan
 Other Pacific Islander
(Specify):

 Other
(Specify):

 No,not Spanish/Hispanic/Latina
 Yes, Mexican, Mexican American, Chicana(o)
 Yes, Puerto Rican
 Yes, Cuban
 Yes, other Spanish/Hispanic/
Latina(o) (Specify):
_____________________________

If other than the parent, the name of the person completing the parent information (first, middle, last) – Please print neatly.

I, the undersigned, hereby certify that the information provided is a true and correct representation of the facts to the best of my knowledge.

Signature:

Page 2 of 2

Date:

06-5356 (Rev 12/2021)